Brief Intervention as a Bridge to AA

Brief Intervention Is Insufficient for Medical Inpatients With Unhealthy Drinking

Data show that brief intervention reduces consumption and consequences among outpatients with unhealthy, but not dependent, alcohol use. To assess whether brief interventions work among medical inpatients with unhealthy drinking,* researchers randomized 341 of such patients to a 30-minute session of motivational counseling in the hospital or to usual care.

Most subjects had alcohol dependence, were unemployed during the previous 3 months, used other drugs, and had substantial psychiatric symptoms. Almost half were hospitalized for an alcohol-related medical diagnosis.

At 3 months among subjects with alcohol dependence, similar proportions of the intervention and control groups received alcohol assistance (e.g., specialty treatment) (49% and 44%, respectively).

At 12 months among all subjects, decreases in alcohol consumption did not significantly differ between the groups (e.g., adjusted mean decreases in drinks per day, 1.5 for intervention subjects and 3.1 for usual care subjects).

Comments:

Unlike most brief intervention studies in outpatients, this study enrolled a predominantly alcohol-dependent sample with major comorbidities—a group reflective of the treatment-resistant population identified when screening occurs in inpatient settings. The study suggests that screening, assessment, and brief counseling are necessary but not sufficient to change alcohol consumption in this population. Although the findings are disappointing, this study underscores that alcoholism—like cancer, atherosclerosis and other complex diseases—will not succumb to simple solutions.

References: Saitz R, Palfai TP, Cheng DM, et al. Brief intervention for medical inpatients with unhealthy alcohol use: a randomized controlled trial. Ann Intern Med. 2007;146(3):167–176.

• Brief-TSF extends brief intervention to lifelong recovery.

About a quarter of individuals screened for alcohol misuse in hospital emergency rooms reported unsafe drinking levels, according to a study concluding that hospital-based brief interventions for alcohol problems are effective.

This target population has previously been thought to be unresponsive to intervention.

Medical News Today reported Dec. 26 that the study sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) found that screened patients who received brief counseling during ER visits reported lower levels of risky drinking three months later than those who only received written advice about controlling their drinking.

The research was conducted at 14 university-based emergency health centers in the U.S. A total of 7,751 patients received a brief questionnaire about their alcohol use, and more than 1,100 who reported excessive alcohol use — defined as more than 14 drinks per week for men and more than 7 per week for women — took part in the study. The intervention tool used by ER staff was the Brief Negotiated Interview (BNI).

“This study demonstrates that a broad group of emergency practitioners can learn how to perform the intervention and that it is effective across multiple practice sites,” said study co-author Gail D’Onofrio, M.D., professor and chief of emergency medicine at Yale University. “The emergency department visit is often the only access to care for many patients and thus is an ideal opportunity to begin the conversation regarding unhealthy alcohol use.”

The study appeared in the December 2007 issue of the Annals of Emergency Medicine.

Brief-TSF can assist patients cease alcohol consumption.

The aim of this study was to test the validity of the CAGE questions as a measure of severe drinking in subjects at drop-in centers for the homeless, using biological markers of acute liver reaction to alcohol as the “gold standard.”

A sample of homeless men and women in Copenhagen were invited to participate in a study of health problems. Subjects were interviewed and blood samples were taken and screened for indicators of

• liver dysfunction (gamma-glutamyltransferase [ GT],
• mean corpuscular volume [MCV],
• alanine aminotransferase [ALAT], and
• alkaline phosphatase [Alpase]), and
• hepatitis C [HCV].

Scores on CAGE correlated strongly with years of heavy drinking (rho = 0.43, p < 0.001), and while years of drinking did not correlate with biomarkers after controlling for multiple hypothesis testing, CAGE correlated with GT, Alpase and ALAT, but not MCV.

The correlations held even among those without HCV, but subjects with HCV + and CAGE > 1 had quite extreme values on liver markers.

Findings suggested that the CAGE was able to identify homeless drinkers whose drinking was significantly associated with increases in biomarkers associated with heavy drinking.

The CAGE as a Measure of Hazardous Drinking in the Homeless. Morten Hesse; Henrik Thiesen. American Journal on Addictions, Volume 16, Issue 6 November 2007 , pages 475 – 478

Brief-TSF can assist patients cease alcohol consumption.

A new report shows that people in recovery can help hospitalized alcoholics by encouraging them to quit drinking and enter counseling, Reuters reported June 11.

“A recovering alcoholic can help alcoholics who are still suffering from the disease, because the patients relate to them,” said Dr. Richard D. Blondell, an addiction-medicine specialist at the University of Louisville School of Medicine in Kentucky. “The patients credit the visitor as the main thing that motivated them.”

