Alcohol Screening and the Brief Negotiated Intervention (BNI). What is it

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Alcohol Screening and the Brief Negotiated
Intervention (BNI).What is it Does it Work?
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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

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Alcohol Screening in the ED

• Why should we care?

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Why Do We Care?

• Prevalence
• Morbidity Mortality
• Diminished Quality of Life
• Harm to Self Others

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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

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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

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Scope of the Problem

• 31 of adults presenting to and urban ED reported
  gt to 2 CAGE positive (Bernstein 1996)
• 24 of adults presenting by ambulance to an urban
  ED reported gt 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)

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Morbidity and Mortality

• gt107,000 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

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Alcohol-Related Fatalities
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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, OMalley, Bachman, et al. Monitoring
  the Future Survey, 2005. www.monitoringthefuture.o
  rg

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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

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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

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Elderly

• 10 of ED patients with alcohol problems are gt 60
  years of age
• Increased sensitivity to alcohol effects
• Associated with depression and suicide attempts
• At risk for medication interactions

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Nations Public Health AgendaHealthy 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

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Why Early intervention?

• Screening and referral increases treatment
  contact
• saved
• Improved prognosis
• Medical opportunity is Teachable Moment

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UNIVERSAL SCREENING WIDENS THE NET
ABSTAINERS MILD DRINKERS (70)
MODERATE (20) at risk drinkers
SEVERE (10)
Specialized Treatment
Brief Intervention
Primary Prevention
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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

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Detection and Referral

• Does it matter?????

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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 19972771039-1047

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Fleming

• Results at 12 months (n723)
• 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

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COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION

• RCT (n774)
• 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 387-18.

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World Health Organization(Am J Pub Health 1996)

• A cross-national trial of brief interventions
  with heavy drinkers
• Multinational study in 10 countries (n1,260)
• 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

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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 (plt.001) at 6 month f/u and were less likely
  to report
• having driven after drinking ( plt0.05),
• having had alcohol involved in an injury (plt0.01)
  
• to have had alcohol-related problems (plt0.05)

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Adolescents BNIMonti, et al

• 94 Randomized
• 87 completed 3 month, 84 (89) completed 6 month
• Monti, et al. J of Consulting and Psychology.
  1999676.

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Adolescents BNIMonti, et al
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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.

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Gentilello et al. Annals Surgery1999230473-483

• 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 (n732)
• Results at 12 months (54 follow-up rate)
• (I) ? alcohol consumption 21.8 drinks/week vs.
  (C) 6.7 (p0.03)

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Gentilello

• Reduction most apparent in mild-mod drinkers ??
  21.6 drinks/week vs 2.3? drinks/week in controls
  (plt0.01)
• 47 reduction in new injuries requiring ED visit
  or readmission to the trauma service (p0.07)
• 48 reduction in new injuries requiring
  hospitalization at 3-year follow-up

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Ok, What is the Brief Negotiated Interview How
do I perform this technique?
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Components of the BNI

• Raise the Subject
• Provide Feedback
• Enhance Motivation
• Negotiate and Advise

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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?

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Establish Rapport

• To understand the patients concerns and
  circumstances
• To explain the providers concern/role
• To avoid a judgmental stance

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Raise the subject

• Get the patients 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

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What if the patient does not want to talk about
their use/abuse ?

• Okay, I see you arent ready to talk about this
  today. Remember that we are here 24 / 7 if you
  change your mind

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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?
• Whats the maximum number of drinks you had on a
  given occasion in the last month?

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Screen Positive
Drinks per week Drinks per occasion
Men gt 14 gt 4
Women gt 7 gt 3
All Age gt65 gt 7 gt 3
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Drinking Patterns
of US adults aged 18 Abuse without dependence Dependence with or without abuse
Exceeds daily limit lt once a week 16 1 in 8 (12) 1 in 20 (5)
Exceeds daily limit once a week or more Exceeds daily limit once a week or more 3 1 in 5 (19) 1 in 8 (12)
Exceeds both weekly daily limits Exceeds both weekly daily limits 9 1 in 5 (19) 1 in 4 (28)
Source NIAAA National Epidemiologic Survey on
Alcohol and Related Conditions, 2003
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ASK Current Drinkers
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Step 2 Provide Feedback

• Review patients drinking patterns
• Make connection to ED visit if possible
• Compare to National Norms and offer NIAAA
  guidelines

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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.

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Express Empathy and Rapport

• Attitude Acceptance by provider
• Technique Skillful reflective listening
• Basis of change Patient ambivalence

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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
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Step 3 Enhance Motivation

• On a scale from 1-10, how ready are you to
  change any aspect of your drinking?
• If patient indicates
• gt 2 Why did you choose that number and
  not a lower one? What are some reasons
  that you are thinking about changing.
• lt 1 Have you ever done anything that you wish
  you hadnt while drinking What would make
  this a problem for you. Discuss pros and cons

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Not Ready for Change

• Dont
• Use shame or blame
• Preach
• Label
• Stereotype
• Confront

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Avoid Argumentation

• Counter productive
• Defending breeds defensiveness
• Perceptions can be shifted
• Labeling is unnecessary
• Resistance is a signal to change strategies
• Rolling with resistance

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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 ?

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Unsure Patients

• Dont
• 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 dont like about your
  alcohol use?

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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)

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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

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Dangerous Assumptions

• This person ought to change
• This person is ready to change
• This persons health is the prime motivating
  factor for them
• If they decide not to change the BNI has failed

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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

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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

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Referral

• Consult the
• Social worker
• Psychiatric services
• Discharge sheet of possible centers and / or
  programs and information

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Summary

• Alcohol problems are common, identifiable and
  treatable disorders
• Knowledge and skills for screening and
  intervention can be learned

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• Remember
• Just start the conversation,
• you may save a life!