Substance abuse is one of the most prevalent comorbid conditions among trauma patients. Alcohol and other drug use are involved in a substantial portion of traumatic injuries.1 As many as 36% of hospitalized trauma patients have blood alcohol concentrations (BAC) higher than 100 mg/dL,2 and up to 23% are under the influence of cocaine or methamphetamine.3 Further, screening positive for alcohol and other drugs at admission is associated with an increased likelihood of future trauma.3,4 Background and basic principles for providing brief substance abuse interventions in trauma centers are described elsewhere.5,6 Since our initial work developing the principles for conducting brief interventions in trauma centers began, we have conducted nearly 3,000 brief interventions with hospitalized patients at Harborview Medical Center, a Level I trauma center. This paper distills our experience to provide a generic model for brief substance abuse intervention along with operational details of our Addiction Intervention Service.
On-site Inpatient Interventions Versus Referrals to Off-Site Treatment
Why should substance abuse be addressed during trauma hospitalization? Why not simply screen all trauma patients for substance abuse and refer screen-positive patients for treatment after discharge? Unfortunately, numerous barriers may prevent all but 5 to 10% of patients who need it from entering substance abuse treatment.7 In some states, qualifying for public funding may take months. Some patients will be discharged to a skilled nursing facility or to jail; others will be prescribed narcotic analgesics, which are forbidden by many substance-abuse treatment agencies. Perhaps the greatest barrier to entering treatment is motivation; many patients simply do not believe they need help.3
Gentilello et al.8 showed that hospitalized trauma patients can be forced into substance-abuse treatment. A patient's family members or employers, when counseled to enforce certain negative consequences if the patient refuses help, can directly intervene. However, this type of intervention is logistically difficult because it requires quick action. A counselor from the trauma center must locate, contact, and then meet with members of an intact social support system, which not all patients have. Patient confidentiality and autonomy are also serious concerns. Without the power to enforce consequences for refusing treatment, it is difficult to persuade patients to get help and almost always results in the patient arguing against the need for change with statements such as “I don't drink every day; I can take it or leave it; I can quit anytime I want.”
Brief counseling interventions derived from motivational interviewing (MI)9 offer a promising strategy for rapid, cost-effective treatment. MI is an evidence-based psychosocial treatment for substance abuse disorders that focuses more on preparing patients for change than on prescribing immediate action.
Efficacy of Brief MIs
Brief MIs (usually ranging from one to four sessions) are among the most effective and least expensive of over 30 alcohol treatment modalities.10 Although there are differences between specific MIs, usually all have several common elements, such as 1) offering patients individualized information about their BAC results or Alcohol Use Disorders Identification Test (AUDIT) results; 2) emphasizing individual responsibility for change; 3) offering advice to change; 4) offering options for taking action; 5) enhancing the individual's self-efficacy for change; and 6) conducting the intervention in an empathic style.11
For over 20 years, studies of brief counseling interventions in various nontrauma medical settings have reported decreases in self-reported drinking and improvements in liver function tests and rates of other alcohol-related morbidity.11–16 Recently, four studies have investigated the efficacy of MI with trauma patients.
Monti et al.17 found that a single MI session in the emergency department (ED), versus standard ED treatment, reduced alcohol-related injuries (50% vs. 21%) and moving violations (23% vs. 3%) for up to 6 months after injury. Gentilello et al.7 found that a single 40-minute bedside session reduced weekly drinking (1 year after injury) by 22 drinks compared with 7 drinks for control subjects. Additionally, there was a 47% reduction in hospital readmission in MI patients compared with the control group, with up to 3 years follow-up during the first 3 years after injury. Longabaugh et al.18 reported a reduction in alcohol-related negative consequences (for up to 1 year) after adults in the ED received one session of MI during initial treatment and one booster session a week later, which increased the effect of the initial session in the ED. Hungerford et al.19 provided a one-session MI to ED patients. This resulted in significant reductions in alcohol-related harm, self-reported drinking, and alcohol-dependence symptoms.