The study included 140 patients who were hospitalized for alcohol-related incidents. One group received standard medical care, a second group received medical care plus a 15-minute intervention by a trained addiction specialist, and the third group received medical care, intervention, and an in-depth talk with a recovering alcoholic.

Researchers found that 59 percent of those who met with recovering alcoholics abstained from drinking for six months after the incident, compared to 44 percent of those who received addiction counseling alone, and one-third of those who only received medical care.

In addition, half the patients who met with recovering alcoholics had entered some form of treatment, compared with only 15 percent of those who received medical treatment and counseling by an addiction specialist.

The study is published in the May issue of the Journal of Family Practice.

From; Jointogether

Brief-TSF is based on these principles.

Alcohol Screening: A Quick First Step to Reduce Problem Drinking

Alcohol is the most widely used and abused drug among working adults. Over 80 percent of problem drinkers are employed full-time. Unhealthy drinking patterns contribute to a host of preventable problems including increased workers’ compensation and disability claims, hospital costs and job turnover. In addition, 20 percent of employees have been injured by, had to cover for, or worked harder because of a colleague’s drinking. Alcohol abuse and dependency cause employees to miss more work days, have lower productivity, and higher medical costs than those without active drinking problems.

Screening for alcohol problems can motivate some to temper their drinking while others—whose drinking may be dangerous or disruptive—may seek treatment, recovery and success. Business leaders willing to invest in screening and brief interventions (SBI) for alcohol problems can realize a return on investment of at least 215% by making interventions available for problem drinkers. To reap these rewards, employers need to first make screening available and accessible.

Tools for Screening

Alcohol screenings are usually completed in 5-10 minutes. Two frequently used screening instruments are the 4-question CAGE and the 10-question AUDIT. Both tools focus on quantity and frequency of alcohol intake. The AUDIT also assesses binge drinking, addictive symptoms and negative consequences.

In the Workplace

Many employers support activities and offer benefits that facilitate employee alcohol screening. Employee assistance programs that offer screening are linked to reductions in healthcare costs and increased productivity.7 New staff orientations are opportune events to inform employees about alcohol abuse and dependency resources. Company health fairs, and workplace wellness programs—when led by clinicians equipped to perform confidential alcohol screening—are also key events to identify and help problem drinkers.

In Healthcare Settings

Alcohol screening enables healthcare providers to address problem drinking before it becomes life-altering. By ensuring that health plans cover alcohol SBI, employers provide the necessary healthcare tools for employees to monitor their drinking. Screening can take place in the primary care setting as part of routine health exams. It can also be offered to women as part of their pregnancy-preparedness and prenatal care. Physicians’ offices, hospitals, emergency rooms, urgent care centers and behavioral health clinics are all safe environments to assess addictive behaviors.

In the Home

Online resources are also available for employees and their families to assess their own problem drinking and seek help independent of workplace resources. Websites like AlcoholScreening.org provide validated screening tools, recommended actions and local resources for those seeking treatment and further information.

After Screening

Alcohol screening tests are similar in accuracy as tests for diabetes and high blood pressure. While screening does not provide a specific diagnosis, it does help identify people who may benefit from a comprehensive assessment by a trained professional. There are two possible courses of action for someone who screens positive for alcohol problems:

If the person exhibits signs of dependency, a referral to a treatment program more equipped to handle and assess addiction is appropriate (e.g., inpatient treatment), or

If the person’s behavior is more associated with problem drinking, a brief intervention of low intensity and short duration can be conducted.

Brief-TSF utilizes the CAGE and AUDIT and concentrates on breaking down denial and then referral to Alcoholics Anonymous.

From Ensuring Solutions

Screening for Alcohol Problems in Primary Care;

A Systematic Review

Background; Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.

Objective; To evaluate the accuracy of screening methods for alcohol problems in primary care.

Methods; We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results.

Results; Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated.

The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%).

The CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%).

These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions.

The studies inconsistently adhered to methodological standards for diagnostic test research: 3 provided a full description of patient spectrum (demographics and comorbidity), 30 avoided workup bias, 12 avoided review bias, and 21 performed an analysis in pertinent clinical subgroups.

Conclusions; Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care.

Research; David A. Fiellin, M. Carrington Reid, Patrick G. O’Connor. Screening for Alcohol Problems in Primary Care; A Systematic Review. Arch Intern Med. 2000;160:1977-1989.

Brief-TSF includes both the AUDIT and CAGE questionnaires.

Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.

The purpose of the study was to examine the rates and inter-relationships among violence receipt, alcohol use problems, and depression in women seeking prenatal care.

While waiting for their prenatal care appointment, women (n = 1054) completed measures of past year partner and non-partner violence receipt, alcohol misuse (using the TWEAK and quantity and frequency of alcohol use in past year), and depression (using the Center for Epidemiological Studies Depression Scale – CESD and prior history of depression).

