Alcohol and Tobacco Screening, Brief Alcohol and Tobacco Screening, Brief Intervention, Referral and Treatment Intervention, Referral and Treatment

(SBIRT) for Emergency Room Patients(SBIRT) for Emergency Room Patients

Mary K. Murphy, Ph.D.1

David Lounsbury, Ph.D. 2

Albert Einstein College of MedicineDepartment of Emergency Medicine1, 2 &

Epidemiology and Population Health1

Tobacco Think Tank Meeting 10/12/10

PURPOSEPURPOSE

A Major Public Health A Major Public Health ProblemProblem

Alcohol and tobacco are among the most Alcohol and tobacco are among the most widely used addictive drugswidely used addictive drugs

Both contribute significantly to preventable Both contribute significantly to preventable morbidity and mortalitymorbidity and mortality

Co-use of alcohol and tobacco further Co-use of alcohol and tobacco further heightens the risk of disease and deathheightens the risk of disease and death Alcohol consumption Alcohol consumption injuries and deaths from injuries and deaths from

motor vehicle accidents, falls, drowning, fires and motor vehicle accidents, falls, drowning, fires and burns, and violenceburns, and violence

Tobacco consumption Tobacco consumption #1 cause of preventable #1 cause of preventable morbidity and mortality in USmorbidity and mortality in US

Rationale for Integrated Rationale for Integrated Treatment ServicesTreatment Services

Among at-risk and dependent drinkers, Among at-risk and dependent drinkers, smoking prevalence is about 70% smoking prevalence is about 70% compared to 24% for non-smokerscompared to 24% for non-smokers

People who drink are 3x more likely to People who drink are 3x more likely to smokesmoke

Alcohol consumption has been identified as Alcohol consumption has been identified as a trigger for smoking and relapse to a trigger for smoking and relapse to smokingsmoking

Highest risk group- multiplicative risk Highest risk group- multiplicative risk increase, possible biological synergyincrease, possible biological synergy

Uncertainty about Uncertainty about Combined Treatment Combined Treatment

StrategiesStrategies We don’t know how much of what kind of We don’t know how much of what kind of

treatment for which kind of co-user will worktreatment for which kind of co-user will work What do patients want to address first? Their What do patients want to address first? Their

alcohol or tobacco use?alcohol or tobacco use? How much of what kind of treatment (counseling How much of what kind of treatment (counseling

and/or pharmacotherapy) is needed to reduce and/or pharmacotherapy) is needed to reduce their drinking to a safe level? Or to quit smoking?their drinking to a safe level? Or to quit smoking?

Phone, face-to-face, e-mail/texting, a Phone, face-to-face, e-mail/texting, a combination. What modality is most effective? combination. What modality is most effective?

How does gender, race, ethnicity, age, years of How does gender, race, ethnicity, age, years of use and/or dependency matter?use and/or dependency matter?

PROPOSED SPECIFIC PROPOSED SPECIFIC AIMSAIMS

Aim 1:Aim 1: Identify and modify existing Identify and modify existing treatment manuals for motivational treatment manuals for motivational counseling interventions to be used counseling interventions to be used with a diverse group of ED patients with a diverse group of ED patients who are current smokers and or at-who are current smokers and or at-risk drinkers, eliciting feedback from risk drinkers, eliciting feedback from experts in the fields of motivational experts in the fields of motivational interventions and emergency interventions and emergency medicine, research staff and study medicine, research staff and study participants.participants.

Aim 2a:Aim 2a: Utilize a computer-based Utilize a computer-based screening program to assess the screening program to assess the prevalence and severity of alcohol prevalence and severity of alcohol and tobacco use among a diverse, and tobacco use among a diverse, urban population during an urban population during an emergency department visit.emergency department visit.

Aim 2bAim 2b: Evaluate the delivery of a : Evaluate the delivery of a brief intervention for at risk alcohol brief intervention for at risk alcohol users and smokers initiated during users and smokers initiated during an ED visit followed by telephone an ED visit followed by telephone counseling conducted over a 2 counseling conducted over a 2 month period post emergency month period post emergency department visit.department visit.

