EMCDDA PAPERS Emergency department-based brief

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1 ISSN EMCDDA PAPERS Emergecy departmet-based brief itervetios for idividuals with substacerelated problems: a review of effectiveess Cotets: Abstract (p. 1) I Backgroud (p. 2) I Methods (p. 7) I Results (p. 7) I Discussio (p. 14) I Coclusios (p. 15) I Ackowledgemets (p. 20) Abstract: This paper reviews the effectiveess of brief itervetios i a emergecy departmet settig. It presets a aalysis of five systematic reviews ad 16 radomised cotrolled trials. Most of these studies focused o alcohol-related cases or o cases of alcohol ad drug use, with four studies specifically targetig illicit drug use. Brief itervetios are psychosocial itervetios desiged to help recipiets recogise harmful patters of substace use, ad to motivate ad support them to address that use. Brief itervetios typically use the collaborative coversatio style of motivatioal iterviewig ad, as the ame suggests, take oly a short time, ragig from 5 to 30 miutes. Brief itervetios are delivered by a rage of professioals, icludig physicias, urses ad other healthcare workers; oe commo structure for brief itervetio delivery employs the 5As approach: ask, advise, assess, assist ad arrage. May studies o brief itervetios i a emergecy departmet settig stress that this cotext offers a importat widow of opportuity i which to egage with people with substace use problems who might otherwise ever receive ay form of assessmet, referral or itervetio. Brief itervetios have become icreasigly popular because they ca be delivered i a variety of settigs, by a rage of workers (after traiig) ad i a short time frame; all three of these factors combie to keep costs relatively low. This review foud that there are potetial beefits of brief itervetios, especially i relatio to behavioural outcomes. However, a defiitive statemet about effectiveess caot be made, as the results of the studies reviewed may ot be geeralisable to other age groups, to patiets with differet levels of substace use, or, give that the focus of may of the studies was o alcohol, to those usig illicit drugs. However, the feasibility of brief itervetios delivered by emergecy departmet persoel, the absece of reported adverse effects ad the potetial costeffectiveess all suggest that brief itervetios could be cosidered as itegral to the traiig of emergecy departmet healthcare staff. Keywords brief itervetios emergecy departmets review Recommeded citatio: Europea Moitorig Cetre for Drugs ad Drug Addictio (2016), Emergecy departmetbased brief itervetios for idividuals with substacerelated problems: a review of effectiveess, EMCDDA Papers, Publicatios Office of the Europea Uio, Luxembourg. 1 / 20

2 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess I Backgroud Psychosocial itervetios are structured psychological or social itervetios that are used to address substacerelated problems. They ca be used at differet stages of a treatmet jourey to idetify the problem ad treat it, ad assist with social reitegratio (EMCDDA, 2015). These itervetios ca be used aloe or i combiatio with other treatmets at differet poits of a idividual s drug treatmet jourey or, more geerally, i the cotext of uiversal prevetio. Ofte, they are used at a patiet s first cotact with health services to help them recogise ad clarify the ature of their drug problem, ad commit to chagig their behaviour. At a later stage, these itervetios are used to support patiets with their treatmet. These itervetios are also employed, sometimes i cojuctio with pharmacological treatmet, i the treatmet of opioidrelated problems. They ca help patiets to maitai behavioural goals ad they support treatmet retetio. Psychosocial itervetios ca also ivolve families ad commuities durig the social reitegratio phase of drug treatmet. Brief itervetios are practices typically used to help people recogise their substace use problems. They aim to idetify a real or potetial substace use problem ad motivate a idividual to chage their behaviour. They ca be admiistered opportuistically or after screeig. However, there is o stadard defiitio of what costitutes brief. For example, i 2003, the World Health Orgaizatio (WHO, 2003, p. 4) defied face-to-face brief itervetios addressig substace use i the cotext of primary care as ragig from 5 miutes of brief advice to miutes of brief cousellig ad, i 2012, as a maximum of two sessios for drug users (WHO, 2012, p. 1); i Australia i 2004, the Departmet of Health ( 1 ) defied brief itervetios as those lastig as little as 30 secods, or extedig over a few sessios lastig 5 60 miutes ; ad the Natioal Health Service i Scotlad ( 2 ) defied brief itervetios as usually less tha five miutes but certaily o more tha twety. Although there is cosesus with regard to the mai characteristics ad purposes of brief itervetios, there is ot a iteratioally agreed defiitio. I the absece of a stadard defiitio, this report uses a operatioal defiitio which characterises a brief itervetio as a itervetio delivered i a short time frame which: is delivered to idividuals or small groups ad aims ot solely to prevet substace use, but also to delay iitiatio, ( 1 ) drugtreat-pubs-frot9-fa-toc~drugtreat-pubs-frot9-fa-secb~drugtreat-pubsfrot9-fa-secb-6~drugtreat-pubs-frot9-fa-secb-6-1 ( 2 ) reduce its itesificatio or prevet escalatio ito problematic use ( 3 ); does ot provide treatmet for substace use (e.g. opioid substitutio/maiteace treatmet, detoxificatio or psychosocial cousellig), although oe of the aims of some brief itervetios may be to ecourage recipiets to cosider treatmet; does ot usually target those who are substace depedet; may iclude advice ad elemets of motivatioal iterviewig, such as empathy, ope-eded questios, a o-directive approach ad reflective listeig, i a attempt to reduce ambivalece about substace use ad possible treatmet. I How the itervetios work Brief itervetios use the collaborative coversatio style of motivatioal iterviewig to address problematic or risky drug use, but are delivered i a shorter time frame, typically ragig from 5 to 30 miutes. Persoalised feedback is provided o a perso s substace use. This eables them to uderstad their use i relatio to other people s use. I this approach, the professioal deliverig the brief itervetio asks for permissio to talk about possible drug or alcohol use ad help patiets to positio themselves o a scale of use level. Questios are asked about the beefits ad harms of substace use i a attempt to elicit a motivatio to chage. Whe cocludig a brief itervetio, a pla for