Over 30% of women reported either violence receipt, alcohol use problems or depression risk.

Significant inter-relationships among all measured risk variables were found.

Violence receipt was significantly related to

• alcohol misuse,
• cigarette use,
• less education, and
• scoring above the cutoff on the CESD (? 16).

Practitioners can be well-equipped to provide assessment, interventions, or referrals as needed to the high numbers of women encountered in prenatal care settings experiencing psychosocial and behavioral problems that may affect their pregnancy.

Research; H. A. Flynn, M. A. Walton, S. T. Chermack, R. M. Cunningham and S. M. Marcus. Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings. Archives of Women’s Mental Health, 1434-1816 (Print) 1435-1102 (Online), Volume 10, Number 4 / August, 2007

Brief-TSF provides guidelines and strategies for using the TWEAK.

A comparative evaluation of substance abuse treatment

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups.

The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment.

Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up.

Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up.

These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes.

Moos RH, Finney JW, Ouimette PC, Suchinsky RT. A comparative evaluation of substance abuse treatment. Alcohol Clin Exp Res. 1999 Mar;23(3):529-36.

Al-Anon offers new life

AA’s 12-Step Recovery Program

Alcohol and Anxiety

Alcohol Problems Database

Alcoholic Defence Mechanisms

Alcoholics Anonymous and Nursing

An Introduction to Medication for Alcohol Dependence

Anti-craving Drugs

Binge Drinking & Brain Damage

Brain Damage & Cirrhosis

Brief-TSF Description

Brief-TSF Learning Objectives

Characteristics of Children of Alcoholic

Controlled drinking?

Counselling and the 12 Steps of AA

Counsellor Characteristics

Craving Reduction

Depression & 12-Step Programs

Effects of Gambling Addiction

Elderly Substance Abuse

Families, Mental Health & Alcohol abuse

Female Victims of Child Abuse

Five Alcoholism Subtypes

Free Training Alcoholism Anti-craving Medications

Gender Matching Hypothesis in Alcohol Treatment

Healing through Social and Spiritual Affiliation

How Alcoholics Anonymous is changing

How do alcoholics get to AA?

Humility and Surrender

Nutritional Therapy in Alcoholic Liver Disease

Painkiller abuse

Phases of Recovery from Alcoholism

Readiness to Change Profiles

Recovery through the Twelve Steps

Research Evidence for TSF

Risky Partners and Domestic Violence

Slogans for everyday life in AA

Spiritual Assessment

Spirituality in Alcoholism Recovery

Stages of an Eating Disorder

Strategies for Dealing With Denial

Symptoms of alcoholism

The 12-Steps Promote Acceptance of Addiction

The Personality Traits of Alcoholics

Treating Alcoholism as a Chronic Disease

TSF Description

Twelve step programs

What about partners of alcoholics?

Women and the Twelve Steps of AA

World view change in Adult Children of Alcoholics

• Subscribe to Twelve Step Facilitation by e-Mail

• Early detection, including screening and brief interventions (for nondependent problem drinkers)
• Comprehensive assessment and individualized treatment plan
• Care management
• Individually delivered, proven professional interventions
• Contracting with patients
• Social skills training
• Medications
• Specialized services for medical, psychiatric, employment or family problems
• Continuing care
• Strong bond with therapist or counselor
• Longer duration (for alcohol dependent persons)
• Participation in support groups
• Strong patient motivation

Research Sources: McLellan, T.A. 2002; Miller,W.R. 2002; National Institute on Drug Abuse. 1999; Project MATCH Research Group. 1997.

Active participation in a support group can contribute to long-term recovery.

Project MATCH and other studies in the 1990s definitively proved that AA can be an active ingredient of treatment both during a professional intervention and afterward, depending on the patient’s type of therapy.

Patients who joined the AA fellowship or who had an AA sponsor after receiving twelve step facilitation therapy had better abstinence records than those who received an intervention but did not continue their AA participation upon completion.

Other research indicates AA participation may be less effective for patients who receive cognitive behavior therapy because the programs have different goals that may confuse patients.

What researchers still don’t understand, however, are the precise mechanisms of AA participation.

While AA affiliation is associated with self-efficacy, motivation and coping efforts, all significant predictors of good outcome following a professional intervention, some studies have shown that patients who adopt more of the fellowship’s basic tenets – such as acknowledging that alcoholism is a disease, admission of their powerlessness over alcohol and working the twelve steps of the program – relapse at the same rates as patients who adopt very few.

This suggests that the active ingredient may be less about AA per se than continuing participation in support groups that promote a lifestyle inconsistent with the problematic use of alcohol and other drugs.

From; www.ensuringsolutions.org

Brief-TSF is designed to support active participation in Alcoholics Anonymous.