alcohol screening and the brief negotiated intervention (bni). what is it & does it work?
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Alcohol Screening and the Brief Negotiated Intervention (BNI).What is it & Does it Work?
Several Truths
Treatment does work The ED/Primary care visit is an opportunity
for intervention Timely referral is effective Practitioners are reluctant to screen and
intervene There are multiple barriers to the SBI
Alcohol Screening in the ED
Why should we care?
Why Do We Care?
Prevalence
Morbidity & Mortality
Diminished Quality of Life
Harm to Self & Others
Alcohol Abuse Effects
$100 billion annual national cost $27 billion is from lost productivity 111 million US regular alcohol users 34% of persons 19-28 years engage in binge
drinking or drank heavily in past 30 days
Dept Health & Human Services, 8th congressional report, 1993x
National Hospital Ambulatory Medical Care Survey 2001 Emergency Department Summary
107.5 million visits 38.4/100 persons
39.4 million injury visits 14.1/100 persons
4.1 hour mean alcohol visit duration
2.5 million (2.3%) documented alcohol related
visits
11.4% referrals for alcohol treatment
Scope of the Problem
31% of adults presenting to and urban ED
reported > to 2 CAGE positive (Bernstein 1996)
24% of adults presenting by ambulance to an
urban ED reported > 2 CAGE positive (Whiteman 2000)
ED patients are 1.5-3.0 times more likely to report
heavy drinking or consequences than those in
Primary Care (Cherpitel 1999)
Morbidity and Mortality
>107,000 alcohol related deaths each year
1/3 of adult admissions are alcohol related
Attributable risk factor for multiple illnesses
Major risk factor for all categories of injury
– Problem drinkers have 2x injury events/yr and 4x as many hospitalizations for injury
– A single alcohol-related visit predicts continued problem drinking
Alcohol-Related Fatalities
0
2,500
5,000
7,500
10,000
12,500
15,000
17,500
20,000
22,500
25,000
27,500
82 84 86 88 90 92 94 96 98 00 02 04
Young Adults
17% of 8th graders, 33% of 10th graders & 47% of 12th graders report alcohol use in the past month
11% of 8th graders, 21% of 10th graders & 28% of 12th graders report binge drinking (5 drinks in a row) in the past two weeks
Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org
Young Adults
Highest prevalence of alcohol consumption
Major concern for college campuses
Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities
Americans 18 and older
10 million (5%) dependent drinkers 40 million (20%) high risk drinkers 70 million (35%) moderate drinkers 80 million (40%) abstain
National Longitudinal Alcohol Epidemiologic Survey, 1992
Elderly
10% of ED patients with alcohol problems
are > 60 years of age
Increased sensitivity to alcohol effects
Associated with depression and suicide
attempts
At risk for medication interactions
Ambulatory medical care survey
Nation’s Public Health Agenda:Healthy People 2010
Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department
Why Early intervention?
Screening and referral increases treatment contact
$ saved Improved prognosis Medical opportunity is ‘Teachable
Moment’
UNIVERSAL SCREENING UNIVERSAL SCREENING WIDENS THE NETWIDENS THE NET
ABSTAINERS & MILD DRINKERS
(70%)
MODERATE(20%)
at risk drinkers
SEVERE (10%)
Primary Prevention
Brief Intervention
Specialized Treatment
Importance of Detection
Davidson, et al noted that a single alcohol related ED visit is an important predictor of continued problem drinking, alcohol impaired driving, and, possibly, premature death
Davidson et al. Ann Emerg Med. 1997
Detection and Referral
Does it matter?????
Fleming
“Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices”
BI in 17 practices with 64 physicians
Intervention included: educational workbook,
(2) 15 minute visits one month apart, and
(2) nurse follow-up calls, 2 weeks after the visit
Fleming et al. JAMA 1997;277:1039-1047
Fleming
Results at 12 months (n=723)
Consumption:
(I) 19.1 drinks/wk to 11.5 vs (C) 18.9 to 15.2
Episodes of binge drinking during prior 30 days:
(I) 5.7 to 3.1 vs (C) 5.3 to 4.2
COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION
RCT (n=774) primary care practice, managed care setting problem drinkers economic cost of intervention = $80,210 ($205 each) economic benefit of intervention = $423,519
– $193,448 in ED and hospital use
– $228,071 avoided costs in motor vehicle crashes and crime
– 5.6 to 1 benefit to cost ratio
– $6 savings for every $ invested
Fleming MF, et al. Medical Care 2000; 38:7-18.
World Health Organization(Am J Pub Health 1996)
“A cross-national trial of brief interventions with heavy drinkers”– Multinational study in 10 countries (n=1,260)– Interventions included simple advice, brief &
extended counseling compared to control group– Results: Consumption decreased:
• 21% with 5 minutes advice, 27% with 15 minutes compared to 7% controls
• Significant effect for all interventions
Adolescents BNIMonti, et al“Brief intervention for harm reduction with
alcohol-positive older adolescents in an ED” 94 patients (18-19 years) were randomized (I) group had a significant reduction in alcohol use
(p<.001) at 6 month f/u and were less likely to report:– having driven after drinking ( p<0.05),
– having had alcohol involved in an injury (p<0.01)
– to have had alcohol-related problems (p<0.05)
Adolescents BNIMonti, et al94 Randomized 87 completed 3 month, 84 (89%) completed
6 month
Monti, et al. J of Consulting and Psychology. 1999;67:6.
