Screening and Intervention Among Undergraduates with Alcohol-Related Emergency Department Visits Erik Gunderson, MD Assistant Professor Department of Psychiatry and Neurobehavioral Sciences, Department of Medicine University of Virginia School of Medicine November 15, 2012
UVa Binge Alcohol Reduction Improvement in binge alcohol use, yet: Broad social norms campaign effective, but further reduction? UVa > national prevalence Substantial consequences persist Targeted screening & intervention potentially beneficial
Outline Definitions Screening, brief intervention, referral to treatment (SBIRT) Emergency department (ED) & collegiate SBIRT data ED current practices
Spectrum of Alcohol Use Saitz et al., 2005
Men At-Risk Drinking > 4 drinks per occasion > 14 drinks per week Women or > 65 years old > 3 drinks per occasion > 7 drinks per week 37% of US college students with per occasion binge alcohol use Dawson DA et al (2005). NIAAA. Helping Patients Who Drink too Much: a Clinician s Guide [NIAAA Web site]. http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf. SAMHSA (2011). Monitoring the Future. US Dept of Health and Human Services.
Defining the Standard Drink A standard drink = 14 g ethanol 12 oz of regular beer (5% alcohol) 5 oz of table wine (12% alcohol) 1.5 oz of hard liquor (40% alcohol, 80 proof) The average person metabolizes about 1 standard drink/hour 12 oz beer or cooler 8-9 oz malt liquor 5 oz table wine 3-4 oz fortified wine (such as sherry or port) 2-3 oz cordial, liqueur, or aperitif 1.5 oz brandy 1.5 oz spirits (a single jigger) (a single jigger of 80-proof gin, vodka, whiskey, etc.) shown straight and in a highball glass with ice to show level before adding mixer 12 oz 8.5 oz 5 oz 3.5 oz 2.5 oz 1.5 oz 1.5 oz Source: NIAAA. Bethesda, MD, 2004. NIH Publication No. 04-3769.
Abuse 1+ criteria in 12-months: 1. Failure to fulfill roles 2. Risky situations 3. Run-ins with law 4. Interpersonal problems Ø Never dependent on this drug
Dependence 3+ criteria in 12-months: 1. Tolerance 2. Withdrawal 3. Larger amounts 4. Desire/attempts to cut down 5. Time spent 6. Give up activities 7. Ongoing use despite problems
Outline ü Definitions Screening, brief intervention, referral to treatment (SBIRT) Emergency department (ED) & collegiate data ED current practices
What is SBIRT? A public health approach to the delivery of early intervention and treatment services for persons with and at risk of developing substance use disorders In contrast to the focus of specialized treatment, which is persons with more severe substance use Helping Patients Who Drink Too Much, NIAAA, 2005
SBIRT: Rationale >50% of health consequences of alcohol occur in risky and problem drinkers Prevention paradox Ø A large number of people at small risk contribute more cases than a smaller number who are individually at greater risk How to identify them and intervene?
SBIRT Components Screening quickly identify substance use severity, need for further assessment or treatment Brief intervention increases patient awareness of substance use and motivation to change Referral to treatment provides those needing more extensive management with access to specialty care
Commonly Used Screening Tools Alcohol NIAAA Screen & Assessment Alcohol Use Disorders Identification Test (AUDIT) CAGE Alcohol and Drugs Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) NIAAA, 2005. Helping Patients Who Drink Too Much
NIAAA single screening question Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages? How many times in the past year have you had 5 or more drinks in a day (men) 4 or more drinks in a day (women) 82% sensitive; 79% specific
What is a Brief Intervention?
Brief Intervention Duration: 30 seconds 4 sessions Continuum of care: Primary prevention specialized treatment Interventionist: non-specialists specialists Settings: opportunistic specialized Outcomes: targeted broad Style / modality: educational client centered Moyer et al., 2002
SBIRT Effectiveness alcohol and drug use risk of trauma % patients entering specialized treatment hospital days and ED visits Cost-effective Madras et al, Drug and Alcohol Dependence, 2009
Outcome Moderators BI effects tend to diminish across time Intervention intensity not related to outcome BI effectiveness greater for risky use or less severe alcohol problems Moyers, 2002; Wutzke, 2002
Outline ü Definitions ü Screening, brief intervention, referral to treatment (SBIRT) Emergency department (ED) & collegiate data ED current practices
Evidence Base: Emergency Settings ~50% injured individuals alcohol involvement Teachable moment BI conducted in emergency settings may: - Reduce re-injury rates by as much as 50% - Prevent one DWI arrest for every 9 BIs - Save 4x their cost in health care expenses American College of Surgeons mandates alcohol SBI for level I trauma centers Nilssen, 1994; Gentilello, 2005; Schermer, 2006
College Settings risky drinking & negative consequences Opportunistic settings: - Student health clinics - Emergency departments - Student organizations - Judicial systems Overall, collegiate alcohol SBIRT appears effective - Evidence mixed for mandated samples - ED data lacking Larimer, 2004; Schaus, 2009
Outline ü Definitions ü Screening, brief intervention, referral to treatment (SBIRT) ü Emergency department (ED) & collegiate data ED current practices
SBIRT Among Undergraduates with Alcohol-Related ED Visits Background Student Health is PCP for >90% students 2006: UVA ED/Student Health alcohol SBIRT collaboration NIAAA SBIRT implementation unknown, but anecdotally sporadic
SBIRT Among Undergraduates with Alcohol-Related ED Visits AIM Evaluate ED SBIRT among undergraduates with alcohol-related visits Methods Retrospective electronic medical record review Student Health tracks ED visits daily Alcohol-related visits between July 2011 - May 2012 Outcome: documented NIAAA SBIRT
Respondent Characteristics Demographics n = 222 Male 55% White 77% Age, mean years 20 Age < 21 73% Visit reasons Acute intoxication 64% Trauma 35% Seizure 2% Mood/anxiety problem 2%
Documented ED Alcohol Screening 100 90 80 70 % 60 50 40 30 20 10 0 Average Quantity Max Drinks Per Occasion DSM Criteria %
Documented ED Alcohol Intervention %
Assessment and Referral Alcohol diagnoses were low Ø 6% abuse Ø 1% dependence 10% referral to Student Health Ø Mostly general follow-up, not specifically for alcohol assessment intervention
Limitations & Methodological Considerations Documented practices may not reflect actual SBIRT delivery Single university hospital 2006 ED alcohol SBIRT initiative impact may have extinguished
Conclusion NIAAA-guided SBIRT underutilized in alcohol-related ED visits Missed opportunity for risky alcohol use identification and prevention Prospective ED SBIRT effectiveness data are needed for students
Future Research Directions Can an alcohol-related ED visit serve as a teachable moment for students? What is the optimal approach to screening and intervention? - Feasible - Effective - Generalizable
Acknowledgements James Turner, MD Jennifer Hettema, PhD James Forrest Calland, MD Robert O Connor, MD, PhD Patrick Tolan, PhD Susan Bruce, MEd Krysten Grymes, BA Thomas Albert, BA UVA Youth Nex Center to Promote Effective Youth Development