Report by Maria Ahmed, MPH Student

Checked by Kevin Mackway-Jones, Faculty Professor

Abstract

A short cut review was carried out to establish whether emergency department (ED) based brief intervention is worthwhile in adults presenting with alcohol related events. A total of 590 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are presented in table 1. The clinical bottom line is that brief psychotherapeutic intervention is worthwhile in adults who attend the emergency department after an alcohol related event.

Three part question

In [adults presenting to the ED with an alcohol related event], is [brief intervention better than standard care] at [reducing subsequent alcohol consumption, reducing alcohol related problems, reducing ED re-attendance and improving psychosocial well-being?]

Clinical scenario

A 33-year-old man arrives at the ED having been involved in a road traffic accident while driving under the influence of alcohol. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated alcohol health workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol related events. Having assessed and treated the patient, you wonder whether it is worthwhile referring him on to them.

Search strategy

Medline 1950 to July week 1 2007; Embase 1980 to 2007 week 28;?PsycINFO 1967 to July week 2 2007;?CINAHL 1982 to July week 1 2007;?The Cochrane Library Issue 2, 2007.

Medline:?{[(alcohol$.mp. OR ethanol.mp. OR exp Ethanol/OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp Alcoholism/OR exp Alcoholic Intoxication/]} AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp Psychotherapy, Brief/OR exp Counseling/OR counsel$.mp. OR exp Health Personnel/OR health worker.mp.]?AND [exp Emergency Service, Hospital/OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]?LIMIT to [humans AND English language].

Embase: [(alcohol$.mp. OR exp ALCOHOL/OR ethanol.mp. OR booze$.mp. OR exp Alcohol Consumption/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/OR exp Drug Dependence/OR exp Drug Misuse/OR exp Alcohol Abuse/OR exp ALCOHOL INTOXICATION/]} AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp PSYCHOTHERAPY/OR exp COUNSELING/OR counsel$.mp. OR exp Health Care Personnel/OR health worker.mp.]?AND [exp Emergency Medicine/OR exp Emergency Health Service/OR emergency department$.mp. OR exp emergency ward/OR (accident and emergency).mp. OR trauma center.mp.]?LIMIT to [humans AND English language].

PsycINFO: {[(alcohol$.mp. OR ethanol.mp. OR exp ETHANOL/OR booze$.mp.) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp)] OR [alcoholism.mp. OR exp ALCOHOLISM/OR exp Alcohol Drinking Patterns/OR exp Drug Dependency/OR exp ALCOHOL ABUSE/OR exp Alcohol intoxication/]}?AND [brief intervention$.mp. OR (brief.mp. AND (exp INTERVENTION/OR intervention$.mp.)) OR exp Brief Psychotherapy/OR exp Counseling/OR counsel$.mp. OR exp Health Personnel/OR health worker.mp.]?AND [exp Emergency Services/OR emergency department$.mp. OR (accident and emergency).mp. OR trauma center$]?LIMIT to [humans AND English language]

CINAHL:?{[(alcohol$.mp. OR ethanol.mp. OR exp Alcohol, Ethyl/OR booze$.mp. OR exp Alcohol Drinking/) AND (addict$.mp. OR hazard$.mp. OR problem$.mp. OR binge$.mp. OR abuse$.mp. OR misuse$.mp OR dependence.mp.)] OR [alcoholism.mp. OR exp ALCOHOLISM/OR exp Alcohol abuse/OR exp Alcoholic Intoxication/]}?AND [brief intervention$.mp. OR (brief.mp. AND intervention$.mp.) OR exp PSYCHOTHERAPY/OR exp COUNSELING/OR counsel$.mp. OR exp Health Personnel/OR health worker.mp.]?AND [exp Emergency Service/OR emergency department$.mp. OR (accident and emergency).mp. OR exp Trauma Centers/]?LIMIT to [humans AND English language].

The Cochrane Library: [Alcohol Drinking/OR alcohol*.mp. OR problem drinking.mp.] AND [Psychotherapy, Brief/OR brief intervention.mp.] AND [Emergency Service, Hospital/OR Emergency Medical Services/OR emergency department*.mp.]

Search outcome

A total of 590 articles were found in all databases, of which eight were relevant and of sufficient quality for inclusion (table 1).

Comments

Variation in inclusion criteria, the content and duration of intervention and the measurement tools used limits comparison of trials. Study weaknesses reflect the difficulties of conducting RCTs in a hard-to-reach population within a busy healthcare setting: time constraints, high staff and patient turnover and emergency care requirements make recruitment difficult, demonstrable by the small sample sizes, high refusal rates and losses to follow up; furthermore, adequate blinding is problematic. Many trials conclude that it is difficult to separate the effect on outcomes of the ED attendance itself versus the screening process for enrolment into trials versus the actual intervention delivered, thus adding to the complexity of interpretation.

Clinical bottom line

Despite the difficulties faced in attempting to conduct robust trials in the ED setting, results show that brief psychotherapeutic intervention is worthwhile in adults who attend the ED after an alcohol related event.

Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma centre as a means of reducing the risk of injury recurrence. Ann Surg 1999;230:473–83.

Longabaugh R, Woolard RE, Nirenberg TD, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. J Stud Alcohol 2001;62:806–16.

Crawford MJ, Patton R, Touquet R, et al. Screening and referral for brief intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet 2004;364:1334–9.

Mello MJ, Nirenberg TD, Longabaugh R, et al. Emergency department brief motivational interventions for alcohol with motor vehicle crash patients. Ann Emerg Med 2005;45:620–5.

Bazargan-Hejazi S, Bing E, Bazargan M, et al. Evaluation of a brief intervention in an inner-city emergency department. Ann Emerg Med 2005;46:67–76.

Sommers MS, Dyehouse JM, Howe SR, et al. Effectiveness of brief interventions after alcohol-related vehicular injury: a randomised controlled trial. J Trauma 2006;61:523–33.

Dauer AR, Rubio ES, Coris ME, et al. Brief intervention in alcohol-positive traffic casualties: is it worth the effort? Alcohol Alcohol 2006;41:76–83.

Schermer CR, Moyers TB, Miller WR, et al. Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. J Trauma 2006;60:29–34.