ALCOHOL AND DRUG USE:
Addressing a Prolific Problem
in Healthcare
David C. Maynard, MA, LPCC, NCC
Emergency and Trauma Services
Chandler Medical Center
American College of Surgeons
• Committee On Trauma (ACS)
– Mandate effective in 2006
– Level Two Trauma Centers: Screen for alcohol
– Level One Trauma Centers (LOTC):
Screen and provide brief interventions for alcohol
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American College of Surgeons
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Education for prevention assume motivation
High-risk individuals are often resistant
Trauma centers can use the teachable moment
Result: effective injury prevention strategy
Example: alcohol counseling for problem
drinkers
American College of Surgeons
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Alcohol is a significant factor in injury
Must identify problem drinkers
LOTC must provide intervention
Reduced trauma recidivism by 50%
American College of Surgeons (ACS) Committee on Trauma. Resources for optimal care of the injured patient 2006. ACS:
Chicago (2006).
Alcohol and Trauma
• Up to 69% meet diagnostic criteria for
alcohol abuse or dependence.
• 46% of patients admitted with a blood
alcohol level (BAL) of zero also meet
aforementioned criteria.
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Jurkovich GJ, Rivara FP, Gurney JG, Seguin D, Fligner CL, Copass M. Effects of alcohol intoxication on the initial assessment
of trauma patients. Ann Emerg Med. 1992; 21:704-708.
Alcohol and Trauma
• 40 - 50% of patients admitted to a LOTC
have positive BAL on admission
• Mean BAL = 187 mg/dL
• Most prevalent chronic illness in trauma
patients.
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Rivara FP, Jurkovich GJ, Gurney JG, et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg.
1993; 128:907-913.
Brief Intervention Efficacy
• Long established history
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Chick, J.; Lloyd, G.; and Crombie, E. Counseling problem drinkers in medical wards: A controlled study. British
Medical Journal 290:965-967, 1985.
Kristenson, H.; Ohlin, H.; Hulten-Nosslin, B.; Trell, E.; and Hood, B. Identification and intervention of heavy
drinking in middle-aged men: Results and follow-up of 24-60 months of long-term study with randomized controls.
Alcoholism: Clinical and Experimental Research 7(2):203-209, 1983.
Persson, J., and Magnusson, P.H. Early intervention in patients with excessive consumption of alcohol: A
controlled study. Alcohol 6(5):403-408, 1989.
• Efficacy
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Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review. Addiction 88:315-336,
1993.
Kahn, M.; Wilson, L.; and Becker, L. Effectiveness of physician-based interventions with problem drinkers: A
review. Canadian Medical Association Journal 152(6):851-859, 1995.
Wilk, A.I.; Jensen, N.M.; and Havighurst, T.C. Meta-analysis of randomized control trials addressing brief
interventions in heavy alcohol drinkers. Journal of General Internal Medicine 12(5):274-283, 1997.
Alcohol Intervention
• Most patients are ready to change use.
• 86% report at least one binge-drinking
episode in the past month.
– Mean of 3.4 days of binge-drinking/month.
• 84% consider changing their drinking.
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Apodaca, TR and Schermer, CR. Readiness to Change Alcohol Use after Trauma. Journal of Trauma. 2003; 54(5), May
2003, 990-994.
Alcohol Intervention
• 94% of patients believes someone from the
trauma team should address their alcohol use.
• Barriers exist to the incorporation of routine
alcohol screening and intervention in trauma
centers.
• Treatment may need to be culturally adapted.
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Schermer, CR; Bloomfield, LA; Lu, SW; Demarest, GB. Trauma Patient Willingness to Participate in Alcohol Screening and
Intervention. Journal of Trauma. 2003; 54(4), April 2003, 701-706.
Alcohol Intervention
• 2524 patients were screened
– 1153 screened positive (46%)
• 366 randomized to intervention group (IG)
• 396 to control group (CG)
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Alcohol Intervention
• At 12 months:
– IG decrease alcohol use by 21.8 ± 3.7
drinks/wk;
– CG decrease was 6.7 ± 5.8 (p< 0.03)
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Alcohol Intervention
• Most apparent reduction in patients with mild
to moderate alcohol problems (SMAST score
3 to 8)
– IG had 21.6 ± 4.2 fewer drinks per week
– CG had 2.3 ± 8.3 drinks per week (p< 0.01)
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Alcohol Intervention
• IG had 47% reduction in injuries requiring
either emergency department or trauma
center admission.
– (hazard ratio 0.53, 95% confidence interval 0.26
to 1.07, p<0.07)
• IG had 48% reduction in injuries requiring
hospital admission (3 years follow-up).
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Gentilello, LM; Rivara, FP, Donovan, DM; Jurkovich, JG; et al. Alcohol Interventions in a Trauma Center as a Means of
Reducing the Risk of Injury Recurrence. Annals of Surgery. 1999. 230(4), 473–483.
Protocol for Patient Identification
• Collection of biological screens
– Glasgow Comma Score <15
• Nursing Admission Assessment
• Clinical Suspicion
– “Chemical Dependency” consult
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Elements of a Brief Intervention
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Never confront
Establish rapport
Communicate risk
Identify pt goals
Provide information
Resolve ambivalence
Develop discrepancy
Use Open-ended
questions
• Build motivation for
change
• Elicit commitment to
change
• Reflective listening
statements
• Demonstrate respect
and empathy
• Use “I” statements
• Choose strategies based on
client readiness
• Initiate thinking about
change in problem
behavior
FRAMES
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Feedback is given about personal risk
Responsibility to change is on the patient
Advice to change
Menu of options
Empathic style is used
Self-efficacy or optimistic empowerment is
engendered in the patient
Reading the Report
• Stages of Change
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Pre-Contemplation
 Not considering change
 Aware of a few negative consequences
 Unlikely to take action soon
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Contemplation
 Aware of pros/cons of use
 Ambivalent about change
 Not decided to commit to change
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Reading the Report
• Stages of Change
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Preparation
 Decision to change
 Begins to plan steps toward recovery
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Action
 Tries new behavior
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Maintenance
 Establishes new behavior on long-term basis
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Conclusion
• These data reinforce the need for:
– a fully integrated BI program in trauma centers;
– greater scrutiny of substance using trauma
patients;
– study to remove bias; and,
– protocol to more effectively address substance
use.
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Questions and Answers
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Contact Information
David C. Maynard, MA, LPCC, NCC
Emergency and Trauma Services
University of Kentucky Chandler Medical Center
800 Rose Street, H213
Lexington, KY 40524-4611
859.323.0881
[email protected]