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Substance Screening, Brief Advice and Discharge: A 10-Year Comparison
The Journal of Emergency Medicine, Vol. 49, No. 4, pp. 400–407, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.014
Original Contributions
EMERGENCY PHYSICIAN UTILIZATION OF ALCOHOL/SUBSTANCE SCREENING, BRIEF ADVICE AND DISCHARGE: A 10-YEAR COMPARISON Kerryann B. Broderick, BSN, MD,* Bonnie Kaplan, MD,† Dyllon Martini, MD,† and Emily Caruso, MSPH* *Denver Health Medical Center, Denver, Colorado and †University of Colorado at Denver, Denver, Colorado Reprint Address: Kerryann B. Broderick, BSN, MD, Denver Health Medical Center, 777 Bannock St., MC#0108, Denver, CO 80204
, Keywords—SBIRT; alcohol abuse; substance abuse; emergency department; discharge advice; substance screening
, Abstract—Background: In 2007, of the 130 million emergency department (ED) visits, 38 million were due to injury, and of those, 1.9 million involved alcohol. The emergency department is a pivotal place to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) due to the high number of patients presenting with alcohol/substance abuse risk factors or related injuries. Study Objective: This study compares two surveys, approximately 11 years apart, of emergency physicians nationwide which assesses the use of validated screening tools, the availability of community resources for alcohol/substance abuse treatment, and the prevailing attitudes of emergency physicians regarding Screening and Brief Intervention for alcohol/substance abuse. Methods: We performed crosssectional anonymous surveys of 1500 emergency physicians drawn from American College of Emergency Physicians members. The survey results were compared for time interval change. Results: The two surveys had comparable response rates. The median percentage of patients screened for alcohol/substance abuse in 1999 was 15%, vs. 20% in 2010. In 2010, 26% of emergency physicians had a formal screening tool, and the majority used Cut-down, Annoyed, Guilty, Eye-opener (85%). In 2010, a statistically significant increase in the number of emergency physicians said they would ‘‘always’’ or ‘‘almost always’’ use discharge instructions that were specific for alcohol/substance abuse, if available, vs. 1999. Conclusion: Few emergency physicians screen for alcohol/substance abuse despite evidence that screening and brief intervention is effective. Emergency physicians are receptive to the use of discharge material. Ó 2015 Elsevier Inc.
INTRODUCTION Approximately 88,000 deaths per year are attributed to excessive alcohol use in the United States. In addition, this excessive alcohol use accounts for ‘‘2.3 million years of potential life lost per year’’ (1). Chen and Yi reported that more than 1.9 million hospitalizations in 2010 in the United States (US) were attributed to alcohol-related causes (2). This is an increase in 300,000 deaths since 2005. Bouchery et al. estimate that in 2006 the estimated economic cost of excessive drinking was $223.5 billion, which is an increase of $38.5 billion from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimate in 2005 (3). The Screening and Brief Intervention (SBI) technique has been studied since the early 1960s as a way to address risky behavior in patients who present to physicians for causes both directly and indirectly related to alcohol/ substance abuse (4). Studies have consistently shown that SBI provided by a physician can increase the likelihood of a patient following up for further treatment for alcohol/substance misuse and can significantly decrease future substance abuse (4–7).
RECEIVED: 8 November 2014; FINAL SUBMISSION RECEIVED: 20 April 2015; ACCEPTED: 14 May 2015 400
Emergency Physician Utilization of Alcohol/Substance Screening
The emergency department (ED) is a pivotal place to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) due to the high number of patients presenting with alcohol/substance abuse risk factors or related injuries. In 2001, 2.5 million of 107.5 million visits to the ED were due to alcohol alone (8). In 2007, of the 130 million ED visits, 38 million were due to injury, and of those, 1.9 million involved alcohol (9). The Drug Abuse Warning Network estimates that in 2009, about 2.1 million ED visits resulted from medical emergencies involving drug misuse or abuse (10). Of those, 21.2% involved illicit drugs and 14.3% involved alcohol in combination with other drugs (10). Despite research indicating the need for widespread SBIRT education for physicians, to our knowledge, this has not been implemented routinely in emergency medicine curricula (7). The impact of the literature to date, as well as the federal grants and programs aimed at improving SBIRT service provision to patients, has not been adequately assessed. Our study attempted to assess if the presence of SBIRT programs and heightened awareness of SBIRT have increased rates of physician utilization of substance screening and referral. We hypothesized that the awareness of, access to, and use of validated screening tools and specific discharge instructions has increased in the 10 years interim when compared to a similar study conducted in 1999 (11). The specific aims of this study will be to measure and compare to similar 1999 data: 1) proportions of physicians who utilize validated screening tools, 2) rates at which physicians directly address substance misuse with patients, 3) the percentage of physicians who have access to discharge instructions for substance abuse, and 4) how often physicians do or would use discharge instruction sheets, when available. METHODS Study Design Cross-sectional self-administered surveys were mailed and completed in 1999 and 2010. Study Setting and Population Both survey studies utilized the same tool and target population pool. An anonymous survey instrument was mailed to emergency medicine physicians along with an introductory letter explaining the nature of the study. We utilized randomly generated mailing list(s) purchased from the American College of Emergency Physicians. Multiple mailings (up to three) were mailed
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to nonrespondents. These studies were approved by the University of Buffalo, School of Medicine (1999) and the University of Colorado at Denver, School of Medicine (2010), respectively. Survey Content The lead author, Kerryann B. Broderick, piloted this survey twice prior to the original 1999 study. The original survey tool draft was first sent to 10 emergency physicians (EPs) from around the country, all of whom had some expertise in survey methodology. Their comments were reviewed and the survey was revised to better reflect those comments. The survey was then sent out to 10 different emergency physicians who were not known experts in survey methodology. Their feedback was also incorporated into the survey and the final version was used in both studies. Data were collected using a closed-response survey tool consisting of 18 questions. Questions consisted of both epidemiological and those designed to measure emergency physicians’ rates of: 1) utilization of validated screening tools; 2) directly addressing substance abuse issues with patients; 3) access to discharge instructions for substance abuse; and 4) physician discharge instruction sheet utilization rates. A numerical system was utilized to track nonresponders for purposes of repeated survey mailings. This number was compared to respondents’ names and marked as completed by a research assistant. This research assistant was not involved in data analysis and only checked which number responded. The survey instrument was de-identified from the participant data. Data Analysis Data were entered into an Access database (Microsoft Corporation, Redmond, WA) and transferred into SAS or Stata formats using translational software (dfPower/ DBMS Copy, DataFlux Corporation, Cary, NC). All statistical analyses were performed using SAS Version 9.2 (SAS Institute, Inc., Cary, NC) or Stata Version 10 (Stata Corporation, College Station, TX). Descriptive statistics for continuous variables were expressed as medians with interquartile ranges, and proportions as percentages with 95% confidence intervals (CIs). RESULTS Survey response rates were comparable between the two surveys. In 1999, 280/500 surveys were obtained (56%, 95% CI 52–60%), and in 2010, 516/1000 (52%, 95% CI 48–55%) responses were obtained.