chage ad a follow-up are egotiated. There are a umber of brief itervetio models, but oe of the most commoly used cosists of five phases, kow as the 5As : ask, advise, assess, assist ad arrage (Babor et al., 2007). A study carried out i the Uited States has show that this approach is used i may differet settigs, icludig i emergecy departmets, with primary care services ad with services for the homeless, i order to address the problems that people have as a result of their substace use by ecouragig them to reflect ad cosider makig a chage (Saitz et al., 2014). While brief itervetios are ofte based o motivatioal iterviewig techiques, the evidece to support their use is still developig ad there is a eed for further research (Yuma-Guerrero et al., 2012; Taggart et al., 2013). I Motivatioal iterviewig versus brief itervetios Motivatioal iterviewig is a collaborative coversatio style for stregtheig a perso s motivatio ad commitmet to chage (Miller ad Rollick, 2012). It is used to help people ( 3 ) 2 / 20

3 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess with differet types of substace problems. Frequetly, idividuals are ot fully aware of their substace problems or they ca be ambivalet about them. Motivatioal iterviewig is ofte referred to as a coversatio about chage, ad it is used to assist drug users to idetify a eed for chage. It seeks to address idividuals ambivalece about their drug problems, as this is cosidered the mai barrier to chage. It comprises five elemets: (1) expressig empathy for patiets; (2) helpig patiets to idetify discrepacies betwee their behaviour ad their goals; (3) avoidig argumets with patiets about their motivatios ad behaviours; (4) goig alog with patiets resistace to talk about certai issues; ad (5) supportig patiets sese of self-efficacy. Motivatioal iterviewig is used to promote chage i may differet situatios ad settigs, icludig outpatiet services ad primary care services. It is used i prisos (Day et al., 2013), by social services ad i the workplace. Motivatioal iterviewig ca be provided by therapists, cousellors or other specifically traied professioals. It ca be used to help someoe make a decisio, to start ad follow a pharmacological treatmet pla or as a stad-aloe psychological treatmet. Geerally, however, motivatioal iterviewig is udertake i multiple sessios over a period of weeks ad at follow-up poits durig a course of treatmet. The beefits of this approach are supported by evidece, with a recet systematic review (Smedslud et al., 2011) of 59 studies ivolvig participats cocludig that it ca reduce the extet of substace abuse compared with o itervetio. Aother systematic review focused o the effectiveess of motivatioal iterviewig for tacklig drug use problems amog adolescets (Barett et al., 2012); this review icluded 39 studies, of which 67 % reported statistically sigificat improvemets i substace use outcomes. While motivatioal iterviewig uses specific tools, itervetio protocols, fidelity criteria ad traiig plus supervisio of the providers, brief itervetios comprise priciples from differet techiques, icludig motivatioal iterviewig, but also advice ad cogitive behavioural therapy. A brief itervetio that icludes elemets of motivatioal iterviewig (or cogitive behavioural therapy) ca be delivered i a wide rage of settigs by a wide rage of healthcare ad social care professioals who have bee traied i the techique, icludig staff at schools, outreach workers ad staff at youth clubs, homeless services, health cetres, geeral practitioers surgeries, emergecy departmets, ad drug ad alcohol services, ad by police, probatio ad priso officers. Brief itervetios may be delivered to idividuals or to small groups, ad may also be self-admiistered. Delivery may be face-to-face, olie or by telephoe (icludig by text message). I Brief itervetios i emergecy departmets Brief itervetios i emergecy departmets emerged from the eed to couterbalace the sigificat impact of the harmful or hazardous use of drugs ad alcohol o healthcare costs, as well as to provide a adequate itervetio to o-treatmet-seekig idividuals (Bogeschutz et al., 2011). May commetators have poited out that effective emergecy departmet-based brief itervetios that address substace use have the potetial to have a large impact o public health, as: they offer a widow of opportuity i which to reach idividuals with urecogised ad umet substace use treatmet eeds who might otherwise ever receive ay form of assessmet, referral or itervetio (Logabaugh et al., 1995; Havard et al., 2012; Newto et al., 2013; Sajua et al., 2014; Ferri et al., 2015); they ca rapidly achieve importat objectives, such as detectig idividuals with high-risk ad depedet alcohol ad drug use, makig such idividuals aware of their coditio ad facilitatig access to specialty treatmet, thus improvig quality of care (Berstei et al., 2009); emergecy departmets are recogised as a settig i which the use of drugs, ad the harms associated with the use of drugs, icludig ew psychoactive substaces, could be moitored ad addressed (e.g. UNODC, 2013; Helader et al., 2014; Wood et al., 2014); the brevity of the itervetios meas that the traiig of staff does ot require a lot of ivestmet, thus miimisig the impact o healthcare budgets (Barrett et al., 2006; Havard et al., 2012; Drummod et al., 2014). 3 / 20

4 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess Emergecy departmets ad acute drug toxicity: results from a multisite Europea project The Europea Drug Emergecies Network (Euro-DEN) is a Europea Commissio-fuded project that brigs together 16 specialist cetres i 10 coutries (Demark, Estoia, Frace, Germay, Irelad, Norway, Polad, Spai, Switzerlad ad the UK) i Europe to collect data o the prevalece of use of recreatioal drugs ad ew psychoactive substaces, ad the associated acute harms. Cliical toxicologists ad poisos cetres frequetly report case series of acute recreatioal drug ad ew psychoactive substace toxicity; however, systematic data o this issue i Europe are limited. The Euro-DEN project has developed a miimum dataset o all acute recreatioal drug/ew psychoactive substace toxicity presetatios to emergecy departmets i these setiel cetres. Data from the first 4 moths (October 2013 Jauary 2014) of the 1-year data collectio period showed that there were presetatios with acute drug toxicity to emergecy departmets i 13 (81.2 %) of the 16 cetres, i 8 of the 10 participatig coutries, the majority of which were related to the use of classical recreatioal drugs. Most of the cases (743; 57.6 %) ivolved the use of oe drug; 357 (27.6 %) ivolved two drugs; 133 (10.3 %) ivolved three drugs; ad 57 cases (4.1 %) ivolved the use of four or more drugs. Alcohol was co-igested i 532 (41.2 %) cases ad ot recorded i 450 (34.9 %) cases. The most commo drugs were heroi (315 cases; 24.4 %), cocaie (228 cases; 17.7 %), gamma-hydroxybutyrate (GHB)/gammabutyrolactoe (GBL) (211 cases; 16.4 %), caabis (205 cases; 15.9 %), amphetamie (175 cases, 13.6 %), MDMA (100 cases, 7.8 %), cloazepam (85 cases, 6.6 %), mephedroe (60 cases, 4.7 %), uspecified bezodiazepie (59 cases, 4.6 %) ad methadoe (56 cases, 4.3 %). There were 126 presetatios (9.8 %) ivolvig the use of ew psychoactive substaces (UK, 94 cases; Polad, 18 cases; Germay, 10 cases; Spai, 2 cases; Norway, 1 case; Switzerlad, 1 case). Source: Aual Meetig of the North America Cogress of Cliical Toxicology (NACCT) (2014) I Why this review? The effectiveess of brief itervetios with regard to alcohol misuse is well documeted (see box o p. 5); however, there is less iformatio i relatio to brief itervetios that address drug use. Moreover, the added value of brief itervetios i emergecy departmet settigs has bee extesively discussed, ad several commetators have stressed the eed for more research. For example: The emergecy departmet (ED) appears to be a particularly promisig settig i which to idetify ad egage problematic drug users. Relatively high rates of psychoactive substace use disorders have bee foud i EDs, exceedig that foud i primary care settigs. This has led cliicias ad researchers to argue for the developmet of more effective methods of screeig ad case fidig, brief itervetios, ad referral to appropriate specialty treatmet, as well as likage betwee substace abuse services ad geeral medical care, for idividuals usig illicit drugs who are see i EDs ad trauma ceters. (Bogeschutz et al., 2011, p. 417) Further research is eeded to determie if ED-based [alcohol] itervetios ca be successful for the reductio or elimiatio of other types of drug misuse. (Youmas et al., 2010, p. 44) The purpose of this review is to gather ad assess the existig evidece o the effectiveess of usig brief itervetios i the cotext of substace use, i a emergecy departmet settig, to idetify idividuals with drug problems, support behavioural chage ad improve referrals to specialised treatmet cetres. 4 / 20

5 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess Brief itervetios for harmful alcohol use i primary care settigs There are umerous reviews, studies ad commetaries o brief itervetios for alcohol use, especially i primary care settigs; a example of such a brief itervetio is show i Figure 1. Primary care settigs are, i fact, cosidered to be a ideal settig i which to coduct these itervetios because it is reported that betwee 22 ad 70 % of patiets use primary care facilities after a alcohol-related ijury (e.g. D Oofrio ad Degutis, 2002; Patto, 2012; Wojar ad Jakubczyk, 2014). Overall, the available evidece poits towards a positive effect of brief itervetios, especially with regard to alcohol-related behavioural outcomes. A recet Cochrae review assessed the effectiveess of brief itervetios i heavy alcohol users admitted to hospital wards (McQuee et al., 2011). The aalysis of 14 radomised cotrolled trials ad cotrolled cliical trials ivolvig idividuals, maily male adults (16 years or older), idicates the potetial beefits of brief itervetios. Patiets i brief itervetio groups showed a greater reductio i alcohol cosumptio tha those i cotrol groups at the 6-moth ad 9-moth follow-ups, although this was ot maitaied at oe year. I additio, effects were evidet i terms of the reductio i death rates after 6 moths (RR (*) 0.42, 95 % cofidece iterval (CI) 0.19 to 0.94) ad oe year (RR 0.60, 95 % CI 0.40 to 0.91). These results cofirmed the fidigs of a earlier systematic review (Kaer et al., 2007) that evaluated brief itervetios for alcohol users i primary care settigs. A total of 29 cotrolled trials from various coutries were idetified i geeral practice (24 trials) or i emergecy settigs (five trials), ad the meta-aalysis showed that participats i the itervetio group had lower alcohol cosumptio tha those i the cotrol group after follow-ups of 1 year or more (mea differece: 38 g/week, 95 % CI 54 to 23 g/week). Iterestigly, the authors also foud that a loger period of cousellig had little additioal beefit. However, as O Doell et al. (2014) suggest, there is still a lack of uderstadig about the active compoets of such itervetios, ad cautio is eeded whe plaig a wider roll-out. Ideed, the effectiveess of alcohol-related brief itervetios is ot overwhelmigly supported by the evidece from all sample populatios ad settigs. For example, studies have typically targeted maily males ad are ot ecessarily applicable to wome; i additio, may do ot take a log-term perspective or the fidigs may ot be geeralisable if the focus of the study is o substaces other tha alcohol. Relevat recet reviews ad commetaries iclude those by Carey ad Myers (2012), Emme et al. (2004), Foxcroft et al. (2014), Gates et al. (2009), Heather (2011), Kaer et al. (2007), O Doell et al. (2013), McCormick et al. (2010), Smedslud et al. (2011) ad Wachtel ad Staiford (2010). (*) RR refers to relative risk (or risk ratio). This compares the ratio of the risk of disease (or death) amog people who are exposed to the risk factor, to the risk amog people who are uexposed. Alteratively, relative risk is defied as the ratio of the cumulative icidece rate amog those exposed to the rate amog those ot exposed. To estimate a relative risk, you eed a cohort study, from which icidece ca be calculated. A RR of 1.0 meas that the two icidece rates are equal, so the factor has o effect. A RR of 2 would idicate that the exposed people are twice as likely to get the disease; a RR of 0.5 meas they are half as likely, so the factor has protected them from the disease. 5 / 20

