Brief interventions to address
substance use among patients
presenting for emergency
services in Cape Town, South
Africa
Katherine Sorsdahl
Presentation Overview
1. Present the rationale for brief interventions in
emergency departments.
2. Present Project STRIVE and preliminary findings
Rational for Brief Interventions in
Emergency Departments
• Close to half of the individuals presenting with injuries at
emergency rooms in the province have been using AODs
(Plüddemann et al, 2004; Parry et al., 2004).
• Most alcohol-related injuries do not involve people who are
dependent on alcohol.
• Emergency departments are the ideal setting for screening
and brief intervention to occur, as they are able to take
advantage of the “teachable moment”.
What is a brief intervention
• A client-centred approach that focuses on changing
risk behaviour.
• Refers to any therapeutic or preventive consultation
of short duration undertaken by a health
professional who is not usually a specialist in
addiction treatment.
• The interventions may involve 1 to 5 sessions of 5 to
60 min.
Evidence for the Effectiveness of
Brief Interventions
• Studies conducted in primary care facilities have generally found SBIs to be
effective for reducing alcohol consumption and related harms (Pilowsky & Wu,
2012), while studies of SBIs conducted in ED settings have resulted in mixed
findings (Crawford et al., 2004; Daeppen et al., 2007).
• There is little research on the effectiveness of SBIs for reducing illicit drug use
among ED patients
• All these studies were conducted in developed country settings.
STRIVE
(Substance use and Trauma InterVEntion)
AIM: To address gaps in current services by testing
two brief, evidence-based interventions for risky
alcohol and drug use among adults at 3 emergency
departments.
Objectives of STRIVE
1.
To screen patients presenting at emergency services for
alcohol and other drug (AOD) use
2.
To administer one of two brief interventions (ASSIST-linked
Brief Intervention or MI modified problem solving therapy
(PST) to patients presenting at these emergency services.
3.
To compare the effectiveness of these two interventions
against a control group (psychoeducation only) on AOD
outcomes and the feasibility of implementing these
interventions in real-world emergency settings.
Study Sites
• This pilot program was implemented at three 24 hour
emergency room services: one in Elsies River and two in
Khayelitsha.
• These public emergency room services were purposively
selected by the Western Cape Department of Health as sites for
the program because of the high proportions of alcohol-related
homicides in these areas and the large numbers of patients
treated for AOD-related injuries
Training of Peer Counsellors
• All of the peer counsellors originated from the communities served by the
selected emergency services.
Intervention training included:
• 18 hours of training in motivational interviewing training.
• 12 hours (1.5 days) of a training program in PST
Other training Included:
(i) alcohol and illicit drugs and the risks associated with substance use, (ii)
using and scoring the ASSIST, (iii) ethics of research and importance of
maintaining confidentiality and reporting adverse events, (iv) the intervention
protocol, and (v) the process of referring patients for specialized care.
To ensure intervention fidelity, peer counsellors participated in biweekly
supervision and debriefing sessions.
Procedure
• Patients were approached for screening after they triaged
and while they were waiting for a consultation with the
attending doctor.
• To be eligible for the intervention program, participants had
to be at least 18 years of and screen at moderate or high
risk for substance-related problems using the Alcohol,
Smoking, and Substance Involvement Screening Test
(ASSIST).
• An interviewer-administered baseline questionnaire that
takes approximately 45 minutes to complete was then
administered to those patients who provided consent.
• Participants were followed up at 3 months
Interventions
Control Group:
• This group did not receive a brief intervention, but was provided with a
brochure providing information on the effects of alcohol and other drug use
MI Group: An ASSIST-Linked Brief Intervention (WHO):
• This manually guided session occurred directly after completion of the
screening interview and lasts between 20-30min.
PST Group:
• Given ASSIST-Linked Brief Intervention (like MI group)
• participants then returned for 4 follow-up sessions approx. 1 week
apart.