How Change Occurs
Why do substance abusers continue to drink or use drugs if it causes unpleasant consequences? Alcohol-dependent patients may typically associate positive outcomes with alcohol use rather than negative ones.20 Drinkers who are unable to form associations between their drinking and negative emotional experiences are at a higher risk for problem drinking.21–23 Consequently, these at-risk drinkers may need more time than most to reflect on their punishing experiences.23 MI may be particularly well suited to help the substance abuser explore negative consequences in a nonjudgmental style. When the interventionist directs the patient's attention to the relation between alcohol use and current suffering, the patient can spend more time reflecting on the injury experience and less time defending a drinking lifestyle.
Instead of prematurely advising patients on how they should change, MI focuses primarily on preparing them for change by exploring why they might want to change.24 Research on health behavior change indicates that the probability of healthy change varies according to each patient's stage of readiness.25 In the earliest stage, people recognize few if any negative consequences of drinking or using drugs. With these people, the clinical task is to create ambivalence about change by helping them to become more aware of current or future harm: “May I give you some information? When you were admitted, your alcohol level was 0.23, and we have learned that most of our stab-wound victims are intoxicated at the time they are stabbed.”
As doubt arises about the “okayness” of the status quo, ambivalence is created between motivation to continue drinking and motivation to change. Nowhere are the negative consequences of substance abuse more palpable than in a trauma center. The motivational task at this stage is to resolve the ambivalence by thoroughly discussing the pros and cons of change. Patients in later stages of readiness are already motivated to change. They need to publicly commit to a plan of action and try to stick to it without relapsing. The emphasis shifts at this point from discussing the why of change to discussing the how: “What options make the most sense to you for quitting drinking? Alcoholics Anonymous (AA)? Professional treatment? Quitting on your own?” Although MI avoids arguing or persuading, the interventionist still has an ethical duty to suggest various courses of action:9 “May I state a concern I have? I know it's important to you to quit on your own, but your chances of success go up if you use treatment and AA.”
GENERIC OUTLINE OF INPATIENT INTERVENTION
The sequence of five clinical tasks shown in Figure 1 is a guideline for trauma center interventions. This sequence is usually completed in a single bedside session lasting 20 to 30 minutes.
Raise the Topic
The first task, raising the topic and getting started, is difficult. The interventionist must start a conversation about drug and alcohol use in a setting where patients expect to discuss surgical matters only. Furthermore, patients often begin by trying to convince the interventionist they do not have a drinking problem. After the interventionist reassures the patient that the purpose of the conversation is not about forcing change, the focus shifts from whether or not the patient has a problem to what the patient likes and dislikes about drugs and alcohol: “I'm not here to push you into changing anything you don't want to change, just to help you think through what options make the most sense for you.” Another helpful strategy is to first allow the conversation to move toward the patient's more immediate concerns. Often there are issues such as pain, self-care after discharge, or work and financial worries.26 Listening to these primary concerns, acknowledging their importance, and summarizing their possible solutions increases rapport and trust. Spending 5 minutes here can result in the patient exploring the why of change more openly during the next 15 minutes.
Look at Substance Abuse from the Patient's Perspective
The second task is to elicit and understand the patient's views on alcohol and drug use, reasons for using, and any perceived negative consequences of use. This will help the patient see the big picture—how substances fit into daily routine in both positive and negative ways. One method is to report BAC test results (if available) along with the behavioral and cognitive effects associated with that BAC level. Liver test results can also be used as an opening topic. After providing this feedback, the interventionist can ask, “What do you make of that?” This may encourage the patient to think about the negative consequences associated with alcohol use. Patients often contest the accuracy of laboratory toxicology tests. In these cases, it is important that interventionists avoid a potential debate by conceding the possibility of human error. Our experience is that many patients who challenge the validity of toxicology laboratory results often want to quit drinking or using anyway. Another way to elicit the patient's views is by exploring the importance of change and the patient's confidence level: “I'm wondering how important it is to you to reduce or quit drinking?” and “If you were to decide to quit drinking, how confident are you that you would be successful?”