6 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess FIGURE 1 How to coduct a brief itervetio for alcohol disorders Feedback Brief Itervetio Traiig Notes Oriet the Patiet Idetify yourself ad explai your role o the trauma team. Get permissio, explicit or implicit, from the patiet to talk together for a few miutes. Explai the purpose of this discussio is to 1) give them iformatio about health risks that may be related to their drikig, 2) get their opiios about their drikig, ad 3) discuss what, if aythig, they wat to chage about their drikig. 0Rage: The umber of driks people have o a sigle occasio varies a great deal, from othig to more tha 10 driks. 0Ad we kow that havig too may driks at oe time ca alter judgmet ad reactio times. 0Normal: Most drikers i the Uited States have fewer tha 2 ( ) or 3 ( ) driks o a sigle occasio. 0Give Bige Questios results. "You drak more tha that times last moth, icreasig your risk for health problems." 0 Elicit the patiet s reactio. "What do you make of that?" Usig Bige Questio 0Rage: AUDIT scores ca rage from 0 (o-drikers) to 40 (probably physically depedet o alcohol). 0AUDIT has bee give to thousads of patiets i medical settigs, so you ca compare your score with theirs. 0Normal AUDIT scores are 0 7, which represet low-risk drikig. About half of the U.S. populatio does't drik. 0Give patiets their AUDIT score. "Your score of meas you are (at risk or high risk), puttig you i dager of health problems." 0 Elicit the patiet s reactio. "What do you make of that?" Usig AUDIT Liste for Chage Talk Goals a) Liste for pro-chage talk the patiet s cocers, problem recogitio, ad dowsides of drikig. b) Summarize the patiet s feeligs both for ad agaist curret drikig behavior. "O the oe had... O the other had..." Methods "What role do you thik alcohol played i your ijury?" Explore pros ad cos of drikig. "What do you like about drikig? What do you like less about drikig?" Is this patiet iterested i chage? "O a scale of 0 to 10 [with 0 idicatig ot importat, ot cofidet or ot ready], rate..." "... how importat it is for you to chage your drikig behavior?" "... your level of readiess to chage your drikig behavior?" "Why did you choose [the # stated] ad ot a lower umber?" If the patiet is iterested i chagig, use these questios. "What would it take to raise that umber?" "How cofidet are you that you ca chage your drikig behavior?" Reflect ad summarize throughout. Optios "Where does this leave you? Do you wat to quit, cut dow, or make o chage?" You could: Maage your drikig, Elimiate drikig from your life, Never drik ad drive, Cotiue Usual drikig patter, or Seek help. If appropriate, ask about a pla. "How will you do that? Who will help you? What might get i the way?" Close o Good Terms 0Summarize the patiet s statemets i favor of chage. 0Emphasize the patiet s stregths. What agreemet was reached? If You Give Advice Whe you have sigificat cocers or importat iformatio to impart, use this approach. It reduces the possibility of patiet resistace. Ask: Advise: Ask: Ask permissio to discuss your cocers. If permissio is grated, give iformatio or share your cocers. Ask for the patiet s reactio to your commets. April 2009: C Du, C Field, D Hugerford, S Shelleberger, J Macleod Always thak the patiet for speakig with you. Source: Ceters for Disease Cotrol ad Prevetio (2014) 6 / 20

7 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess I Methods We icluded systematic reviews or radomised cotrolled trials published i Eglish betwee 2000 ad 2014, focusig o brief itervetios for substace use i emergecy settigs. The defiitio of brief itervetio used was very broad (see Backgroud) ad substace use icluded the use of alcohol, tobacco or illicit drugs. All participats were icluded regardless of age, sex ad atioality. The iclusio criteria did ot specify ay particular outcome ad all outcomes were cosidered. aspects of three radomised cotrolled trials were reported i two publicatios each (Barrett et al., 2006, ad Crawford et al., 2004; Daeppe et al., 2007, 2010; Magill et al., 2009; Moti et al., 2007), resultig i a total of 16 primary studies. FIGURE 2 Flow-chart of icluded studies ad subdivisio by target substace Icluded studies I Search strategy A literature search was coducted usig a variety of search terms, icludig emergecy departmet/room/accidet ad emergecy, brief itervetio, drug, alcohol, tobacco, substace, systematic review, radomised (or radomized ) radom cotrolled/cotrol trial ad radomised (or radomized ) cotrolled/cotrol cliical trial. The academic databases available via EBSCO (e.g. MEDLINE ad PsycINFO) were searched. Searches were also coducted of the Cochrae Library, Drug ad Alcohol Fidigs, the EMCDDA website ad Medscape, ad of referece lists from relevat published studies. I Data collectio ad aalysis The author screeed all of the titles ad abstracts idetified through the search strategies. If a abstract suggested that a paper might be potetially relevat, the full text was read ad the study was excluded if the focus was ot o substace use, if the itervetio was ot a brief itervetio ad/or if the study was ot coducted i a emergecy settig. Studies that were ot radomised cotrolled trials were also excluded. Iformatio was collated from systematic reviews accordig to the characteristics of the review, the substace(s) it focused o ad the results/authors coclusios. Iformatio from the radomised cotrolled trials was collated accordig to the coutry i which they were coducted, the characteristics of the trials, the substace(s) they focused o, the samples, ad the measures used ad their outcomes. I Results After the results of the search were scrutiised to esure that they fitted the criteria for iclusio, ad those that did ot were elimiated, five systematic reviews ad 19 publicatios o radomised cotrolled trials ad radomised cotrolled cliical trials remaied (see Figure 2). However, differet alcohol =3 Systematic reviews =5 drugs =0 I Systematic reviews alcohol ad drugs =2 Radomised cotroled trials =16 alcohol =10 drugs =4 alcohol ad drugs =2 We icluded five systematic reviews, which aalysed a total of 78 studies. Three of the five systematic reviews focused solely o studies amog youg people, youth, college studets ad adolescets, while the rest icluded the geeral populatio. All five were cocered with alcohol, three with alcohol aloe ad two with alcohol ad drugs, although oe of the latter group cosidered seve studies, of which six were cocered with alcohol aloe. To varyig degrees, the five publicatios discussed the quality of the studies they reviewed, poitig out that the poor quality of some ad the methodological variatios amog them meat that firm coclusios about the effectiveess of brief itervetios i emergecy departmets could ot be draw. I Radomised cotrolled trials We foud publicatios usig the search methods described i Methods; however, differet aspects of three radomised cotrolled trials were reported i two publicatios each, resultig i a total of 16 studies ad a total sample size of idividuals. Te of the radomised cotrolled trials were based i the Uited States, two i the Uited Kigdom, two i Australia, oe i Polad ad oe i Switzerlad. Thus, oly 4 of the 16 radomised cotrolled trials were delivered i Europea 7 / 20

