Journal of Addictions Nursing, 17:7982, 2006 Copyright c International Nurses Society on Addictions ISSN: 1088-4602 print / 1548-7148 online

DOI: 10.1080/10884600600724121

GUEST EDITORIAL

Screening and Brief Intervention for Alcohol Problems in the Emergency Room: Is There a Role for Nursing?
Cheryl J. Cherpitel, RN, Dr. PH
Associate Director, National Alcohol Research Center, and Senior Scientist, Public Health Institute, Alcohol Research Group, Berkeley, Ca

Trauma is a signicant problem in many countries, and is the fth leading cause of death in the U.S. Trauma accounts for an even higher rate of morbidity, with the rate of serious injury estimated to be over 300 times the mortality rate, and about one in every three individuals treated in the emergency room (ER) is treated for an injury (Vyrostek, et al., 2004). Globally, alcohol is among the most important risk factors for both disability and mortality, with injuries constituting 46% of the deaths attributable to alcohol (and 60% in the Americas) and 42% of the Disability-Adjusted Life Years (DALYs) (Rehm, et al., 2004; Room, et al., 2005). In the U.S. alcohol misuse is estimated to be responsible for more than 100,000 deaths annually, and has been identied as the leading cause of morbidity (Secretary of Health and Human Services, 2000). Much of the data linking alcohol with injuries have come from studies carried out in the ER (reviewed in Cherpitel & Driggers, 2005), and have shown that not only are injured patients, compared to the non-injured, more likely to be both positive for blood alcohol concentration (BAC) and legally intoxicated at the time of ER arrival and to report drinking prior to the event, 79

but non-injured patients are also more likely to report frequent, heavy and problem drinking compared to those in the general population from which they come. ER studies of both injured and non-injured patients have found high rates of prior alcoholrelated injuries, and an alcohol-related ER admission for injury has been found to be predictive of future injury admission. Injury recidivists have also been found signicantly more likely to test positive for alcohol and to have a higher BAC at the time of readmission compared with other injury patients (Rivara, et al., 1993). These data underscore the importance of the ER as a point of screening and brief intervention for at-risk and dependent drinking to reduce subsequent alcohol-related ER visits and associated costs and to improve quality of life. While the prevalence of heavy and problem drinking is high in the ER, national surveys in the U.S. have repeatedly found that almost half of the trauma centers do not routinely obtain admitting blood alcohol on patients (Soderstrom, et al., 1994), and concerns with legal issues and reimbursement from health insurance have been cited as major constraints, among others (Gentilello et al., 2005). A, heretofore, relatively little-known law in the U.S., the Uniform Accident and Sickness Policy Provision Law (UPPL), permits third-party payers to deny reimbursement for medical services for patients who are alcohol positive at the time of injury. This law has been in effect since 1947, and while it has been repealed by the National Association of Insurance Commissioners, it is, unfortunately, still on the books in the majority of states (Chezem, 2004/2005). Additionally, estimated BAC at the time of ER admission often fails to detect the majority of heavy drinkers or those with alcohol use disorders. One study found that while two-thirds of BAC positive trauma patients met standard diagnostic criteria for alcohol dependence, almost half of the BAC negative patients also met diagnostic criteria (Soderstrom, et al., 1994) while another study found that a positive BAC identied only 20% of those with current alcohol use disorder (Cherpitel, 1995a). Despite the poor performance of BAC status as a clinically useful predictor of the presence of current harmful drinking or alcohol dependence in the ER setting, until recently little research has been conducted evaluating the performance of screening

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instruments that would be considered especially suitable for use (in relation to brevity, ease of use and scoring) in this setting. One study examined the performance of a number of brief screening instruments for current alcohol use disorders (including the CAGE and the AUDIT, two of the most commonly used instruments) in an ER sample, and identied the optimal ve-item subset, subsequently called the Rapid Alcohol Problems Screen (RAPS), which out-performed other instruments (Cherpitel, 1995b). The CAGE (Ewing, 1984), a four-item instrument that has achieved widespread popularity for use in clinical settings, was developed and tested on known male alcoholics on a lifetime basis, and its performance has not been as good for current harmful drinking or alcohol abuse in primary care settings (Cherpitel, 1995a). Although the AUDIT (Saunders, et al., 1993) was specically developed to identify current problem drinking in primary care settings, its performance has not been consistently high across gender or cultural subgroups (Cherpitel, 1995a). The RAPS instrument was rened to the following four items (RAPS4), and subsequently tested in a number of other ER settings where it was found to perform consistently well across gender and ethnic subgroups (Cherpitel, 2005): 1) During the last year have you had a feeling of guilt or remorse after drinking? ( R emorse); 2) During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? ( Amnesia, also called blackouts); 3) During the last year have you failed to do what was normally expected from you because of drinking? ( P erform); 4) Do you sometime take a drink in the morning when you rst get up? ( S tarter, also called eye-opener). A positive response on any one of the four questions is considered positive on the RAPS4. None of the brief screening instruments, including the RAPS4, has been found to perform as well for identifying those meeting criteria for harmful drinking or alcohol abuse as for those meeting criteria for alcohol dependence. Consequently, two quantityfrequency items were added to the RAPS4, which were found to increase sensitivity for abuse and harmful while maintaining good specicity (Cherpitel, 2002; Cherpitel & Bazargan, 2003). This instrument, the RAPS4-QF, consists of the RAPS4 items plus the following: During the last year have you had 5 or more drinks on at least one occasion? ( Q uantity); During the last year do you drink as often as once a month? ( F requency). A positive response on any one of the four RAPS4 items and/or both of the quantity-frequency items is considered positive on the RAPS4-QF. Most individuals meeting criteria for heavy/problem at risk drinking or those with alcohol use disorders do not seek specialized treatment. Brief interventions have been found useful in motivating dependent drinkers to seek specialized treatment and to stimulate motivation to change drinking behavior and utilize referral resources (reviewed in Ballesteros, 2004). The rationale for brief intervention in the ER for those with alcohol-involved injuries as well as patients with alcohol-related medical conditions is compelling. An intervention that can successfully link drinking to the reason for the ER visit, possibly in combination