Clarify Patient Goals
The third task is helping the patient clarify goals regarding substance use behavior. Often, the only substance use goals the patient has considered are those that have been offered by concerned others (usually unsolicited). A discussion in which the patient is not put on the defensive can encourage the patient to set attainable personal goals. These goals vary widely among patients. Some may want to quit alcohol and drugs completely and permanently; others may want to quit specific drugs and cut down on others; some may want to quit for only a specified time period before trying less harmful ways of drinking. Another category consists of patients who are just not ready to decide. In these cases, it is useful to discuss goals hypothetically: “If you were at a point in your life where you were ready for a change, what changes would you want to make?” Interventionists inform all patients that abstinence is their safest option. If they will not commit to this goal, then the interventionist discusses strategies to reduce harm from alcohol and drug use.
Discuss Options for Attaining Goals
The fourth task is to discuss a menu of change options to assist the patient in reaching personal goals. This optimistically conveys to the patient that there are many ways to solve substance abuse problems. Presenting a menu of options may also reduce defensive reactions by not forcing an all-or-nothing decision. For any given behavior change under discussion, this menu should include a continuum of options with broad motivational appeal to those who are not committed to change and to those who are very committed to change. For example, a menu of options for drinking might include doing nothing, experimenting with cutting down for a limited period, quitting without outside help, or quitting with professional treatment or AA. This negotiation process follows an elicit-provide-elicit cycle.27 First, the interventionist elicits from the patient what the patient is already thinking about doing to change. Next, the interventionist provides a menu of options, and then elicits the patient's reactions. Most advice by the interventionist is made only in response to the patient's ideas. This helps to prevent vacuous agreement or further resistant statements and pushes the patient to seriously consider change.
Close on Good Terms
The fifth task involves summarizing statements the patient has made in favor of change and acknowledging any agreement reached.28 Without condoning substance abuse, the interventionist assures the patient that ambivalence is normal and everyone experiences it as they move toward lasting change. Conveying acceptance of ambivalence, rather than impatience with inaction, seems to bring about change more quickly.
OPERATIONAL ISSUES FOR AN ADDICTION INTERVENTION SERVICE
The Gentilello et al.7 study at Harborview Medical Center convinced the hospital to implement brief interventions with trauma patients as a daily hospital service. The Addiction Intervention Service began in 1998 using the same psychologist who had performed interventions in the randomized trial (C.D.). At first, only 20% of the patients who received an intervention were referred by hospital staff; the other 80% were proactively identified through screening by the interventionist. The number of referrals increased as hospital staff became more familiar with the Addiction Intervention Service. Now, 5 years later, 75% of all patients receiving interventions are referred to the Addiction Intervention Service by hospital staff including trauma social workers, psychiatrists, nurses, residents, and medical students.
In addition to screening and providing evidence-based brief interventions, the Addiction Intervention Service also provides “curbside consults” to trauma center staff, involving discussions of addiction and specific intervention strategies. The result is an increase in staff morale. Many on the staff had become pessimistic from years of treating the injury without addressing the primary cause of the injury, and they are grateful to see the problem being directly addressed.
