David C. Maynard, MA, LPCC, NCC Emergency and Trauma Services Chandler Medical Center

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1 ALCOHOL AND DRUG USE: Addressing a Prolific Problem in Healthcare David C. Maynard, MA, LPCC, NCC Emergency and Trauma Services Chandler Medical Center

2 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 3

Centers: Screen for alcohol Level One Trauma Centers

3 American College of Surgeons 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 4

centers can use the teachable moment Result: effective injury

4 American College of Surgeons Alcohol is a significant factor in injury Must identify problem drinkers LOTC must provide intervention Reduced trauma recidivism by 50% 5 American College of Surgeons (ACS) Committee on Trauma. Resources for optimal care of the injured patient ACS: Chicago (2006).

trauma recidivism by 50% 5 American College of Surgeons (ACS) Committee on

5 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. 6 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:

criteria. 6 Jurkovich GJ, Rivara FP, Gurney JG, Seguin D, Fligner CL, Copass M.

6 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. 7 Rivara FP, Jurkovich GJ, Gurney JG, et al. The magnitude of acute and chronic alcohol abuse in trauma patients. Arch Surg. 1993; 128:

patients. 7 Rivara FP, Jurkovich GJ, Gurney JG, et al.

7 Brief Intervention Efficacy Long established history Chick, J.; Lloyd, G.; and Crombie, E. Counseling problem drinkers in medical wards: A controlled study. British Medical Journal 290: , 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 months of long-term study with randomized controls. Alcoholism: Clinical and Experimental Research 7(2): , Persson, J., and Magnusson, P.H. Early intervention in patients with excessive consumption of alcohol: A controlled study. Alcohol 6(5): , Efficacy Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review. Addiction 88: , Kahn, M.; Wilson, L.; and Becker, L. Effectiveness of physician-based interventions with problem drinkers: A review. Canadian Medical Association Journal 152(6): , 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): ,

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.

8 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. 9 Apodaca, TR and Schermer, CR. Readiness to Change Alcohol Use after Trauma. Journal of Trauma. 2003; 54(5), May 2003,

4 days of binge-drinking/month. 84% consider changing their drinking.

9 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. 10 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,

Treatment may need to be culturally adapted. 10 Schermer, CR; Bloomfield, LA; Lu, SW; Demarest, GB.

10 Alcohol Intervention 2524 patients were screened 1153 screened positive (46%) 366 randomized to intervention group (IG) 396 to control group (CG) 11

11 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) 12

12 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) 13

13 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). 14 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 (4),

07) IG had 48% reduction in injuries requiring hospital admission (3 years follow-up).

14 Protocol for Patient Identification Collection of biological screens Glasgow Comma Score <15 Nursing Admission Assessment Clinical Suspicion Chemical Dependency consult 15

15 Elements of a Brief Intervention 16 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

for change Elicit commitment to change Reflective listening statements Demonstrate respect and empathy

16 FRAMES 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 17

change Menu of options Empathic style is used

17 Reading the Report 18 Stages of Change Pre-Contemplation Not considering change Aware of a few negative consequences Unlikely to take action soon Contemplation Aware of pros/cons of use Ambivalent about change Not decided to commit to change

Unlikely to take action soon Contemplation Aware of

18 Reading the Report Stages of Change Preparation Decision to change Begins to plan steps toward recovery Action Tries new behavior Maintenance Establishes new behavior on long-term basis 19

19 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. 20

of substance using trauma patients; study to remove bias;

20 21 Questions and Answers

21 Contact Information David C. Maynard, MA, LPCC, NCC Emergency and Trauma Services University of Kentucky Chandler Medical Center 800 Rose Street, H213 Lexington, KY

Screening, Brief Intervention, and Referral for Treatment: Evidence for Use in Clinical Settings: Reference List

Screening, Brief Intervention, and Referral for Treatment: Evidence for Use in Clinical Settings: Reference List Elinore F. McCance Katz, MD, PhD Professor of Psychiatry University of California San Francisco