ABSTRACT
OBJECTIVE: We evaluated the relative effectiveness of 2 interventions for patients with alcohol problems.
STUDY DESIGN: A nonrandomized intervention study was used to compare usual care (control) with a 5- to 15-minute physician-delivered message (brief intervention) and with the physician message plus a 30- to 60-minute visit by a recovering alcoholic (peer intervention). Telephone follow-up was obtained up to 12 months after hospital discharge that focused on patient behaviors during the first 6 months following discharge.
POPULATION: We included 314 patients with alcohol-related injuries admitted to an urban teaching hospital.
OUTCOMES MEASURED: We measured complete abstinence from alcohol during the entire 6 months following hospital discharge, abstinence from alcohol during the sixth month following hospital discharge, and initiation of alcohol treatment or self-help within 6 months of hospital discharge.
RESULTS: Valid responses were obtained from 140 patients (45%). Observed success rates were: 34%, 44%, and 59% (P=.012) for abstinence from alcohol since discharge in the usual care group, the brief intervention group, and the peer intervention group, respectively; 36%, 51%, and 64% (P=.006) for abstinence at the sixth month following hospital discharge; and 9%, 15%, and 49% (P <.001) for initiation of treatment/self-help. During the telephone follow-up interview, several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital. A few patients dramatically changed their lives. They went from being unemployed and homeless to full-time employment and having a permanent residence. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. One of these individuals serves as a volunteer, visiting hospitalized patients with drinking problems.
CONCLUSIONS: Among trauma victims with injuries severe enough to require hospital admission, brief advice from a physician followed by a visit with a recovering alcoholic appears to be an effective intervention. Although further study is needed to confirm these findings, in the meantime physicians can request that members of Alcoholics Anonymous (AA) visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are part of their twelfth-step work (an essential part of the AA program) and are simple, practical, involve no costs, and pose little patient risk. They can be arranged from the patient’s bedside telephone. Some patients will show a dramatic response to these peer visits.
The extent to which the physician intervenes with a hospitalized patient who has an alcohol use disorder correlates with the patient’s reported change in alcohol use after discharge.1 Primary care physicians may be called on to help manage hospitalized patients with alcohol use disorders, but exactly what they should do to help these patients is not always clear.
Alcohol abuse and trauma are common and related clinical problems.2 A dose-response relationship has been observed between alcohol consumption and the risk of fatal injury.3 Traumatic injury is a major public health problem and a leading cause of morbidity and mortality in the United States. It ranks first in years of life lost, first in the utilization of hospital-days, second in disability-adjusted life-years, and fourth in overall mortality.4 Sims and colleagues5 found that violent trauma had a recurrence rate of 44% and a 5-year mortality rate of 20% and that 62% of these patients abused alcohol or drugs. Rivera and coworkers6 found that trauma victims who were intoxicated on presentation to a trauma center were 2.5 times more likely to be readmitted for another injury than those who were not intoxicated, and those with evidence of a chronic alcohol problem were 3.5 times more likely. Others have noted similar findings.7,8 There is a unique opportunity to initiate treatment for patients with substance abuse disorders when they are hospitalized for a traumatic injury.9 Often this opportunity is missed.10,11
It is not known how to intervene with victims of alcohol-related injuries to prevent subsequent injuries. Currently there are several options that could potentially improve the outcomes of hospitalized patients who have substance use disorders, such as brief advice, brief interventions, referral to a consultation team, and referral to a treatment center. At the very least, trauma victims with substance abuse problems should be given some brief advice from the surgeon. Although most surgeons appear willing to give this advice, many feel inadequately prepared to do it.12 Thus, the burden of performing these interventions may fall to the patient’s primary care physician or the physician who is requested by the surgeon to provide consultation services.
A technique known as “brief intervention” consists of advice in a structured format that is given to patients with a substance use disorder.13 These interventions have been found to be effective in a number of clinical settings, including outpatient primary care.14-16 In particular, brief interventions performed by a trained psychologist in a trauma center have been associated with a reduction in alcohol intake and a reduced risk of trauma recidivism.17 However, these interventions require significant physician training to implement. What is needed is a simple and practical method that can be used by primary care physicians that does not require extensive physician training.