Scope of Problem

Unhealthy alcohol use is a major preventable public health problem resulting in over 100,000 deaths each year and costing society over 185 billion dollars annually. The effects of unhealthy alcohol use have far reaching implications not only for the individual drinker, but also for the family, workplace, community, and the health care system.

Opioid dependence is a major public health concern and remains primarily an untreated medical condition in the United States. In 2006 there were approximately 560,000 individuals who used heroin, and 11.4 million individuals who had non–medical use of prescription opioids. Economic costs of opioid dependence are estimated at greater than $21 billion/year and have far reaching implications for the individual, workplace, society and the healthcare system. Untreated opioid dependence is associated with HIV transmission via injection drug use and high risk sexual behaviors. However, treatment is associated with significant individual and society benefits, and opioid agonist treatment, including methadone and buprenorphine, has been demonstrated to be the most effective treatment. However, opioid dependent patients often do not seek help through specialized treatment centers, but do frequently visit Emergency Departments (ED) of hospitals, either for medical consequences of theirs addictive disorder or for comorbid medical and psychiatric conditions. Many of these patients, particularly young adults, have few if any other interactions with the health care system. Therefore, the medical visit may be their only contact with the treatment system and represents an ideal opportunity for screening, intervention and referral for treatment.

In 2007, an estimated 19.9 million Americans aged 12 or older were current illicit drug users. This estimate represents 8.0 percent of the population aged 12 years or older. Illicit drugs include marijuana/hashish, cocaine, heroin, hallucinogens, inhalants, or prescription–type psychotherapeutics used nonmedically. In 2007, 23.2 million persons needed treatment for an illicit drug or alcohol problem. Of these, 2.4 million received treatment and 20.8 million did not receive treatment. Of the 20.8 million people who did not receive treatment, 1.3 million felt they needed treatment, 380,000 reported they made an effort to get treatment, and 955,000 reported making no effort to get treatment.

Brief Interventions Work for Alcohol, Tobacco and Other Drug Use

Brief interventions are short counseling session, ranging from 5–60 minutes that incorporate feedback, advice, and motivational enhancement techniques to assist the patient in reducing their alcohol consumption to low–risk guidelines thereby reducing their risk of illness/injury. The Brief Negotiation Interview (BNI) used in this grant was first developed in 1994 by Drs Edward Bernstein, Judith Bernstein and Gail D’Onofrio in consultation with Dr. Stephen Rollnick for Project ASSERT in the ED. It was later refined and tested for hazardous and harmful drinkers in the ED by our research team.

There is compelling evidence in the literature that brief interventions for alcohol problems are effective, in a variety of settings including primary care, and inpatient trauma settings. ED–based randomized controlled trial testing the effectiveness of screening, brief intervention and referral to treatment have had mixed results. Researchers in Germany studied a computer–generated intervention in injured patients presenting to an ED and found a significant decrease in alcohol consumption in the intervention group, while two other studies reported a similar decrease in alcohol consumption in the intervention and control groups but demonstrated significant reductions in negative consequences after the initial brief intervention session or a booster session in the intervention group. One study detected no difference in consumption between the intervention and control groups. Our own study (see preliminary data section) that enrolled both injured and noninjured patients with harmful and hazardous drinking showed similar significant reductions in the control and BNI groups, without a treatment effect. Cohort studies without control groups have shown a significant reduction in alcohol use. A recently published study conducted at 14 ED sites that used a quasiexperimental comparison group design, in which we participated, revealed that screening, brief intervention and referral for treatment on patients with all degrees of unhealthy alcohol use was effective. A total of 1,132 patients were enrolled (581 control, and 551 intervention (BNI)). At 3–month follow–up, the BNI group reported consuming 3.25 fewer drinks per week than controls. Of the at risk drinkers, 37% no longer exceeded NIAAA low–risk guidelines compared with 19% in the control group, 95% CI 12% to 26% (see preliminary study section). A more recent meta–analysis of strategies targeting alcohol problems in the ED examined the extent to which interventions were effective in reducing alcohol consumption and related harm. Meta–analysis revealed that interventions did not significantly reduce subsequent alcohol consumption, but were associated with approximately half the odds of experiencing an alcohol–related injury (OR=0.59, CI 0.42–0.84).

Brief interventions have long been shown to be effective in treating tobacco use and dependence in all populations including adolescents, pregnant women, older adults and racial and ethnic minorities. As a result formal clinical practice guidelines have been developed for treating tobacco use by a US public Health Panel and Consortium.

Few studies have investigated brief interventions in drug users. Bernstein and colleagues reported their experience with Project ASSERT in Boston, which used health promotion advocates to screen for alcohol and other drug use in an urban ED. This cohort study showed that during a one year period of time, 2,931 (41%) patients screened positively for substance abuse. Of the 1,096 enrolled in a follow up program, 245 kept a referral appointment and demonstrated a significant 45% reduction in severity of drug problems and a 56% reduction in alcohol use. More recently Bernstein and colleagues tested the impact of a single, structured encounter by similar peer educators that targeted cessation of drug use in a hospital’s hospital “Walk–In” Clinics. Of the 1175 patients enrolled, the intervention group at 6 months was more likely to be abstinent than the control group for cocaine (22.3% versus 16.9%), heroin (40.2% versus 30.6%), and both drugs (17.4% versus 12.8%). Another study evaluated the effect of a brief alcohol intervention for injection drug users at a needle exchange facility. Significant reductions were observed in both treatment conditions; participants reported an average of 12.0 drinking days at baseline and 8.3 at 6 months. Those in the brief intervention group were over two times more likely than controls to report reductions of 7 days or more, P‹0.05.

These findings support further investigation of brief intervention for drug use in the ED. Given the chronic and relapsing nature of opioid dependence, the goal of these brief interventions may be to facilitate an effective referral for the patient to a formal treatment program which can have an impact on reducing drug use.

Project ASSERT (Alcohol & Substance Abuse Services, Education, and Referral to Treatment) is an innovative program of the Yale-New Haven Hospital (YNHH) Emergency Department that helps patients access drug and alcohol treatment services.

For more information about Project ASSERT, please contact Caitlin Johnson at 203-737-6152 or caitlin.johnson@yale.edu