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Table 1. SBIRT National Survey: Overall Results Summary Table Responses
1999 Survey (n = 280), n (%)
2010 Survey (n = 480), n (%)
1- Community hospital 2- Urgent care facility 3- Academic/tertiary hospital 99- Missing 1- Urban 2- Suburban 3- Rural 99- Missing Median (IQR) Northeast South Midwest West Missing 1- Male 2- Female 99- Missing Median (IQR) Median (IQR) EM residency trained Surgical residency trained Medicine residency trained Family medicine trained EM boarded or qualified Surgical boarded or eligible Medicine boarded or eligible Family medicine boarded or eligible 1- Yes 2- No 99- Missing 1- Yes 2- No 99- Missing 1- Yes 2- No 99- Missing
201 (72) 6 (2) 67 (24) 6 (2) 123 (44) 110 (39) 37 (13) 10 (4) 36,000 (25K–50K) 45 (16) 75 (27) 73 (26) 77 (27) 10 (4) 213 (76) 61 (22) 6 (2) 43 (38–48) 12 (7–18) 162 (58) 17 (6) 37 (13) 27 (13) 249 (89) 3 (1) 35 (13) 27 (10) 158 (56) 115 (41) 7 (3) 103 (65) 15 (9) 40 (25) 54 (19) 221 (79) 5 (2)
340 (71) 12 (3) 118 (24) 10 (2) 191 (40) 209 (43) 67 (14) 13 (3) 50,000 (30K–72K) 83 (17) 132 (28) 135 (27) 118 (25) 12 (3) 377 (79) 94 (20) 9 (1) 46 (39–53) 15 (9–22) 363 (76) 12 (3) 55 (11) 35 (7) 424 (88) 3 (0.6) 45 (9) 32 (7) 270 (56) 198 (41) 12 (3) 220 (81) 39 (14) 11 (4) 126 (26) 336 (70) 18 (4)
Survey Item 1. The majority of time do you practice in a:
2. Is this practice setting:
3. Your emergency department annual census is: 4. The state you practice in is: (responses categorized into Census Region)
5. Your gender is: 6. Your age is: 7. Number of years in Emergency Medicine practice: 8. Type of training/board qualification:
9. Have you had any formal education in alcohol/ substance abuse? If yes: Was it in residency training? 10. Do you have a formal tool that you use in your practice to screen for alcohol/substance abuse? If yes: (check all that apply to you) CAGE AUDIT BMAST TWEAK Other 11. Do you have a means of referring patients for alcohol/substance treatment? If yes: (check all that apply to you) Inpatient detox Outpatient treatment AA Designated staff for alcohol/substance interventions 12. What percentage of patients do you estimate you screen for alcohol/substance abuse who present to the emergency department specifically for alcohol/substance intoxication? 13. What percentage of patients do estimate you personally screen or confront for alcohol/ substance abuse who present to the emergency department injured or ill and with suspected alcohol/substance use (excluding intoxication)? 14. Do you have a discharge instruction sheet that is specifically for alcohol/substance abuse?
1- Yes 2- No 99- Missing
39 (72) 4 (7) 1 (2) 1 (2) 12 (22) 254 (91) 19 (7) 7 (2)
112 (89) 8 (6) 1 (0.8) 3 (0.8) 16 (13) 431 (90) 28 (6) 21 (4)
160 (63) 214 (84) 124 (49) 120 (47)
241 (56) 377 (87) 151 (35) 180 (42)
Median (IQR)
15 (2–100)
20 (5–90)
Median (IQR)
15 (5–60)
20 (5–50)
1- Yes 2- No 3- Don’t know 99- Missing
102 (36) 145 (52) 22 (8) 11 (4)
348 (73) 108 (23) 0 (0) 24 (4) (Continued )
Emergency Physician Utilization of Alcohol/Substance Screening
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Table 1. Continued
Survey Item If no: Do you have a discharge instruction sheet that includes alcohol/substance abuse somewhere in its content? 15. If you have or had a discharge instruction sheet specifically for alcohol/substance abuse how often do you think you would use it in patients with suspected alcohol/substance abuse? 16. For those individuals in you whom you would not use a discharge instruction sheet specifically for alcohol/substance abuse, (if you had one) why not? (check all that apply to you) Possible patient repercussions Feel it is not my place Don’t use discharge instruction sheets Feel it would not impact on the patient Other: 17. Regarding fear of patient repercussions, how often would you say that this would be a factor?
18. If you had a nationally sanctioned alcohol/ substance abuse discharge instruction sheet how often do you think you would use it?
Responses 1- Yes 2- No 3- Don’t know 99- Missing 1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing
1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing 1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing
1999 Survey (n = 280), n (%)
2010 Survey (n = 480), n (%)
27 (19) 61 (42) 9 (6) 48 (33) 6 (2) 10 (4) 75 (27) 129 (46) 34 (12) 26 (9)
29 (27) 33 (31) 15 (14) 31 (29) 0 (0) 10 (2) 117 (24) 238 (50) 94 (20) 21 (4)
46 (16) 6 (2) 4 (1) 105 (38)
106 (22) 8 (2) 7 (1) 187 (38)
56 (20) 123 (44) 73 (26) 7 (3) 0 (0) 21 (7) 2 (1) 6 (2) 95 (34) 124 (44) 37 (13) 16 (6)
140 (29) 189 (39) 110 (23) 18 (4) 1 (0) 22 (5) 7 (1) 10 (2) 141 (29) 198 (41) 109 (23) 15 (4)
SBIRT = Screening, Brief Intervention and Referral to Treatment; IQR = interquartile range; EM = emergency medicine; CAGE = Cut-down, Annoyed, Guilty, Eye-opener; AUDIT = Alcohol Use Disorders Identification Test; BMAST = brief Michigan Alcoholism Screening Test; TWEAK = Tolerance, Worried, Eye-opener, Amnesia, Kut-down; AA = Alcoholics Anonymous.