8 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess coutries, of which three were i Europea Uio Member States. The majority of studies ( = 10) ivestigated alcohol-related cases. Te focused o use defied as hazardous/risky/ harmful drikig, with oe specifically targetig the combiatio of alcohol ad peer violece, aother targetig alcohol ad risky drivig, ad a third examiig alcohol ad huma immuodeficiecy virus (HIV) risk behaviour. Four studies targeted oly drugs-related cases, with three focusig o drug use (whether recet, i the last 3 moths or i the last 30 days), while oe study icluded idividuals with substace use disorders i geeral. Two studies targeted both alcohol ad drug use. Three also looked ito the cost-effectiveess of the brief itervetio. I Heterogeeity The aalysis of the 16 trials revealed eormous variatio i every aspect of the trials. The participats, study desigs, types of itervetios ad outcome measures varied sigificatly amog studies makig compariso difficult, as outlied i the paragraphs below. this lack of log term follow up. Perhaps loger follow up to 2 years would demostrate reductios i cosequeces (Woolard et al., 2013, p. 1737). Of the 16 brief itervetios aalysed, seve icluded two follow-ups, five had oe follow-up, oe had three follow-ups ad oe had four follow-ups. Follow-ups were ot part of the study desig i two cases, ad i the other case follow-up was ogoig at the time of publicatio ad fial results were ot available. The brief itervetios that coducted follow-ups used a variety of methods: telephoe (used by six brief itervetios); telephoe, or mail (used by two brief itervetios); self-admiistratio usig a computer (used by two brief itervetios); face-to-face iterview (used by two brief itervetios); a combiatio of face-to-face iterview ad hair aalysis (used by oe brief itervetio); a combiatio of telephoe ad face-to-face iterview (used by oe brief itervetio); a combiatio of face-to-face questioaire ad scrutiy of records from hospitals, commuity health services ad social services, ad iformatio from the police ad courts (used by oe brief itervetio). Samples Idividually, the size of the differet studies varied from 45 to participats, ad their ages raged from 14 to over 66 years. Four studies focused exclusively o youg people aged 25 years or uder. A lack of effectiveess was reported by oe of the studies described here (Cuigham et al., 2012), but this was apparetly because of the selectio criteria used. Cuigham et al. (2012) reported o a brief itervetio that had several aims, oe of which was to reduce alcohol use. The itervetio was ieffective at achievig this, but this might have bee because of the low level of alcohol use (i.e. ay alcohol use, eve oe drik) required for study iclusio ad, as oted by recet reviews, positive effects of brief itervetios are typically foud oly with higher tha baselie cosumptio levels. Follow-up periods ad attritio rates The follow-up periods of the trials reported here varied from 1 to 12 moths, ad oe brief itervetio (cocered with chagig attitudes) coducted oly a sigle follow-up immediately after the itervetio. Woolard et al. (2013) are amog those who argue for loger follow-up periods as Oe year follow up may be too short a time to detect small but importat chages i egative cosequeces ad ijuries. Oe criticism of studies of BI [brief itervetios] has bee Attritio rates varied widely. At 12 moths, the lowest rate was 16 % ad the highest was 69 %. Overall, the highest rate was 69 % at 12 moths ad the lowest was 13 % at 3 moths. Attritio ca bias the results of studies i which the effectiveess of a itervetio is assessed. For example, i a publicatio that sythesised results from alcohol-related brief itervetios delivered i emergecy departmets, WHO (2009) commeted that as may as 47 % of patiets i the studies refused to participate. Refusal rates of this magitude ca itroduce sigificat bias (e.g., oly patiets who have less severe problems or are motivated to chage their drikig behaviour may agree to participate) (WHO, 2009, p. 166). Itervetios ad comparisos We observed that, after screeig, trial participats that met iclusio criteria were radomised to a diverse rage of itervetios. Nie trials had three itervetio arms, six trials had two ad oe trial had four. All participats were screeed ad/or their substace use was assessed, ad most of the o-itervetio groups received stadard care, a iformatio or referral leaflet, or feedback, which, i some cases, was tailored to the participat s assessmet results. The brief itervetios were delivered by a rage of methods. May icluded more tha oe method because they had more tha oe itervetio coditio ad differet methods were 8 / 20

9 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess employed for each itervetio coditio. The methods used were as follows: face-to-face delivery of the itervetio by a therapist, health worker, urse or doctor, which raged from a few miutes of advice to oe or more 30- to 60-miute sessios that icluded elemets of motivatioal iterviewig; delivery by a therapist assisted by a computer; delivery by a computer; a advice leaflet; persoalised feedback o screeig results; mail; text messagig. Most of the publicatios examied provided details of the traiig that the brief itervetio delivery staff had received, ad may used professioals that were already experieced i the techique. However, Daeppe et al. (2010) highlighted that, despite systematic traiig, there were importat differeces i cousellor performaces with regard to elicitig chage. These authors oted that Cousellors who had superior MI [motivatioal iterviewig] skills achieved better outcomes overall ad maitaied efficacy across all levels of patiet ability to chage, whereas cousellors with iferior MI skills were effective mostly with patiets who had higher levels of ability to chage (Daeppe et al., 2010, p. 612). Several of the brief itervetios that had more tha oe itervetio coditio used differet staff for each coditio. The iformatio o brief itervetio delivery staff was uclear i three of the publicatios o the 16 trials, but the delivery staff of the remaiig 13 trials comprised: traied research assistats (two trials); a computer oly ad therapists assisted by a computer (two trials); alcohol health workers (oe trial); urses (oe trial); emergecy departmet doctors ad urses, ad drug ad alcohol cousellors (oe trial); members of the research team, emergecy departmet staff ad alcohol health workers (oe trial); therapists with a Bachelor s or Master s degree (oe trial); traied research assistats ad urse cliicias (oe trial); traied iterveers with a Master s degree i the