with other hazardous behaviors (e.g., risk taking in the case of injury), may be sufcient to tip decisional balance in favor of reducing alcohol consumption and future alcohol-related negative consequences (Gentilello, et al., 1999). Some ER studies have examined the causal link established by the patient between his drinking and the event which brought him to the ER, and this perceived role of alcohol in the injury event may also be important for tailoring effective intervention strategies. Such attributions, for example, may be predictive of the extent of readiness for change (Miller et al., 1993) with closer attributional links between alcohol and injury associated with higher motivation to change drinking behavior. Motivation to change, based on aversiveness of the injury and perception of the degree of alcohol involvement, has been found to be predictive of readiness to change (Longabaugh, et al., 1995), which in turn has been found to be positively correlated with effectiveness of the brief intervention. Thus interventions may be improved when the locus of patient motivation is taken into account. Additionally, the ER visit may also provide a window of opportunity for change in drinking behaviors for those who may be alcohol negative at the time of the ER visit and/or presenting to the ER with conditions unrelated to alcohol consumption, but who have a history of at-risk or dependent drinking. Studies in the published literature reporting outcomes of brief intervention among adult ER patients are still relatively small in number, however, compared to those reporting ndings from primary care settings (reviewed in DOnofrio & Degutis, 2004/2005) and some of these studies were restricted to ER patients who were subsequently hospitalized. While those studies have generally found brief intervention to be effective for a reduction in drinking and alcohol-related problems at follow-up compared to controls, studies of non-hospitalized ER patients have reported more mixed results, and vary in relation to a number of factors, including whether: 1) the brief intervention was applied in the ER or in the hospital; 2) the study was restricted to injured patients (and perhaps only one injury type) or also included non-injured patients; 3) the intervention was applied across the spectrum of drinking behaviors; or 4) a control group was included. Findings have also varied in relation to length of follow-up and follow-up rates. Additionally, when control groups undergo assessment, it has been difcult to disentangle whether improvement among controls is due to regression to the mean (which occurs when a patient is identied at a high point in his or her drinking career which then subsequently tapers off), or whether the assessment, itself, served as a minimal intervention resulting in improved outcomes. While the ER appears to hold a great deal of promise as a site for identication of those with alcohol-related problems who may benet from a brief intervention or referral for problem drinking, screening and/or brief intervention have generally not been undertaken in this setting. Most practitioners in the ER, physicians and nurses alike, are not familiar with screening instruments or know how to administer them. Protocols for best practices are lacking in this regard, as practitioners believe