Because of the reality of limited resources, it is best to minimize screening time to maximize the time spent providing interventions. Although laboratory toxicology screens are less sensitive and specific than standardized screening questionnaires used in randomized clinical trials, our study revealed that they are a more time-efficient screening method. However, in a substantial number of trauma centers that do not routinely order BAC or urine toxicology screens, the intervention service must rely on staff referrals and screening questionnaires to identify patients. We caution against using any version of the Michigan Alcoholism Screening Test,29 because the wording in a number of questions may elicit defensiveness in patients (e.g. “Have you ever neglected your…family for two or more days in a row because you were drinking?”). The AUDIT may be a better screening tool in medical settings because the questions are posed in a more general and neutral tone. Additionally, the AUDIT generates normative feedback about the incidence of alcohol-related problems, which can be a starting point for patients to begin thinking about behavior change.30 Nurses can administer the AUDIT and convey the results to the interventionist, or the interventionist can administer the AUDIT directly to patients. We have found that drug use can be assessed with a single question from the Addiction Severity Index, “How many days out of the past month have you used any nonprescription drugs such as cocaine or marijuana?”31
Trauma centers are well staffed with a variety of medical and psychosocial clinicians able to learn and implement the brief intervention model. At Harborview Medical Center, the chief of the intervention service is a faculty psychologist who also trains psychiatry and psychology residents to conduct interventions. This not only increases the number of patients receiving interventions, but also provides valuable instruction early in residents' training. Later, residents can then use these skills to perform interventions throughout their careers. Other trauma centers use nurses, social workers, pharmacists, and substance abuse specialists to perform interventions. Studies have demonstrated that interventionists do not have to be substance abuse treatment specialists for substance abuse interventions to be successful. However, regardless of the training background of the interventionist, brief intervention programs should adhere to a standardized protocol, which usually uses a patient-centered counseling style.32
The issue of confidentiality is critical in substance abuse interventions for a number of reasons. In many states, insurance companies can deny medical coverage for injuries sustained while intoxicated.33 Additionally, a federal confidentiality law (42 CFR Part 2) requires that providers of substance abuse services keep clinical notes separate from the patient's medical record.34 Trauma centers can keep intervention notes in a locked location separate from the medical record and require a special patient consent for release of this information to other parties. (Note: This includes police, attorneys, etc., not just providers.) If interventionists chart electronically, a password should be established to prevent other hospital staff from viewing the substance abuse notes. Some surgeons argue that drawing a BAC is required for medical management of injury.35 However, access to those screening results is not protected by 42 CFR Part 2.
Number of Patients Receiving Interventions
In 1 year of full-time employment, an interventionist can screen about 2,000 patients and provide 700 brief interventions. Patients may be seen in ED observation wards, on the surgical wards, and in clinics. A typical day might include ward rounds, with or without the trauma team, gathering BAC from the previous day's admissions, administering screening questionnaires, providing interventions, consulting with hospital staff, tracking patients who are still too ill to receive intervention, and tracking service data. Hospital discharge seldom requires delay until the interventionist can see the patient. Nevertheless, because of operational and logistic factors (language barriers, brain injury, and sedation) approximately 20 to 30% of patients are discharged without being approached by the interventionist.
Brief Interventions and Alcohol Dependence
The severity of substance abuse problems among trauma patients varies widely from mild to severe. The Institute of Medicine36 and American Society of Addiction Medicine37 recommend matching the intensity of treatment to the severity of the problem. Accordingly, a brief intervention would be the best match for a patient who is not dependent on alcohol, whereas dependent patients would be best matched to inpatient, residential, or long-term outpatient care. If all trauma patients were ready, willing, and able to engage in the appropriate level of treatment, this is how treatment matching should occur, and we could adhere strictly to this formula. Unfortunately, only 5 to 10% of trauma patients meeting diagnostic criteria for dependence seek this intensive level of treatment in the year after injury.7 A brief intervention may be all the treatment these patients are likely to receive in the foreseeable future. Diagnostic interviews during the Gentilello et al.7 study revealed that patients who met criteria for alcohol dependence still benefited from a brief intervention, despite requiring more intensive treatment, which they were not willing or able to access. For these reasons, we recommend providing brief interventions to all substance abusing trauma patients, including those who are dependent and those who do not meet criteria for dependence.
Previous studies of trauma patients who received brief interventions have shown that substance abuse decreases markedly for several months after injury but then returns to preinjury levels as patients recover from their injuries and the memory of the experience fades.3 As patients recover physically, their motivation to abstain or limit substance use may diminish. Intermittent booster sessions over a period of months after injury may help to maintain changes that patients resolved to make during their hospitalization. Research indicates that outpatient booster sessions delivered within a few months of discharge do prevent or delay the return to problem drinking.18 We believe that bedside interventions are a good place to start, but a high-quality psychosocial trauma service should extend beyond the bedside and address a wider range of patient concerns. Zatzick et al. 38 has documented that trauma patients have multiple psychosocial concerns limiting their ability to function for up to a year after injury. A pilot study revealed that skilled case management over the 6 months after injury can reduce both drinking and symptoms of posttraumatic stress disorder.39 As our knowledge of the psychosocial impact of severe injury grows, our psychosocial services should expand accordingly.
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