CONTEXTCONTEXT

Emergency Dept Patients ProfileEmergency Dept Patients Profile

High prevalence of unmet substance abuse treatment need among adult ED patients (Rockett, 2005) 1.5 - 3.0 times more likely to report heavy drinking

than primary care patients (Cherpitel, 1999) Between 9% and 46% of ED patients have recently

consumed alcohol and a significant number of the 32 million ED injury visits are alcohol-related (Bernstein, E., 1997)

Approximately 25% use tobacco; 12% are at-risk drinkers and smoke (Murphy pilot project)

Methodological approachMethodological approach

SBIRT (SAMHSA public health SBIRT (SAMHSA public health approach)approach) Comprehensive brief intervention approach that Comprehensive brief intervention approach that

delivers early intervention and treatment services delivers early intervention and treatment services to people with substance use disorders and people to people with substance use disorders and people who are at-risk of developing these disorderswho are at-risk of developing these disorders

Goal Goal early intervention with at-risk substance early intervention with at-risk substance users before more severe consequences occurusers before more severe consequences occur

Screening, Brief Screening, Brief Intervention, Referral & Intervention, Referral &

Treatment Treatment (SBIRT) Goals(SBIRT) Goals

NIAAA safe drinking guidelines PHS guideline for treating tobacco use

and dependence (5As and 5Rs) Apply standardized screening

instruments Provide:

Normative feedback Treatment resources when indicated (i.e.,

above safe drinking limits and/or currently using tobacco)

Prior SBIRT Research Prior SBIRT Research A recent systematic review of 39 SBIRT

alcohol studies (predominantly RCTs) targeting alcohol users found that such interventions are effective in facilitating significant reductions in alcohol consumption (D’Onofrio & Degutis 2002)

Challenge: SBIRT most effective with primary care pts, ED injury pts, decrease neg consequences assoc drinking such as DUI- inconsistent alc reductions w/in ED pop (Havard et al 2008). Why?

Studies note computers should be utilized in SBIRT interventions (Hungerford & Pollock , 2003; Bernstein, SL et al 2007)

CASI PilotCASI Pilot

Cross sectional designCross sectional design Bilingual RAs 24/7 ED coverageBilingual RAs 24/7 ED coverage Medically stable, > 1 hr since triage, AO X3, Medically stable, > 1 hr since triage, AO X3,

>> 21 yo, No SI/HI, informed consent, no gross 21 yo, No SI/HI, informed consent, no gross intoxication, pass computer screenintoxication, pass computer screen

Computer program provided by Boston Computer program provided by Boston University School of Public Health / Join University School of Public Health / Join Together syndicated website (Together syndicated website (www.alcoholscreening.org) Eng / Span) Eng / Span

AUDIT, normative feedback, alcohol AUDIT, normative feedback, alcohol education, treatment referral, debriefing education, treatment referral, debriefing session (10-15 min)session (10-15 min)

Patient acceptance of CASI program %

Correctly identified their alcohol risk level after participating in the CASI program (comprehension)

91

Reported the program was easy to use 93

Liked using the computer program 89

Felt comfortable using computer to receive this information

92

Felt others would be helped by this program 92

Would be willing to participate in future computer-based study during an ED visit

78

Found information useful to them 82

Learned information would not have asked their doctor

46

METHODSMETHODS

R21 Proposed DesignR21 Proposed Design

1.1. Computer assisted self interview (CASI) in Computer assisted self interview (CASI) in ED ED

2.2. Motivational interviewing (MI) counseling Motivational interviewing (MI) counseling intervention in ED by MA level counselor intervention in ED by MA level counselor (goal to encourage treatment engagement (goal to encourage treatment engagement & promote reduction in drinking / smoking)& promote reduction in drinking / smoking)