In 2010, of the 516 responses, 480 (93%, 95% CI 90–95%) included completed surveys. The two longitudinal survey results were similar with respect to age, location, number of years practicing, and gender of respondents (Table 1). There was no significant difference between the median percentage of alcohol/ substance abuse (A/SA)-screened patients in 1999 (median 15, 95% CI 10–27%) vs. 2010 (median 20%, 95% CI 10–30%) Among the 2010 respondents, only 126 respondents (26%) indicated that they have a formal tool they use for screening. Among these, 107 (85%) indicated that they use the Cut-down, Annoyed, Guilty, Eyeopener (CAGE) tool. In 2010, there were more emergency physicians who reported that they would almost always or always use discharge instructions that were specific for A/SA, if available when compared to the respondents in 1999, 332/4802010 (69%, 95% CI 65–73%) vs. 163/2801999 (58%, 95% CI 52–64%). The most common reason to not give substance abuse discharge instructions in both 1999 and 2010 was ‘‘feeling it would not impact the patient.’’
DISCUSSION Despite educational efforts and numerous scientific studies showing the efficacy of alcohol screening and addressing A/SA with patients, the practice of emergency physicians over the past 10 years has seen little change (4–7,12,13). A 2008 survey of ED directors of Level I and Level II US institutions examined alcohol screening and intervention practices and found that only 7% had either routine formal training or had hosted a formal training in brief alcohol intervention techniques (14). This same study showed that only 56% of ED directors were aware of the 2007 American College of Surgeons ‘‘Green Book’’ recommendations for alcohol screening for Level I and II trauma centers for admitted patients (14). Even though our study shows increased formal training of practitioners, it seems there has been no integration into their practice of this education. One potential reason may be that most of the physicians surveyed used the CAGE and not formal SBI.
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Studies have consistently shown that SBI provided by a physician can increase the likelihood of a patient following up for further treatment for alcohol/substance misuse and can significantly decrease future substance abuse (5–7,15,16). One such study demonstrated an up to 67.7% decrease in drug abuse and 38.6% decrease in alcohol use at some sites (5). Although SBIRT programs began to be implemented in the ED in 1957, it was not formally utilized until much later (17). It was during these years that the work of Ed and Judith Bernstein, D’Onofrio, and others really began to attempt to disseminate this knowledge base into the general emergency medicine residency training and practices of emergency physicians. SBIRT is aimed at universal screening of patients with regard to substance use to identify patients who are at risk for substance misuse, as well as those patients who already exhibit some substance use disorder. Babor et al. note that, of the numerous studies looking at SBIRT, the majority supports the efficacy of the program when applied to misuse of alcohol (6). There are some negative studies for SBI and alcohol. Daeppen et al. reported evidence that SBI did not reduce drinking or health care utilization addiction (18). Other studies showed no decrease in drinking, but decreased harm. D’Onofrio demonstrated that SBIRT education for emergency medicine residents improved knowledge and SBIRT utilization from 17% to 58% (12). They also reported that training and education on SBIRT over a 3-month time period demonstrated an 11% improvement in confidence by providers with respect to performing SBIRT, and a 7% increase in perceived responsibility to perform SBIRT. That same study showed a 12-month partially sustained improvement in continuing to deliver SBIRT services to patients (12). Yet in 2006, the Academic ED SBIRT Research Collaborative survey results suggested that the majority of providers surveyed had < 10 h of alcohol education in their postgraduate training (13). However, in a busy ED, or if physicians don’t have time for further training, it has been shown that discharge instructions alone can provide a brief intervention. D’Onofrio’s study on scripted discharge instructions vs. the Brief Intervention demonstrated that scripted discharge instructions by providers also had a significant effect in decreasing patients’ substance use (15). Interestingly, in our 1999 and 2010 studies, respondents cited the most common reason for not doing the brief conversation as, ‘‘they felt it would have no impact.’’ However, studies clearly demonstrate that SBI does have a profound impact on harm reduction. Multiple studies show significant decrease in AS/A after a provider screens and performs the brief intervention (5,7,13,16). This misconception by providers and the lack of resource utilization in SBI points to the need for better education that is directed at
K. B. Broderick et al.
these specific areas. More literature on this topic is needed in emergency medicine to educate and stimulate possible discourse and further research. Despite earlier research that indicated the need for widespread SBIRT education for physicians, to our knowledge, this has not been implemented as a standardized part of any emergency medicine curriculum (7). The Substance Abuse and Mental Health Services Administration (SAMHSA) has multiple SBI professional school grantees. These grantees include medical, nursing, and pharmacy schools, in an effort to develop ‘‘Best Practices’’ in curriculum development and delivery of SBI. The outcomes of these studies are not as yet known. SAMHSA currently has an Request for Application for another cycle of professional school curriculum grants. This shows promise that they are gathering knowledge and Best Practices. There are barriers to implementation of SBI, which may account for the lack of its widespread implementation. Some of these barriers may include: nursing acceptance, time to train on the questions, time to ask the questions, and reluctance to ask based on anticipated resource needs if the questions are positive. Other barriers may be lack of formal training on SBI and alcohol abuse, and societal pressures to not talk about alcohol abuse. Many national organizations have responded to the literature and the need for SBIRT service to be provided to patients, and have called for adoption of routine screening and intervention for substance use. Most measures are particularly in regards to alcohol misuse in ED patients as supported by the literature. Institutions include: American College of Emergency Physicians, American Medical Association, American College of Surgeons, NIAAA, and the National Highway and Traffic Safety Administration (19–23). Despite these institutions’ support for SBI, there has been little evidence of widespread adoption. In February 2012 the Joint Commission published a ‘‘core measure’’ around SBIRT provision of service. Although this is a positive and promising move on the part of The Joint Commission, if or how this has been implemented in hospitals is currently unknown. The United States Preventative Services Task Force recommends that clinicians screen adults for alcohol misuse and provide those with risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse and has level B evidence associated with it (24). Although this is directed at primary care, EDs are a pivotal place to screen and provide SBI due to the high numbers of patients engaging in risky and hazardous drinking, as cited earlier (8). The majority of physicians practicing Emergency Medicine surveyed in our study are not significantly screening for A/SA despite having access to some
Emergency Physician Utilization of Alcohol/Substance Screening
resources for alcohol abuse. This indicates that the majority of EPs may likewise not be screening for A/SA even if resources are available. With statistics clearly stating the growing financial, personal, and societal cost of alcohol abuse, it is imperative that Emergency Medicine physicians gain the knowledge and skill set they need to provide an effective A/SA SBI. The Centers for Disease Control and Prevention, NIAAA, and multiple other organizations have noted that the personal and societal cost of alcohol dependence has continued to increase. Research has shown the positive impact SBI and discharge instructions can have on alcohol use. Although our study has demonstrated that the current educational standards have not led to increased utilization, we feel that further research is needed to examine the roadblocks to widespread implementation and utilization. Limitations There are several limitations to this study. The first is the response rates. However, our response rate(s) are similar to other mailed surveys to emergency physicians and trauma surgeons on the subject (25–27). An additional limitation of this analysis is that we are inferring practices according to the responses that we received. These may not fully represent the practices, perceptions, and attitudes of all emergency physicians. It is highly probable that the responders were more engaged in this topic and thus more likely to respond. If this assumption is correct, the actual number of emergency physicians who screen and refer is most likely lower than our results state. Due to the anonymous design of this survey, we are unable to characterize the nonresponders. However, because responses were anonymous, there is less reason to believe that survey responses were biased. CONCLUSIONS We found no significant difference when comparing the survey results from 1999 to 2010. Although 90% of respondents have means of referral for A/SA, the screening median was only between 15% and 20% for both surveys. With more education and social awareness of the repercussions of A/SA, it is extremely surprising to see no change in the implementation of screening and discharge instructions. With the results of this study showing no significant change from 1999 to 2010, we need to further explore other methods to disseminate information and resources to physicians and patients. We recommend further research toward identifying the barriers in the implementation and
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utility of Substance Screening and Brief Intervention Programs.