social work field or a related field (oe trial); professioal health educators (oe trial); traied iterveers with a PhD or Master s degree i a disciplie related to metal health (oe trial). Outcome measures The majority of the studies ( = 11) focused o behavioural outcomes ad substace use, ad used self-reported measuremets. Istrumets varied amog studies but the most commoly used were the Alcohol, Smokig ad Substace Ivolvemet Screeig Test (ASSIST), the Alcohol Use Disorders Idetificatio Test (AUDIT), a shorteed versio of the Addictio Severity Idex (ASI-Lite), the Quick Drikig Assessmet Iterview (form 90-AQ), the Driker Ivetory of Cosequeces, the Short Idex of Problems (DrIC, SIP) ad the Timelie Followback (TLFB) method. I five studies, the primary outcomes were the followig: alcohol-related cosequeces ad peer violece (Cuigham et al., 2012); attitudes ad itetios with regard to drugs ad HIV (Boar et al., 2014); uptake of HIV/ hepatitis C virus (HCV) screeig, ad attitudes ad beliefs towards HIV/HCV screeig (Merchat et al., 2014); risky drivig ad alcohol use (Sommers et al., 2013); ad attedace for substace use treatmet (Tait et al., 2005). I Effects of the itervetios A summary of the effects of the itervetios aalysed, i both systematic reviews ad experimetal studies, is preseted i Table 1. Systematic reviews Oe review (D Oofrio ad Degutis, 2002) cocluded that emergecy departmet-based screeig ad brief itervetios were effective at reducig repeated visits to the emergecy departmet. Nilse et al. (2008) also suggested a positive effect of brief itervetios o substace-related outcomes, albeit improvemets were also observed i cotrol groups. The remaiig three reviews stressed that the overall effectiveess of the studied itervetios was icoclusive: Newto et al. (2013) reported that the brief itervetios did ot reduce alcohol use sigificatly more tha other care; Yuma-Guerrero et al. (2012) observed that six of the seve studies that they reviewed showed positive effects o alcohol cosumptio ad/or its cosequeces for all participats regardless of study coditio; ad Taggart et al. (2013) cocluded that the seve studies they reviewed showed promise but had variable success. Implicitly or explicitly, the review authors suggested the eed for more research, developmet ad testig of brief itervetios i emergecy departmets, to establish their short- ad log-term effectiveess amog a variety of populatios. Two issues are particularly sigificat i this cotext: variatios i the study protocols, which make it difficult to compare differet studies, ad the poor quality of some of the studies reviewed. Yuma-Guerrero et al. (2012) 9 / 20

10 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess therefore call for future studies to have more cosistet methodology (eg, outcome measures, iclusio criteria) so the results ca support decisive coclusios ad policy chages (Yuma-Guerrero et al., 2012, p. 6). Radomised cotrolled trials/cliical trials Overall, the heterogeeity amog the 16 trials is clear (see Table 1). This makes comparisos difficult ad hampers defiitive coclusios about the effectiveess of brief itervetios. Six of the 16 trials (Moti et al., 2007; Walto et al., 2008; Magill et al., 2009; Cherpital et al., 2010; Havard et al., 2012; Suffoletto et al., 2012; Boar et al., 2014) reported that the brief itervetio had bee effective, although Boar et al. (2014) reported o a ogoig trial ad had o data o follow-ups at the time of publicatio. I two trials (Crawford et al., 2004; Barrett et al., 2006; Sommers et al., 2013), the brief itervetio had bee effective iitially, but the effect had dimiished by the 12-moth follow-up. Partial effectiveess, that is, measures of differet outcomes that showed differet degrees of effectiveess (icludig ieffectiveess), was reported by four trials (Tait et al., 2005; Daeppe et al., 2007, 2010; Cuigham et al., 2012; Woolard et al., 2013). The ieffectiveess of a brief itervetio was reported i four trials (Det et al., 2008; Drummod et al., 2014; Merchat et al., 2014; Woodruff et al., 2014). TABLE 1 Sythesis of trials Brief itervetio effectiveess Trials Referece Effective 6 Moti et al., 2007; Walto et al., 2008; Magill et al., 2009; Cherpital et al., 2010; Havard et al., 2012; Suffoletto et al., 2012; Boar et al., 2014 Effective but ot sustaied at follow-up 2 Crawford et al., 2004; Barrett et al., 2006; Sommers et al., 2013 Partial effectiveess 4 Tait et al., 2005; Daeppe et al., 2007, 2010; Cuigham et al., 2012; Woolard et al., 2013 Ieffective 4 Det et al., 2008; Drummod et al., 2014; Merchat et al., 2014; Woodruff et al., 2014 May studies of brief itervetios i emergecy departmets, icludig those discussed here, have reported improvemets i their cotrol groups, at least i the short term. Two explaatios have bee give for this. First, the implemetatio of brief itervetios addressig substace use i emergecy departmets ecessarily ivolves screeig ad/or assessmet before radomisatio to itervetio coditios, ad establishes the ature ad extet of participats substace use. This, especially if the assessmet is legthy, may motivate participats to chage their behaviour without further itervetio because their attetio will be draw to their substace use, ad, i may trials, feedback is give o the results, or the cotrol groups are give a advice leaflet. Secod, participats who perceive that the reaso for their emergecy departmet visit is related to their substace use may be motivated to chage their substace-usig behaviour. Overall, the evidece suggests a positive tred with regard to the use of brief itervetios i emergecy settigs to reduce substace use. There is also some tetative evidece poitig to the effectiveess of brief itervetios at reducig substace-related harms ad cosequeces, such as peer violece ad retur visits to the emergecy departmet, as well as facilitatig access to treatmet. However, because the studies are very heterogeeous, it would be premature to make defiitive statemets about the effectiveess of brief itervetios i emergecy departmet settigs. I Cost-effectiveess Three of the radomised cotrolled trials reported here iclude data o the cost-effectiveess of brief itervetios i emergecy departmets. Barrett et al. (2006), who reported a effective brief itervetio, cocluded that a face-to-face itervetio with a alcohol health worker was cost-effective. Specifically, the radomised cotrolled trial did ot show sigificat differeces i costs or effectiveess at 12-moth follow-up; however, a cost-effectiveess acceptability aalysis revealed that there is at least a 65 % probability that a referral to a