3.3. 2 month follow up period 2 month follow up period

4.4. Timepoints: In ED (in person) followed by 2 Timepoints: In ED (in person) followed by 2 weeks, 1 month and 2 months post ED weeks, 1 month and 2 months post ED (phone)(phone)

Staffing, Training and Staffing, Training and SupervisionSupervision

Bilingual Research Assistants staff ED Bilingual Research Assistants staff ED 24/7 –will complete baselines & follow up 24/7 –will complete baselines & follow up assessmentsassessments

Two trained Masters Level study Two trained Masters Level study therapists will be hired to conduct MI therapists will be hired to conduct MI phone counseling sessionsphone counseling sessions

BNI-ART Institute at Boston University BNI-ART Institute at Boston University will provide therapist trainingwill provide therapist training

Audio taped counseling sessions will be Audio taped counseling sessions will be reviewed for reliability & protocol fidelityreviewed for reliability & protocol fidelity

CASI Instruments and CASI Instruments and MI Assessment GuidesMI Assessment Guides

Emergency Room Patient Demographics Emergency Room Patient Demographics General Health (Questionnaire)General Health (Questionnaire) Alcohol Use Disorders Identification TestAlcohol Use Disorders Identification Test Fagerstrom Test for Nicotine DependenceFagerstrom Test for Nicotine Dependence

CASI Satisfaction (Questionnaire)CASI Satisfaction (Questionnaire) Who, What, When, Where Why (5Ws) Who, What, When, Where Why (5Ws)

QuestionnaireQuestionnaire Medical Problems and Prior Treatment Medical Problems and Prior Treatment

QuestionnaireQuestionnaire

Proposed Recruitment Proposed Recruitment StrategyStrategy

Approach approximately n=1,000 ED Approach approximately n=1,000 ED patientspatients Identify approx 120 alc / tob co-users (our main Identify approx 120 alc / tob co-users (our main

interest)interest) Possible designs:Possible designs:

1.1. Randomize half patients to MI intervention Randomize half patients to MI intervention

2.2. Deliver intervention to ALL patients; no control Deliver intervention to ALL patients; no control groupgroup

3.3. Alternate multifactorial design: Alc only, Tob Alternate multifactorial design: Alc only, Tob only, Alc+tob no interv (different from all of the only, Alc+tob no interv (different from all of the above, allows for multiple comparisons & above, allows for multiple comparisons & doubles the sample size)doubles the sample size)

Outcomes/EndpointsOutcomes/Endpoints

Alcohol: Past 30 days mean number of Alcohol: Past 30 days mean number of standard drinks per week; drinking within standard drinks per week; drinking within NIAAA guidelines; change in stage of NIAAA guidelines; change in stage of changechange

Tobacco: Number of quit attempts; smoking Tobacco: Number of quit attempts; smoking status; change in stage of changestatus; change in stage of change

Community service access: Number of Community service access: Number of services contacted; number of contacts per services contacted; number of contacts per service; satisfaction with services receivedservice; satisfaction with services received

ADDRESSING REVIEWER ADDRESSING REVIEWER COMMENTSCOMMENTS

• “ “Proposed treatment has already Proposed treatment has already demonstrated less than sufficient demonstrated less than sufficient effectiveness in smokers in the ED, effectiveness in smokers in the ED, there is not a compelling case made in there is not a compelling case made in the grant that combining the 2 the grant that combining the 2 interventions for one multiply-interventions for one multiply-diagnosed population will be more diagnosed population will be more effective than the mono therapy”effective than the mono therapy”

Does it make clinical sense to combine these two interventions?

Aims are too ambitiousAims are too ambitious

““First 2 aims are feasible but third aim First 2 aims are feasible but third aim of conducting an RCT is overreaching, of conducting an RCT is overreaching, timeline does not allow for 5 follow timeline does not allow for 5 follow ups”. ups”.

R21: Encourages new, exploratory and R21: Encourages new, exploratory and developmental research projects by developmental research projects by providing support for the early stages providing support for the early stages of project development.  Sometimes of project development.  Sometimes used for pilot and feasibility studies.used for pilot and feasibility studies.