• The first of these follow-up sessions was about 60 minutes in duration
while the remaining sessions lasted between 35 and 45 minutes.
**Participants who screed high risk for substance-related problems were referred
to specialist substance treatment facilities for further treatment**
Outcome Measures
Primary outcome measure : Reduction in Substance Use (ASSIST)
Secondary outcomes included:
• Depression: (CES-D)
• Frequency of substance use related injury
• Frequency of physical and verbal violence
• Frequency of police interaction
• Problem Solving Skills (SPSI-R:SF)
Statistical Analysis
• Multiple imputation was used to deal with the issue of
missing data
• Baseline between-group differences in demographic data and
pre-treatment measures were analysed with one-way
ANOVAs and chi-square tests.
• Between-group changes in questionnaire scores were
analysed using univariate ANCOVAs, assigning pre-treatment
scores as the covariate. This approach is recommended as a
robust and reliable statistical strategy for analysing the results
of RCTs (Vickers, 2005b; Vickers, 2005a). Within-group
changes in questionnaires were analysed using pairedsamples t-tests.
Project STRIVE: Patient Flow Chart
Assessed for eligibility
(n =2736)
Excluded (n =2401)
FOLLOW-UP
ALLOCATION
ENROLMENT
Did not meet inclusion criteria (n =2205)
Refused to participate (n =104)
No telephone contact (n =88)
Did not return after seeing doctor (n=4)
Randomized (n =335)
Allocated to Control
Group
(n = 110)
Received allocated
intervention (n = 110)
Lost to follow up
(n = 44)
Unable to
locate/unavailable
ANALYSIS
Analyzed (n = 66)
Allocated to MI
intervention
(n =113)
Received allocated
intervention (n = 113)
Allocated to PST
intervention
(n =112)
Received allocated
intervention (n = 90)
Lost to follow up
(n = 43)
Unable to
locate/unavailable
Lost to follow up (n =44)
Discontinued intervention (n = 22)
Admitted to tertiary care (n=3)
Unable to locate/unavailable (19)
Analyzed (n = 70)
Analyzed (n =46)
Table 1: Baseline Characteristics of Participants
Age
Total (N=335)
Control (N=110)
MI (N= 113)
PST (112)
28 (18-75)
27 (18-75)
28 (18-65)
28.5 (18-61)
Gender
0.378
Male N (%)
218 (65.5)
68 (62.4)
71 (63.4)
79 (70.5)
Female N (%)
115 (34.5)
41 (37.6)
41 (36.6)
33 (29.5)
Black N (%)
195 (58.2)
58 (53.7)
68 (60.7)
69 (61.6)
Coloured N (%)
135 (40.7)
49 (45.4)
42 (37.5)
White/Asian N(%)
2 (0.6)
1 (0.9)
44 (39.30
0
Race
0.621
1 (0.9)
Marital Status
0.54
Single N (%)
272 (82.9)
91 (85.8)
89 (80.2)
92 (82.9(
Married or attached N (%)
56 (17.1)
14 (14.2)
22 (19.8)
19 (17.1)
Education
Did not finish high school N (%)
0.788
168 (50.1)
58 (52.7)
56 (49.6)
54 (48.2)
167 (49.9)
52 (47.30
57 (50.4)
58 (51.8)
Employed N (%)
147 (44.4)
45 (41.3)
46 (40.7)
56 (51.4)
Unemployed N (%)
184 (55.6)
64 (58.7)
67 (59.3)
53 (48.6)
242 (72.2)
78 (70.9)
82 (72.6)
82 (73.2)
93 (27.8)
32 (29.1)
31 (27.4)
30 (26.8)