REFERENCES 1. Centers for Disease Control and Prevention (CDC). Alcohol-related disease impact (ARDI). Available at: http://www.cdc.gov/alcohol/ ardi.htm. Accessed April 17, 2015. 2. Chen CM, Yi H. Trends in alcohol-related morbidity among shortstay community hospital discharges, United States, 1979-2010. Surveillance Report #94. National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/ Surveillance94/HDS10.htm. Accessed April 17, 2015. 3. Bouchery EE, Harwood HJ, Sacks JJ. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 2011;41: 516–24. 4. Saitz RM. Screening and brief intervention enter their 5th decade. Subst Abus 2007;28:3–6. 5. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend 2009;99:280–95. 6. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus 2007;28:7–30. 7. D’Onofrio G, Degutis L. Preventative care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med 2002;9:627–38. 8. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data 2003;(335):1–29. 9. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;(26):1–31. 10. The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies); 2010. Available at: http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/ 31921. Accessed April 17, 2015. 11. Broderick KB. Alcohol/Substance Abuse regarding Screening and Discharge Instruction Utilization in Emergency Physician Practices. Presented at ACEP 2000, Philadelphia. Ann Emerg Med 2000;36(4):S71. 12. D’Onofrio G, Nadel ES, Degutis LC, et al. Improving emergency medicine residents’ approach to patients with alcohol problems: a controlled educational trial. Ann Emerg Med 2002; 40:50–62. 13. Bernstein E, Bernstein J, Feldman J, et al. An evidence-based alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Subst Abus 2007;28:79–92. 14. Cunningham RM, Harrison SR, McKay MP, et al. National survey of emergency department alcohol screening and intervention practices. Ann Emerg Med 2010;55:555–62. 15. D’Onofrio G, Pantalon MV, Degutis LC. Brief intervention for hazardous and harmful drinkers in the emergency department. Ann Emerg Med 2008;51:742–50. 16. Gentiello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999;230:473–80. 17. Bernstein E, Bernstein JA, Stein JB, Saitz R. SBIRT in emergency care settings: are we ready to take it to scale? Acad Emerg Med 2009;16:1072–7.
406 18. Daeppen JB, Gaume J, Brady P, et al. Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controlled trial. Addiction 2007;102:1224–33. 19. American College of Emergency Physicians (ACEP). Policy compendium. Available at: http://www.acep.org/workarea/Download Asset.aspx?id=101698. Accessed April 9, 2015. 20. American Medical Association (AMA). Screening for alcohol and other drug use in trauma patients. 1991 Resolution A91. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/amacouncils/council-science-public-health/reports/reports-topic.page? ;alcohol/nicotine/other drug use, Screening and Brief Intervention for Alcohol Problems, I-99. Accessed April 9, 2015. 21. American College of Surgeons. Statement on insurance, alcoholrelated injuries, and trauma centers. Available at: https://www.facs. org/about-acs/statements/55-alcohol-trauma. Accessed April 9, 2015. 22. National Institute on Alcohol Abuse and Alcoholism. Search results: SBIRT. Available at: http://www.niaaa.nih.gov/search/site/ SBIRT. Accessed April 9, 2015.
K. B. Broderick et al. 23. National Highway Traffic Safety Administration. Search results: SBIRT. Available at: http://www.nhtsa.gov/search?q=SBIRT. Accessed April 9, 2015. 24. U.S. Preventative Services Task Force. Alcohol misuse: screening and behavioral counseling interventions in primary care. Available at: http://www.uspreventiveservicestaskforce.org/ Page/Topic/recommendation-summary/alcohol-misuse-screeningand-behavioral-counseling-interventions-in-primary-care. Accessed April 17, 2015. 25. Graham DM, Maio RF, Blow FC, et al. Emergency physician attitudes concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report. J Addict Dis 2000;19:45–53. 26. Schermer CR, Gentilello LM, Hoyt DB, et al. National survey of trauma surgeons’ use of alcohol screening and brief intervention. J Trauma 2003;55:849–56. 27. Danielsson PE, Rivara FP, Gentilello LM, et al. Reasons why trauma surgeons fail to screen for alcohol problems. Arch Surg 1999;134:564–8.
Emergency Physician Utilization of Alcohol/Substance Screening
ARTICLE SUMMARY 1. Why is this topic important? Substance abuse is pervasive in our emergency department populations. Screening and giving brief advice changes patients’ behavior. But first we must change the practice behaviors of emergency physicians. 2. What does the study attempt to show? The interval change over the 10-year period of emergency physician attitudes and practices around substance screening and brief advice. 3. What are the key findings? There has been no significant change in behaviors over the past 10 years. 4. How is patient care impacted? This is a lost opportunity to do harm reduction in our emergency patients, This is a lost opportunity to do harm reduction in our emergency patients. This may inform studies going forward on how to study impact on provider screening and advice.