alcohol health worker is more cost-effective tha the cotrol treatmet for all values that a decisio-maker would be willig to pay for a uit of reductio i alcohol cosumptio. I additio, the brevity of the treatmet, its low cost ad its short-term effectiveess add to its case for selectio. Similarly, Havard et al. (2012), i a study of a brief itervetio that was reported to be effective, cocluded that mailig persoalised feedback represets a good ecoomic ivestmet, especially relative to face-to-face emergecy departmet-based brief alcohol itervetios: the direct cost of providig mailed feedback was AUD 5.83 per patiet, a fractio of the equivalet per-patiet cost of USD associated with the face-to-face itervetio evaluated i the oly comparable study coducted (Havard et al., 2012, p. 328). However, Drummod et al. (2014), who reported that the brief itervetio that they studied was ieffective, recommeded, without providig detailed results of a cost-effectiveess aalysis, that screeig ad feedback is likely to be easier ad less expesive to implemet tha more complex itervetios (p. 9). 10 / 20

11 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess TABLE 2 Summary of the effects of the brief itervetios Authors ad date Systematic reviews D Oofrio ad Degutis (2002); = 41 Nilse et al. (2008); = 14 Newto et al. (2013); = 9 Taggart et al. (2013); = 7 Yuma-Guerrero et al. (2012); = 7 Effectiveess quick guide Outcome(s) Itervetios Results + ED visits Screeig ad BI for alcohol problems i the EDs + Alcohol use, risky drikig practices, harms/cosequeces ad ijury frequecy Alcohol use, drug use ad substace use-associated ijuries? Alcohol use ad alcohol-related harms/cosequeces? Alcohol use ad alcohol-related harms/cosequeces Radomised cotrolled trials/cliical trials 1.* Barrett et al. (2006); Uited Kigdom * Crawford et al. (2004); Uited Kigdom 2. Boar et al. (2014); USA 3. Cherpitel et al. (2010); Polad Emergecy care BAIs for ijury patiets Brief ED itervetios for youth who use alcohol ad other drugs ED itervetios for college drikers Screeig, BI ad referral for alcohol use i adolescets (+) Alcohol use Iformatio leaflet ad referral to a AHW who delivered a BI (lastig miutes); or a iformatio leaflet oly I the six ED-based studies, the itervetio led to fewer ED visits Of the 12 studies that compared pre- ad post-bi results, 11 observed a sigificat effect of the BI o at least some of the outcomes: alcohol itake, risky drikig practices, alcohol-related egative cosequeces ad ijury frequecy. BI patiets achieved greater reductios tha cotrol group patiets, although there was a tedecy for the cotrol group(s) to also show improvemets. Moreover, five studies failed to show sigificat differeces betwee the compared treatmet coditios Uiversal ad targeted BIs did ot sigificatly reduce alcohol use more tha other care. Clear beefits of usig ED-based BIs to reduce alcohol ad other drug use ad associated ijuries or high-risk behaviours remai icoclusive because of variatio i the methods used to assess outcomes ad poor study quality Each study foud reductios i alcohol itake patters or reductios i alcohol-related harm i the itervetio group, although some betwee-group differeces were ot statistically sigificat Four of the seve studies demostrated a sigificat itervetio effect, but o sigle itervetio reduced both alcohol cosumptio ad alcohol-related cosequeces. Moreover, six of the seve studies reviewed showed positive alcohol cosumptio ad/or cosequece effects for all participats regardless of itervetio coditio Six-moth follow-up: statistically sigificatly lower levels of drikig i those referred to a AHW Twelve-moth follow-up: observably lower drikig levels i those referred to a AHW (+) Six-moth follow-up: those referred to a AHW were cosumig a mea of 59.7 uits of alcohol per week compared with 83.1 uits i the iformatio leaflet oly group. This differece is statistically sigificat Twelve-moth follow-up: those referred to a AHW were drikig 57.2 uits per week compared with 70.8 uits i the iformatio-oly group (ot statistically sigificat) ad had a mea of 0.5 fewer visits to the ED over the followig 12 moths. Differeces i quality of life were ot foud + Attitudes ad itetios towards drugs ad HIV + Alcohol use ad alcohol-related harms/cosequeces Iterveer-delivered BI assisted by computer (30 miutes); 30-miute computerised BI; or ehaced usual care, icludig a 3-miute oral review of health resource brochures SBIRT (Screeig, Brief Itervetio ad Referral to Treatmet) Differeces betwee baselie ad immediately postitervetio were measured: compared with ehaced usual care, participats receivig the iterveer-delivered BI showed sigificat improvemets i cofidece ad itetios; computerised BI (delivered by computer aloe) patiets showed icreased importace, readiess, cofidece ad help-seekig; both iterveer-delivered BI (assisted by a computer) ad computerised BI groups showed a icreased likelihood of codom use with regular parters relative to the ehaced usual care group Three-moth follow-up: all three coditios showed a sigificat reductio i at-risk drikig ad umber of driks per drikig day (Cherpitel et al., 2009) Twelve-moth follow-up: sigificat declies betwee baselie ad 12 moths i secodary outcomes of the RAPS4 test (four questios to test for alcohol depedece), i the umber of drikig days per week ad the maximum umber of driks o a occasio (oly for the itervetio coditio) ad i egative cosequeces for both the assessmet ad itervetio coditios 11 / 20

12 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess Authors ad date 4. Cuigham et al. (2012); USA 5.* Daeppe et al. (2010); Switzerlad * Daeppe et al. (2007); Switzerlad 6. Det et al. (2008); Australia 7. Drummod et al. (2014); Uited Kigdom 8. Havard et al. (2012); Australia Effectiveess quick guide Outcome(s) Itervetios Results (+) Alcohol-related harms/cosequeces ad peer violece Alcohol use + Alcohol-related predictors of chage A BI delivered by a computer aloe or a BI delivered by a therapist assisted by a computer A BAI delivered by a traied research assistat; cotrol group with screeig ad assessmet; or cotrol group with screeig oly Six-moth follow-up: sigificat reductios i alcoholrelated cosequeces reported for both BI coditios Twelve-moth follow-up: the sigificat reductios i alcohol-related cosequeces reported i both BI groups at 6 moths were ot maitaied; the BIs did ot affect alcohol cosumptio: the BI delivered by computer aloe group, the BI delivered by a therapist assisted by a computer group ad the cotrol group did ot differ i alcohol-related variables; i compariso with the cotrol