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there is no time or need for screening. Certainly these attitudes and practices in identifying patients with alcohol use disorders result in a reluctance to intervene even if such patients are identied. The adoption of screening, brief intervention and referral to treatment (SBIRT) in the ER by emergency service providers to reduce alcohol-related ER visits is one of the objectives of Healthy People 2010 (U.S. Department of Health and Human Services, 2000), and SBIRT has been recently mandated, as well, by the American College of Surgeons Committee on Trauma, to begin in 2007. A form of brief motivational intervention, the brief negotiated interview (BNI), has been in place at Boston City Hospital since 1994 with observed reductions in both alcohol use and negative consequences of drinking (Bernstein, et al., 1997). A recent study has developed methods to effectively implement a model of SBIRT into ER practice in an attempt to overcome often cited barriers to implementation. This study, which was recently conducted at 14 academic-based ERs (Emergency Medicine Research Collaborative (SBIRT), 2004), is the rst multi-site collaborative study of brief intervention in the ER, and included development of a SBIRT curriculum and training of ER practitioners, including physicians, nurses, physician assistants and social workers (Bernstein & Bernstein, 2005). Analysis of brief intervention outcome data found signicant decreases in both the typical number of drinks and the maximum number of drinks consumed per occasion at 3-month follow-up for both the intervention and control group. Although signicant differences were also found between the intervention and control group at three-month follow-up, differences were small (4.1 vs. 4.7, respectively for the typical number of drinks consumed, and 6.5 vs. 7.2 for the maximum number of drinks) (Aseltine, 2005a). Signicant decreases in both the usual and maximum number of drinks continued to be found at six-month followup (Aseltine, 2005b). No differences were found between the intervention and control group among dependent drinkers, however, at either three-month or six-month follow-up. Referral to subsequent treatment is a particularly important part of SBIRT for dependent drinkers, and failure to nd differences was likely due largely to the fact that those in the intervention group were not able to access alcohol treatment following brief intervention and referral in the ER at any higher rate than those in the control group (13% of both groups). Because ER practitioners miss many opportunities for SBIRT due to a number of factors including lack of knowledge and skills, and recent evidence suggests that ER providers with training and institutional support can use brief motivational intervention with at-risk or dependent drinking, the SBIRT study also included development of a SBIRT curriculum for use in the ER setting, and training of ER practitioners across the 14 sites to facilitate adoption of SBIRT as a standard of care in the ER in addressing the following: 1) knowledge base in addiction, 2) exposure to standardized clinical screening instruments, 3) exposure to and skill in motivational interviewing, and 4) familiarity with referral resources.

Practitioners, including nurses, undergoing training (n = 401) were administered pre- and post-training questionnaires. Signicant but only modest changes were found at twelve months following training compared to baseline: a 5% increase in believing it is their responsibility to screen and intervene, a 3% increase in believing that barriers to SBIRT were less troublesome and that SBIRT would make a difference, an 8% increase in condence in their ability to perform SBIRT, and an 11% increase in actually providing SBIRT (Bernstein & Bernstein, 2005). Unfortunately, despite what could be considered a successful study, these gures do not seem overly encouraging in suggesting that such intensive training will result in substantial long-term changes in attitudes and practice. Although ndings from studies of screening and brief intervention in the ER have been mixed, as noted earlier, and not all of the evidence is yet in regarding the efcacy of SBIRT in the ER, nurses, nevertheless, are in an important and unique position to institute SBIRT in the ER setting, and nursing seems especially suited to assume this role. Although ofcial recognition and support for SBIRT is important, and SBIRT training in effecting provider change has been demonstrated to some degree, the likelihood of routinely implementing SBIRT in ERs seems highly unlikely unless the prevailing attitudes among emergency service nurses and other practitioners can be overcome. REFERENCES
Aseltine, R. (2005a). The impact of SBIRT on Emergency Department patients alcohol use. Society for Academic Emergency Medicine (SAEM), New York, NY, May 23. Aseltine, R. (2005b). The impact of SBIRT on ED patients alcohol use. International Conference on Alcohol and Injuries: New Knowledge from Emergency Room Studies, Berkeley, CA, October 36. Ballesteros, J. (2004). Brief interventions for hazardous drinkers delivered in pimary care are equally effective in men and women. Addiction, 99, 103108. Bernstein, E., & Bernstein, J. (2005). Alcohol screening, brief intervention, and referral to treatment: an evidence-based curriculum for academic ED providers. International Conference on Alcohol and Injuries: New Knowledge from Emergency Room Studies, Berkeley, CA, October 36. Bernstein, E., Bernstein, J., & Levenson, S. (1997). Project ASSERT: an EDbased intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine, 30, 181189. Cherpitel, C. J. (1995a). Screening for alcohol problems in the emergency department. Annals of Emergency Medicine, 26(2), 158166. Cherpitel, C. J. (1995b). Screening for alcohol problems in the emergency room: A rapid alcohol problems screen. Drug and Alcohol Dependence, 40, 133 137. Cherpitel, C. J. (2002). Screening for alcohol problems in the U.S. general population: comparison of the CAGE, and RAPS4, and RAPS4-QF by gender, ethnicity, and services utilization. Alcoholism: Clinical & Experimental Research, 26(11), 16861691. Cherpitel, C. J. (2005). The Rapid Alcohol Problems Screen: methods and application. In V. R. Preedy & R. R. Watson (Eds.), Comprehensive Handbook of Alcohol Related Pathology, (Vol. 3, Selective Methods Used in Alcohol Research, pp. 14151427). London, UK: Academic Press/Elsevier Science. Cherpitel, C. J., & Bazargan, S. (2003). Screening for alcohol problems: comparison of the AUDIT, RAPS4, and RAPS4-QF among Black and Hispanic patients in an inner city emergency department. Drug and Alcohol Dependence, 71, 275280.

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