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http://dx.doi.org/10.1016/j.jemermed.2015.05.014
Original Contributions
EMERGENCY PHYSICIAN UTILIZATION OF ALCOHOL/SUBSTANCE SCREENING, BRIEF ADVICE AND DISCHARGE: A 10-YEAR COMPARISON Kerryann B. Broderick, BSN, MD,* Bonnie Kaplan, MD,† Dyllon Martini, MD,† and Emily Caruso, MSPH* *Denver Health Medical Center, Denver, Colorado and †University of Colorado at Denver, Denver, Colorado Reprint Address: Kerryann B. Broderick, BSN, MD, Denver Health Medical Center, 777 Bannock St., MC#0108, Denver, CO 80204
, Keywords—SBIRT; alcohol abuse; substance abuse; emergency department; discharge advice; substance screening
, Abstract—Background: In 2007, of the 130 million emergency department (ED) visits, 38 million were due to injury, and of those, 1.9 million involved alcohol. The emergency department is a pivotal place to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) due to the high number of patients presenting with alcohol/substance abuse risk factors or related injuries. Study Objective: This study compares two surveys, approximately 11 years apart, of emergency physicians nationwide which assesses the use of validated screening tools, the availability of community resources for alcohol/substance abuse treatment, and the prevailing attitudes of emergency physicians regarding Screening and Brief Intervention for alcohol/substance abuse. Methods: We performed crosssectional anonymous surveys of 1500 emergency physicians drawn from American College of Emergency Physicians members. The survey results were compared for time interval change. Results: The two surveys had comparable response rates. The median percentage of patients screened for alcohol/substance abuse in 1999 was 15%, vs. 20% in 2010. In 2010, 26% of emergency physicians had a formal screening tool, and the majority used Cut-down, Annoyed, Guilty, Eye-opener (85%). In 2010, a statistically significant increase in the number of emergency physicians said they would ‘‘always’’ or ‘‘almost always’’ use discharge instructions that were specific for alcohol/substance abuse, if available, vs. 1999. Conclusion: Few emergency physicians screen for alcohol/substance abuse despite evidence that screening and brief intervention is effective. Emergency physicians are receptive to the use of discharge material. Ó 2015 Elsevier Inc.
INTRODUCTION Approximately 88,000 deaths per year are attributed to excessive alcohol use in the United States. In addition, this excessive alcohol use accounts for ‘‘2.3 million years of potential life lost per year’’ (1). Chen and Yi reported that more than 1.9 million hospitalizations in 2010 in the United States (US) were attributed to alcohol-related causes (2). This is an increase in 300,000 deaths since 2005. Bouchery et al. estimate that in 2006 the estimated economic cost of excessive drinking was $223.5 billion, which is an increase of $38.5 billion from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimate in 2005 (3). The Screening and Brief Intervention (SBI) technique has been studied since the early 1960s as a way to address risky behavior in patients who present to physicians for causes both directly and indirectly related to alcohol/ substance abuse (4). Studies have consistently shown that SBI provided by a physician can increase the likelihood of a patient following up for further treatment for alcohol/substance misuse and can significantly decrease future substance abuse (4–7).
RECEIVED: 8 November 2014; FINAL SUBMISSION RECEIVED: 20 April 2015; ACCEPTED: 14 May 2015 400
Emergency Physician Utilization of Alcohol/Substance Screening
The emergency department (ED) is a pivotal place to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) due to the high number of patients presenting with alcohol/substance abuse risk factors or related injuries. In 2001, 2.5 million of 107.5 million visits to the ED were due to alcohol alone (8). In 2007, of the 130 million ED visits, 38 million were due to injury, and of those, 1.9 million involved alcohol (9). The Drug Abuse Warning Network estimates that in 2009, about 2.1 million ED visits resulted from medical emergencies involving drug misuse or abuse (10). Of those, 21.2% involved illicit drugs and 14.3% involved alcohol in combination with other drugs (10). Despite research indicating the need for widespread SBIRT education for physicians, to our knowledge, this has not been implemented routinely in emergency medicine curricula (7). The impact of the literature to date, as well as the federal grants and programs aimed at improving SBIRT service provision to patients, has not been adequately assessed. Our study attempted to assess if the presence of SBIRT programs and heightened awareness of SBIRT have increased rates of physician utilization of substance screening and referral. We hypothesized that the awareness of, access to, and use of validated screening tools and specific discharge instructions has increased in the 10 years interim when compared to a similar study conducted in 1999 (11). The specific aims of this study will be to measure and compare to similar 1999 data: 1) proportions of physicians who utilize validated screening tools, 2) rates at which physicians directly address substance misuse with patients, 3) the percentage of physicians who have access to discharge instructions for substance abuse, and 4) how often physicians do or would use discharge instruction sheets, when available. METHODS Study Design Cross-sectional self-administered surveys were mailed and completed in 1999 and 2010. Study Setting and Population Both survey studies utilized the same tool and target population pool. An anonymous survey instrument was mailed to emergency medicine physicians along with an introductory letter explaining the nature of the study. We utilized randomly generated mailing list(s) purchased from the American College of Emergency Physicians. Multiple mailings (up to three) were mailed
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to nonrespondents. These studies were approved by the University of Buffalo, School of Medicine (1999) and the University of Colorado at Denver, School of Medicine (2010), respectively. Survey Content The lead author, Kerryann B. Broderick, piloted this survey twice prior to the original 1999 study. The original survey tool draft was first sent to 10 emergency physicians (EPs) from around the country, all of whom had some expertise in survey methodology. Their comments were reviewed and the survey was revised to better reflect those comments. The survey was then sent out to 10 different emergency physicians who were not known experts in survey methodology. Their feedback was also incorporated into the survey and the final version was used in both studies. Data were collected using a closed-response survey tool consisting of 18 questions. Questions consisted of both epidemiological and those designed to measure emergency physicians’ rates of: 1) utilization of validated screening tools; 2) directly addressing substance abuse issues with patients; 3) access to discharge instructions for substance abuse; and 4) physician discharge instruction sheet utilization rates. A numerical system was utilized to track nonresponders for purposes of repeated survey mailings. This number was compared to respondents’ names and marked as completed by a research assistant. This research assistant was not involved in data analysis and only checked which number responded. The survey instrument was de-identified from the participant data. Data Analysis Data were entered into an Access database (Microsoft Corporation, Redmond, WA) and transferred into SAS or Stata formats using translational software (dfPower/ DBMS Copy, DataFlux Corporation, Cary, NC). All statistical analyses were performed using SAS Version 9.2 (SAS Institute, Inc., Cary, NC) or Stata Version 10 (Stata Corporation, College Station, TX). Descriptive statistics for continuous variables were expressed as medians with interquartile ranges, and proportions as percentages with 95% confidence intervals (CIs). RESULTS Survey response rates were comparable between the two surveys. In 1999, 280/500 surveys were obtained (56%, 95% CI 52–60%), and in 2010, 516/1000 (52%, 95% CI 48–55%) responses were obtained.