Finished high school N (%)
Employment
0.395
0.202
Presented with Injury
Yes
No
Intent of Injury
0.925
0.465
Intentional N (%)
1876.5)5 (
49 (62.0)
43 (52.4)
46 (56.1)
Non-intentional (N (%)
57 (23.5)
20 (38.0)
39 (47.6)
36 (32.1)
Under the influence when injured
0.029*
Yes N (%)
197 (59.2)
70 (63.6)
72 (64.9)
57 (50.9)
No N (%)
136 (40.8)
40 (36.4)
39 (35.1)
55 (49.1)
Substance Use Involvement Score (Total) 19 (6-38)
19 (7-35)
19.75 (6.57)*
18 (6-35)
0.451
Alcohol (n=286)
19 (10-38)
19 (10-30)
20 (10-38)
17 (10-30)
0.107
Dagga (n=24)
20.5 (8-35)
21.5 (12-27)
18.09 (7.9)
19.9 (10.1)*
0.802
Cocaine (n=1)
26 (26-26)
n/a
n/a
n/a
Methamphatemine (n=20)
23.5 (6-35)
19 (7-35)
27 (17-32)
23.3 (9.98)*
0.436
Mandrax (n=4)
9.5 (6-23)
23 (23-23)
6 (6-13)
n/a
n/a
Results of ANCOVAs
Control Group
MI Group
Change
from
Baseline Baseline
Follow-up
PST Group
Change
from
Baseline
Baseline
Follow-up
Change from
Baseline
p-value
Baseline
Follow-up
19.18 (6.22)
12.17 (7.16) -7.01
20.33 (6.71) 12.31 (7.87) -8.01
19.20 (6.59) 7.4 (5.9)
21. 28 (5.91) -1.5
23.28 (7.84) 16.92 (7.85) -6.28
26.0 (6.85) 12.91 (5.93) -13.08
p<0.001
Primary Outcome
Total ASSIST
Secondary Outcomes
CES-D
(Depression)**
22.78 (5.27)
-11.8
p<0.001
SPSI-F:SF-Social
PPPO
2.04 (0.62)
2.20(0.66)
0.16
1.93 (0.65) 2.06 (0.65) 0.11
2.3 (0.74)
2.28 (0.63)
-0.01
0.639
NPO
1.25 (0.75)
1.14 (0.79)
-0.12
1.31 (0.73) 1.16 (0.75) -0.14
1.63 (0.94) 1.33 (0.94)
-0.28
0.991
RPS
1.96 (1.8)
2.23 (0.91)
0.26
1.95 (0.89) 2.08 (0.88) 0.12
2.48 (0.85) 2.61 (0.71)
-0.15
0.161
ICS
1.3 (0.83)
1.00 (0.85)
-0.24
1.27 (0.73) 1.05 (0.74) -0.22
1.39 (0.83) 0.79 (0.68)
-0.40
0.037
AS
1.15 (0.82)
1.08 (0.73)
-0.07
1.16 (0.71) 1.10 (0.73) -0.05
1.31 (0.78) 1.01 (0.78)
-0.24
0.514
0.77 (1.06)
0.76 (0.96)
-0.01
0.53 (0.94) 0.23 (0.46) -0.3
0.83 (1.34) 0.65 (1.2)
-0.17
0.004
Verbal Arguments
Group Changes in ASSIST scores
30
25
A 20
S
S
15
I
S
T 10
5
0
Baseline
Followup
Control Group
Baseline
Followup
MI Group
Baseline
Followup
PST Group
Discussion
•
It is not only feasible to screen large numbers of people presenting
for emergency services for possible inclusion in a substance use risk
reduction intervention, but that such an intervention program is
urgently needed among this population.
•
PST appears to be the most effective intervention for reducing
substance and depression among at risk patients in ED settings.
•
The data reported here also show no AOD use outcome differences
between the MI and control group.
•
The MI interventions significantly reduced verbal arguments among
participants, but did result in diminished odds of alcohol-related
injuries compared to the control group.
Acknowledgments
Thanks to the Provincial Government of the Western
Cape for funding and supporting the project!
SAVI for funding the preliminary qualitative work
Research Team: Bronwyn Myers, Tracey Naledi, Dan
Stein, Susan Cleary, & Joanne Corrigal