Still engaging in this behavior
Adolescents BNIMonti, et al
BNI SC
Drinking & Driving
62% 85%
Moving Violations
3% 23%
Alcohol related injuries
21% 50%
Longbaugh et al
386 patients entered 3 groups: Control, Intervention and
Intervention with a booster session The Brief intervention with booster showed
the best results.
Longbaugh. J of Studies on Alcohol. Nov 2001.
Gentilello et al. Annals Surgery1999;230:473-483
“Alcohol Interventions in a Trauma Center as a Means of Reducing Risk of Injury Recurrence”
– Admitted injured patients who tested and/or screened positive for alcohol problems were randomized (n=732)
– Results at 12 months (54% follow-up rate):
• (I) alcohol consumption 21.8 drinks/week vs. (C) 6.7 (p=0.03)
Gentilello
• Reduction most apparent in mild-mod drinkers: 21.6 drinks/week vs 2.3 drinks/week in controls (p<0.01)
• 47% reduction in new injuries requiring ED visit or readmission to the trauma service (p=0.07)
• 48% reduction in new injuries requiring hospitalization at 3-year follow-up
Ok, What is the Brief Negotiated Interview & How do I perform this technique?
Components of the BNI
1. Raise the Subject
2. Provide Feedback
3. Enhance Motivation
4. Negotiate and Advise
Step 1: Raise The Subject
Establish Rapport Raise the subject of alcohol use
“Hello, I am….... Would you mind taking a few minutes to talk with me about your alcohol use?”
Establish Rapport
To understand the patient’s concerns and circumstances
To explain the providers concern/role
To avoid a judgmental stance
Raise the subject Get the patient’s agreement to talk
about the alcohol or drug use
Talk about the pros and cons of their use/abuse
Re-state what they have said regarding the pros and cons
What if the patient does not want to talk about their use/abuse ?
“ Okay, I see you aren’t ready to talk about this today. Remember that we are here 24 / 7 if you change your mind”
ASK Current Drinkers
• On average, how many days per week do you
drink alcohol?
• On a typical day when you drink, how many
drinks do you have?
• What’s the maximum number of drinks you
had on a given occasion in the last month?
Screen Positive
Drinks per
week
Drinks per occasion
Men > 14 > 4
Women > 7 > 3
All Age >65 > 7 > 3
Drinking Patterns% of
US adults aged 18+
Abusewithout
dependence
Dependencewith or without
abuse
Exceeds daily limit< once a week
16% 1 in 8(12%)
1 in 20(5%)
Exceeds daily limitonce a week or more
3% 1 in 5(19%)
1 in 8(12%)
Exceeds bothweekly & daily limits
9% 1 in 5(19)
1 in 4(28)
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
ASK Current Drinkers
CAGE
C Cut DownA AnnoyedG GuiltyE Eye Opener
Step 2: Provide Feedback
Review patient’s drinking patterns Make connection to ED visit if possible Compare to National Norms and offer
NIAAA guidelines
Step 2: Provide Feedback
“From what I understand you are drinking…”
“What connection (if any) do you see between your drinking and this ED visit?”
“These are what we consider to be the upper limits of low-risk drinking for your age and sex. By low-risk we mean that you would be less likely to experience illness or injury.”
Express Empathy and Rapport
Attitude : Acceptance by provider
Technique: Skillful reflective listening
Basis of change: Patient ambivalence
Assess Readiness To Change
“On a scale of 1-10 (1 being not ready and 10 being very ready) how ready are you to change any aspect your drinking patterns?”
1 2 3 4 5 6 7 8 9 10
Step 3: Enhance Motivation
“On a scale from 1-10, how ready are you to change any aspect of your drinking?
If patient indicates:
> 2 : “Why did you choose that number and not a lower one? What are some
reasons that you are thinking about changing.”
< 1: “Have you ever done anything that you wish you hadn’t while drinking: What would
make this a problem for you.” Discuss pros and cons
Not Ready for Change
Don’t – Use shame or blame– Preach– Label– Stereotype– Confront
Avoid Argumentation
Counter productive Defending breeds defensiveness Perceptions can be shifted Labeling is unnecessary Resistance is a signal to change strategies
– Rolling with resistance
Not Ready for change
Do– Offer information, support and further contact– Present feedback and concerns, if permitted– Negotiate: “What would it take you to consider
a change ?”
Unsure Patients
Don’t– Jump ahead
– Give advice
– Expect argument about change
Do– Explore pros & cons
– “help me to understand what alcohol does for you”
– “Are there things you don’t like about your alcohol use?”
Step 4: Negotiate and Advise
Elicit response “How does all this sound to you?”
Negotiate a goal“What would you like to do?”
Give advice“It is never safe to drink and drive, etc…”
Summarize“This is what I heard you say.. Thank you… (Provide PCP f/u or treatment referral)
Develop DiscrepancyExplore Pros and Cons Patient awareness of situation
Discrepancy between present behavior and important goals as change motivator
Let the patient name the problem and the pros and cons
Dangerous Assumptions
This person ought to change This person is ready to change This person’s health is the prime motivating
factor for them If they decide not to change the BNI has
failed
Dangerous Assumptions
Patients are either motivated or not Now is the right time to change A tough approach is best I am the expert and they should follow my
advice
The Ready Patient
Help the patient to:– Name a solution for themselves– Choose a course of action– Decide how to achieve it– Encourage patient choice
Referral
Consult the– Social worker– Psychiatric services
Discharge sheet of possible centers and / or programs and information
Summary
Alcohol problems are common, identifiable
and treatable disorders
Knowledge and skills for screening and
intervention can be learned
Remember:
Just start the conversation,
you may save a life!
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