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Table 1. SBIRT National Survey: Overall Results Summary Table Responses
1999 Survey (n = 280), n (%)
2010 Survey (n = 480), n (%)
1- Community hospital 2- Urgent care facility 3- Academic/tertiary hospital 99- Missing 1- Urban 2- Suburban 3- Rural 99- Missing Median (IQR) Northeast South Midwest West Missing 1- Male 2- Female 99- Missing Median (IQR) Median (IQR) EM residency trained Surgical residency trained Medicine residency trained Family medicine trained EM boarded or qualified Surgical boarded or eligible Medicine boarded or eligible Family medicine boarded or eligible 1- Yes 2- No 99- Missing 1- Yes 2- No 99- Missing 1- Yes 2- No 99- Missing
201 (72) 6 (2) 67 (24) 6 (2) 123 (44) 110 (39) 37 (13) 10 (4) 36,000 (25K–50K) 45 (16) 75 (27) 73 (26) 77 (27) 10 (4) 213 (76) 61 (22) 6 (2) 43 (38–48) 12 (7–18) 162 (58) 17 (6) 37 (13) 27 (13) 249 (89) 3 (1) 35 (13) 27 (10) 158 (56) 115 (41) 7 (3) 103 (65) 15 (9) 40 (25) 54 (19) 221 (79) 5 (2)
340 (71) 12 (3) 118 (24) 10 (2) 191 (40) 209 (43) 67 (14) 13 (3) 50,000 (30K–72K) 83 (17) 132 (28) 135 (27) 118 (25) 12 (3) 377 (79) 94 (20) 9 (1) 46 (39–53) 15 (9–22) 363 (76) 12 (3) 55 (11) 35 (7) 424 (88) 3 (0.6) 45 (9) 32 (7) 270 (56) 198 (41) 12 (3) 220 (81) 39 (14) 11 (4) 126 (26) 336 (70) 18 (4)
Survey Item 1. The majority of time do you practice in a:
2. Is this practice setting:
3. Your emergency department annual census is: 4. The state you practice in is: (responses categorized into Census Region)
5. Your gender is: 6. Your age is: 7. Number of years in Emergency Medicine practice: 8. Type of training/board qualification:
9. Have you had any formal education in alcohol/ substance abuse? If yes: Was it in residency training? 10. Do you have a formal tool that you use in your practice to screen for alcohol/substance abuse? If yes: (check all that apply to you) CAGE AUDIT BMAST TWEAK Other 11. Do you have a means of referring patients for alcohol/substance treatment? If yes: (check all that apply to you) Inpatient detox Outpatient treatment AA Designated staff for alcohol/substance interventions 12. What percentage of patients do you estimate you screen for alcohol/substance abuse who present to the emergency department specifically for alcohol/substance intoxication? 13. What percentage of patients do estimate you personally screen or confront for alcohol/ substance abuse who present to the emergency department injured or ill and with suspected alcohol/substance use (excluding intoxication)? 14. Do you have a discharge instruction sheet that is specifically for alcohol/substance abuse?
1- Yes 2- No 99- Missing
39 (72) 4 (7) 1 (2) 1 (2) 12 (22) 254 (91) 19 (7) 7 (2)
112 (89) 8 (6) 1 (0.8) 3 (0.8) 16 (13) 431 (90) 28 (6) 21 (4)
160 (63) 214 (84) 124 (49) 120 (47)
241 (56) 377 (87) 151 (35) 180 (42)
Median (IQR)
15 (2–100)
20 (5–90)
Median (IQR)
15 (5–60)
20 (5–50)
1- Yes 2- No 3- Don’t know 99- Missing
102 (36) 145 (52) 22 (8) 11 (4)
348 (73) 108 (23) 0 (0) 24 (4) (Continued )
Emergency Physician Utilization of Alcohol/Substance Screening
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Table 1. Continued
Survey Item If no: Do you have a discharge instruction sheet that includes alcohol/substance abuse somewhere in its content? 15. If you have or had a discharge instruction sheet specifically for alcohol/substance abuse how often do you think you would use it in patients with suspected alcohol/substance abuse? 16. For those individuals in you whom you would not use a discharge instruction sheet specifically for alcohol/substance abuse, (if you had one) why not? (check all that apply to you) Possible patient repercussions Feel it is not my place Don’t use discharge instruction sheets Feel it would not impact on the patient Other: 17. Regarding fear of patient repercussions, how often would you say that this would be a factor?
18. If you had a nationally sanctioned alcohol/ substance abuse discharge instruction sheet how often do you think you would use it?
Responses 1- Yes 2- No 3- Don’t know 99- Missing 1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing
1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing 1- Never 2- Almost never 3- Sometimes 4- Almost always 5- Always 99- Missing
1999 Survey (n = 280), n (%)
2010 Survey (n = 480), n (%)
27 (19) 61 (42) 9 (6) 48 (33) 6 (2) 10 (4) 75 (27) 129 (46) 34 (12) 26 (9)
29 (27) 33 (31) 15 (14) 31 (29) 0 (0) 10 (2) 117 (24) 238 (50) 94 (20) 21 (4)
46 (16) 6 (2) 4 (1) 105 (38)
106 (22) 8 (2) 7 (1) 187 (38)
56 (20) 123 (44) 73 (26) 7 (3) 0 (0) 21 (7) 2 (1) 6 (2) 95 (34) 124 (44) 37 (13) 16 (6)
140 (29) 189 (39) 110 (23) 18 (4) 1 (0) 22 (5) 7 (1) 10 (2) 141 (29) 198 (41) 109 (23) 15 (4)
SBIRT = Screening, Brief Intervention and Referral to Treatment; IQR = interquartile range; EM = emergency medicine; CAGE = Cut-down, Annoyed, Guilty, Eye-opener; AUDIT = Alcohol Use Disorders Identification Test; BMAST = brief Michigan Alcoholism Screening Test; TWEAK = Tolerance, Worried, Eye-opener, Amnesia, Kut-down; AA = Alcoholics Anonymous.