group, the therapistdelivered BI group showed sigificat reductios i peer violece Twelve-moth follow-up: the BAI had o ifluece o the mai alcohol use outcome. Across all three groups (BAI, cotrol group with screeig ad assessmet, cotrol group with screeig oly), there were similar proportios of low-risk drikers; there were similar reductios i drikig frequecy, quatity, bige drikig frequecy ad scores; ad there were similar umbers of days hospitalised ad umbers of medical cosults Alcohol use Twelve-moth follow-up: data show a impact resultig from the progressio of chage talk durig the course of the itervetio. Commuicatio characteristics of cousellors (i.e. MI-cosistet behaviours) ad patiets (e.g. a expressio of a ability to chage) durig the itervetio predicted chages i alcohol cosumptio 12 moths later Despite systematic traiig, importat differeces i cousellor performace were highlighted as cousellors with superior MI skills achieved better outcomes overall ad maitaied efficacy across all levels of patiets ability to chage, whereas cousellors with iferior MI skills were effective mostly oly with patiets who had higher levels of ability to chage Alcohol use No cousellig (stadard care); same-day BI by a emergecy urse or doctor; or motivatioal itervetio withi 1 week by off-site drug ad alcohol cousellors (by MI) AUDIT status A patiet iformatio leaflet; 5 miutes of brief advice; or referral to a AHW who provided 20 miutes of brief lifestyle cousellig + Alcohol use The itervetio group received persoalised feedback via mail regardig their alcohol cosumptio; the cotrol group received o feedback Three-moth follow-up: overall, maximum daily alcohol cosumptio decreased from a media of 13.5 stadard driks at erolmet to 9.25 driks at 3 moths, ad participats that received stadard care reported fewer driks tha those radomised to MI Six- ad 12-moth follow-ups: there was o differece betwee itervetio coditios for AUDIT status or ay other outcome measures. At moth 6, the odds ratio of beig AUDIT egative for the brief advice (5 miutes of advice) group compared with the patiet iformatio leaflet group was 1:103. The odds ratio for the brief lifestyle cousellig group (20 miutes of lifestyle cousellig by a AHW) compared with the patiet iformatio leaflet group was 1:247 Mailed persoalised feedback achieved a statistically sigificat reductio i the quatity/frequecy of alcohol cosumptio relative to screeig aloe. However, the effect was limited to patiets who reported alcohol cosumptio i the 6 hours prior to the oset of the coditio that led to the ED visit or who perceived that alcohol was a cotributig factor i the coditio for which they preseted 12 / 20

13 EMCDDA PAPERS I Emergecy departmet-based brief itervetios for idividuals with substace-related problems: a review of effectiveess Authors ad date 9.* Magill et al. (2009); USA * Moti et al. (2007); USA 10. Merchat et al. (2014); USA 11. Sommers et al. (2013); USA 12. Suffoletto et al. (2012); USA 13. Walto et al. (2008); USA Effectiveess quick guide Outcome(s) Itervetios Results + Herbal caabis use A oe-sessio motivatioal itervetio that icluded persoalised feedback; or a persoalised feedback report oly Six-moth follow-up: herbal caabis use declied from baselie for both groups (a oe-sessio motivatioal itervetio or oly a persoalised feedback report) Twelve-moth follow-up: oly motivatioal itervetio participats cotiued to reduce their use of herbal caabis. Reductios i the umber of days of use of herbal caabis with alcohol appeared to be primarily a fuctio of decreased alcohol use + Alcohol use Six-moth follow-up: motivatioal itervetio participats cosumed alcohol o fewer days, had fewer heavy drikig days ad cosumed fewer driks per week i the moth prior to follow-up tha feedback-oly patiets Twelve-moth follow-up: the effects at the 6-moth follow-up were maitaied. Twice as may motivatioal itervetio participats as feedback-oly participats had reliably reduced their volume of alcohol cosumptio Uptake of HIV/HCV test screeig ad attitudes ad beliefs towards HIV/HCV screeig (+) Risky drivig ad alcohol use A self-admiistered HIV/HCV risk assessmet aloe (cotrol arm), followed by a post-assessmet questioaire; or the assessmet plus a BI about drug misuse ad screeig for HIV/HCV (itervetio arm), followed by a postitervetio questioaire BI group (assessed at baselie ad received the BI); cotact cotrol group (assessed at baselie but received o itervetio); or o-cotact cotrol group (ot assessed at baselie, received o itervetio) + Alcohol use Weekly text-messagig feedback with goal settig (itervetio); weekly text-messagig drikig assessmets without feedback (assessmet); or cotrol (o itervetio) + Alcohol use ad alcohol-related predictors of chage Advice ad tailored booklet; advice ad geeric booklet; o advice ad tailored booklet; or o advice ad geeric booklet Uptake of combied rapid HIV/HCV screeig was early idetical for each study arm. There were o differeces betwee the BI ad cotrol study arms with regard to chages i beliefs about the value of combied HIV/HCV screeig, self-perceptio of HIV/HCV risk ad opiios about HIV/HCV screeig, post- vs. pre-hiv/hcv risk assessmet (with or without the BI) Six-, 9- ad 12-moth follow-ups: risky drivig ad hazardous drikig were sigificatly lower i the BI group tha i the cotact cotrol group with o itervetio, at 6 ad at 9 moths, but ot at 12 moths Three-moth follow-up: the itervetio group (weekly feedback with goal settig) were reported to have fewer heavy drikig days ad fewer driks per drikig day tha the other groups. The assessmet group icreased their drikig over the course of the study The attributio of ijury to alcohol-related factors was foud to be a importat moderator of chage, ad highlightig the alcohol ijury coectio i brief ED-based alcohol itervetios may augmet their effectiveess. Twelve-moth follow-up: overall, average weekly cosumptio, frequecy of heavy drikig ad egative cosequeces decreased over time. Compared with those who attributed their ijury to alcohol but did ot receive advice, those who attributed their ijury to alcohol ad did receive advice had sigificatly lower levels of average weekly alcohol cosumptio ad less frequet heavy drikig sessios, while this was ot sigificatly associated with a reductio i egative cosequeces Participats who reported higher levels of self-efficacy (i.e. those who were cofidet that they could cotrol their drikig) had lower weekly cosumptio levels ad fewer egative cosequeces, whereas those with higher readiess to chage had greater weekly cosumptio levels ad more egative cosequeces 13 / 20