In 2010, of the 516 responses, 480 (93%, 95% CI 90–95%) included completed surveys. The two longitudinal survey results were similar with respect to age, location, number of years practicing, and gender of respondents (Table 1). There was no significant difference between the median percentage of alcohol/ substance abuse (A/SA)-screened patients in 1999 (median 15, 95% CI 10–27%) vs. 2010 (median 20%, 95% CI 10–30%) Among the 2010 respondents, only 126 respondents (26%) indicated that they have a formal tool they use for screening. Among these, 107 (85%) indicated that they use the Cut-down, Annoyed, Guilty, Eyeopener (CAGE) tool. In 2010, there were more emergency physicians who reported that they would almost always or always use discharge instructions that were specific for A/SA, if available when compared to the respondents in 1999, 332/4802010 (69%, 95% CI 65–73%) vs. 163/2801999 (58%, 95% CI 52–64%). The most common reason to not give substance abuse discharge instructions in both 1999 and 2010 was ‘‘feeling it would not impact the patient.’’
DISCUSSION Despite educational efforts and numerous scientific studies showing the efficacy of alcohol screening and addressing A/SA with patients, the practice of emergency physicians over the past 10 years has seen little change (4–7,12,13). A 2008 survey of ED directors of Level I and Level II US institutions examined alcohol screening and intervention practices and found that only 7% had either routine formal training or had hosted a formal training in brief alcohol intervention techniques (14). This same study showed that only 56% of ED directors were aware of the 2007 American College of Surgeons ‘‘Green Book’’ recommendations for alcohol screening for Level I and II trauma centers for admitted patients (14). Even though our study shows increased formal training of practitioners, it seems there has been no integration into their practice of this education. One potential reason may be that most of the physicians surveyed used the CAGE and not formal SBI.
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Studies have consistently shown that SBI provided by a physician can increase the likelihood of a patient following up for further treatment for alcohol/substance misuse and can significantly decrease future substance abuse (5–7,15,16). One such study demonstrated an up to 67.7% decrease in drug abuse and 38.6% decrease in alcohol use at some sites (5). Although SBIRT programs began to be implemented in the ED in 1957, it was not formally utilized until much later (17). It was during these years that the work of Ed and Judith Bernstein, D’Onofrio, and others really began to attempt to disseminate this knowledge base into the general emergency medicine residency training and practices of emergency physicians. SBIRT is aimed at universal screening of patients with regard to substance use to identify patients who are at risk for substance misuse, as well as those patients who already exhibit some substance use disorder. Babor et al. note that, of the numerous studies looking at SBIRT, the majority supports the efficacy of the program when applied to misuse of alcohol (6). There are some negative studies for SBI and alcohol. Daeppen et al. reported evidence that SBI did not reduce drinking or health care utilization addiction (18). Other studies showed no decrease in drinking, but decreased harm. D’Onofrio demonstrated that SBIRT education for emergency medicine residents improved knowledge and SBIRT utilization from 17% to 58% (12). They also reported that training and education on SBIRT over a 3-month time period demonstrated an 11% improvement in confidence by providers with respect to performing SBIRT, and a 7% increase in perceived responsibility to perform SBIRT. That same study showed a 12-month partially sustained improvement in continuing to deliver SBIRT services to patients (12). Yet in 2006, the Academic ED SBIRT Research Collaborative survey results suggested that the majority of providers surveyed had < 10 h of alcohol education in their postgraduate training (13). However, in a busy ED, or if physicians don’t have time for further training, it has been shown that discharge instructions alone can provide a brief intervention. D’Onofrio’s study on scripted discharge instructions vs. the Brief Intervention demonstrated that scripted discharge instructions by providers also had a significant effect in decreasing patients’ substance use (15). Interestingly, in our 1999 and 2010 studies, respondents cited the most common reason for not doing the brief conversation as, ‘‘they felt it would have no impact.’’ However, studies clearly demonstrate that SBI does have a profound impact on harm reduction. Multiple studies show significant decrease in AS/A after a provider screens and performs the brief intervention (5,7,13,16). This misconception by providers and the lack of resource utilization in SBI points to the need for better education that is directed at
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these specific areas. More literature on this topic is needed in emergency medicine to educate and stimulate possible discourse and further research. Despite earlier research that indicated the need for widespread SBIRT education for physicians, to our knowledge, this has not been implemented as a standardized part of any emergency medicine curriculum (7). The Substance Abuse and Mental Health Services Administration (SAMHSA) has multiple SBI professional school grantees. These grantees include medical, nursing, and pharmacy schools, in an effort to develop ‘‘Best Practices’’ in curriculum development and delivery of SBI. The outcomes of these studies are not as yet known. SAMHSA currently has an Request for Application for another cycle of professional school curriculum grants. This shows promise that they are gathering knowledge and Best Practices. There are barriers to implementation of SBI, which may account for the lack of its widespread implementation. Some of these barriers may include: nursing acceptance, time to train on the questions, time to ask the questions, and reluctance to ask based on anticipated resource needs if the questions are positive. Other barriers may be lack of formal training on SBI and alcohol abuse, and societal pressures to not talk about alcohol abuse. Many national organizations have responded to the literature and the need for SBIRT service to be provided to patients, and have called for adoption of routine screening and intervention for substance use. Most measures are particularly in regards to alcohol misuse in ED patients as supported by the literature. Institutions include: American College of Emergency Physicians, American Medical Association, American College of Surgeons, NIAAA, and the National Highway and Traffic Safety Administration (19–23). Despite these institutions’ support for SBI, there has been little evidence of widespread adoption. In February 2012 the Joint Commission published a ‘‘core measure’’ around SBIRT provision of service. Although this is a positive and promising move on the part of The Joint Commission, if or how this has been implemented in hospitals is currently unknown. The United States Preventative Services Task Force recommends that clinicians screen adults for alcohol misuse and provide those with risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse and has level B evidence associated with it (24). Although this is directed at primary care, EDs are a pivotal place to screen and provide SBI due to the high numbers of patients engaging in risky and hazardous drinking, as cited earlier (8). The majority of physicians practicing Emergency Medicine surveyed in our study are not significantly screening for A/SA despite having access to some
Emergency Physician Utilization of Alcohol/Substance Screening
resources for alcohol abuse. This indicates that the majority of EPs may likewise not be screening for A/SA even if resources are available. With statistics clearly stating the growing financial, personal, and societal cost of alcohol abuse, it is imperative that Emergency Medicine physicians gain the knowledge and skill set they need to provide an effective A/SA SBI. The Centers for Disease Control and Prevention, NIAAA, and multiple other organizations have noted that the personal and societal cost of alcohol dependence has continued to increase. Research has shown the positive impact SBI and discharge instructions can have on alcohol use. Although our study has demonstrated that the current educational standards have not led to increased utilization, we feel that further research is needed to examine the roadblocks to widespread implementation and utilization. Limitations There are several limitations to this study. The first is the response rates. However, our response rate(s) are similar to other mailed surveys to emergency physicians and trauma surgeons on the subject (25–27). An additional limitation of this analysis is that we are inferring practices according to the responses that we received. These may not fully represent the practices, perceptions, and attitudes of all emergency physicians. It is highly probable that the responders were more engaged in this topic and thus more likely to respond. If this assumption is correct, the actual number of emergency physicians who screen and refer is most likely lower than our results state. Due to the anonymous design of this survey, we are unable to characterize the nonresponders. However, because responses were anonymous, there is less reason to believe that survey responses were biased. CONCLUSIONS We found no significant difference when comparing the survey results from 1999 to 2010. Although 90% of respondents have means of referral for A/SA, the screening median was only between 15% and 20% for both surveys. With more education and social awareness of the repercussions of A/SA, it is extremely surprising to see no change in the implementation of screening and discharge instructions. With the results of this study showing no significant change from 1999 to 2010, we need to further explore other methods to disseminate information and resources to physicians and patients. We recommend further research toward identifying the barriers in the implementation and
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utility of Substance Screening and Brief Intervention Programs.
REFERENCES 1. Centers for Disease Control and Prevention (CDC). Alcohol-related disease impact (ARDI). Available at: http://www.cdc.gov/alcohol/ ardi.htm. Accessed April 17, 2015. 2. Chen CM, Yi H. Trends in alcohol-related morbidity among shortstay community hospital discharges, United States, 1979-2010. Surveillance Report #94. National Institute on Alcohol Abuse and Alcoholism. Available at: http://pubs.niaaa.nih.gov/publications/ Surveillance94/HDS10.htm. Accessed April 17, 2015. 3. Bouchery EE, Harwood HJ, Sacks JJ. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med 2011;41: 516–24. 4. Saitz RM. Screening and brief intervention enter their 5th decade. Subst Abus 2007;28:3–6. 5. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend 2009;99:280–95. 6. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abus 2007;28:7–30. 7. D’Onofrio G, Degutis L. Preventative care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med 2002;9:627–38. 8. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data 2003;(335):1–29. 9. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;(26):1–31. 10. The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (formerly the Office of Applied Studies); 2010. Available at: http://www.icpsr.umich.edu/icpsrweb/SAMHDA/studies/ 31921. Accessed April 17, 2015. 11. Broderick KB. Alcohol/Substance Abuse regarding Screening and Discharge Instruction Utilization in Emergency Physician Practices. Presented at ACEP 2000, Philadelphia. Ann Emerg Med 2000;36(4):S71. 12. D’Onofrio G, Nadel ES, Degutis LC, et al. Improving emergency medicine residents’ approach to patients with alcohol problems: a controlled educational trial. Ann Emerg Med 2002; 40:50–62. 13. Bernstein E, Bernstein J, Feldman J, et al. An evidence-based alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Subst Abus 2007;28:79–92. 14. Cunningham RM, Harrison SR, McKay MP, et al. National survey of emergency department alcohol screening and intervention practices. Ann Emerg Med 2010;55:555–62. 15. D’Onofrio G, Pantalon MV, Degutis LC. Brief intervention for hazardous and harmful drinkers in the emergency department. Ann Emerg Med 2008;51:742–50. 16. Gentiello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999;230:473–80. 17. Bernstein E, Bernstein JA, Stein JB, Saitz R. SBIRT in emergency care settings: are we ready to take it to scale? Acad Emerg Med 2009;16:1072–7.
406 18. Daeppen JB, Gaume J, Brady P, et al. Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controlled trial. Addiction 2007;102:1224–33. 19. American College of Emergency Physicians (ACEP). Policy compendium. Available at: http://www.acep.org/workarea/Download Asset.aspx?id=101698. Accessed April 9, 2015. 20. American Medical Association (AMA). Screening for alcohol and other drug use in trauma patients. 1991 Resolution A91. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/amacouncils/council-science-public-health/reports/reports-topic.page? ;alcohol/nicotine/other drug use, Screening and Brief Intervention for Alcohol Problems, I-99. Accessed April 9, 2015. 21. American College of Surgeons. Statement on insurance, alcoholrelated injuries, and trauma centers. Available at: https://www.facs. org/about-acs/statements/55-alcohol-trauma. Accessed April 9, 2015. 22. National Institute on Alcohol Abuse and Alcoholism. Search results: SBIRT. Available at: http://www.niaaa.nih.gov/search/site/ SBIRT. Accessed April 9, 2015.
K. B. Broderick et al. 23. National Highway Traffic Safety Administration. Search results: SBIRT. Available at: http://www.nhtsa.gov/search?q=SBIRT. Accessed April 9, 2015. 24. U.S. Preventative Services Task Force. Alcohol misuse: screening and behavioral counseling interventions in primary care. Available at: http://www.uspreventiveservicestaskforce.org/ Page/Topic/recommendation-summary/alcohol-misuse-screeningand-behavioral-counseling-interventions-in-primary-care. Accessed April 17, 2015. 25. Graham DM, Maio RF, Blow FC, et al. Emergency physician attitudes concerning intervention for alcohol abuse/dependence delivered in the emergency department: a brief report. J Addict Dis 2000;19:45–53. 26. Schermer CR, Gentilello LM, Hoyt DB, et al. National survey of trauma surgeons’ use of alcohol screening and brief intervention. J Trauma 2003;55:849–56. 27. Danielsson PE, Rivara FP, Gentilello LM, et al. Reasons why trauma surgeons fail to screen for alcohol problems. Arch Surg 1999;134:564–8.
Emergency Physician Utilization of Alcohol/Substance Screening
ARTICLE SUMMARY 1. Why is this topic important? Substance abuse is pervasive in our emergency department populations. Screening and giving brief advice changes patients’ behavior. But first we must change the practice behaviors of emergency physicians. 2. What does the study attempt to show? The interval change over the 10-year period of emergency physician attitudes and practices around substance screening and brief advice. 3. What are the key findings? There has been no significant change in behaviors over the past 10 years. 4. How is patient care impacted? This is a lost opportunity to do harm reduction in our emergency patients, This is a lost opportunity to do harm reduction in our emergency patients. This may inform studies going forward on how to study impact on provider screening and advice.
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