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Three Part Question

In [children and adolescents presenting to the Emergency Department 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 16 year old male arrives at the ED having sustained a head injury after falling over whilst intoxicated. 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 you should refer him on to them...

Search Strategy

MEDLINE 1966 to June week 4 2006:
{[(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 1980 to 2006 week 28:
{[(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 1967 to June week 4 2006:
{[(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$]
LIMIT to [humans AND English language]
CINAHL 1982 to June week 4 2006
{[(alcohol$.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 Issue 2, 2006:
[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

560 articles were found in all databases, of which 5 were relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tait et al, 2004, Australia	127 ED patients aged 12 to 19 years with presentation involving alcohol or other drug (AOD) and consenting. 60 randomised to intervention, 67 to control Control – usual care Intervention – referral to external treatment agency facilitated via consistent support person (social/ health worker) by identifying and discussing specific negative consequences associated with their personal drug use, identifying impediments to reducing negative consequences and trigger situations; advice regarding appropriate services available in local area and type of intervention offered by agency	RCT	Attendance at treatment agency by 4 months	Significantly more of intervention group than usual care group attended a community treatment agency (47% vs. 4%, p<0.001)	Lack of definitive diagnosis of substance dependence; questionable validity of adolescent self-reported data; patients and interviewer not blinded to treatment allocation; only 25% of intervention group attended agency; AOD consumption analyses not performed by intention-to-treat; higher loss to follow-up in intervention group (47% versus 24% in control); unable to assure sufficiency of sample size
			Psychosocial indicators using GHQ (General Health Questionnaire) and FAD (Family Assessment Device) at 4 months	Greater improvement in GHQ in intervention vs. usual care group at 4 months (mean 7.1 vs. 3, p<0.05). No corresponding change in FAD
			AOD consumption using DDUT (The Demographics and Drug use of Teenagers Questionnaire) and AUDIT-3 (first 3 questions of Alcohol Use Disorders Identification Test) at 4 months	40% of those attending agency moved to 'safer' alcohol use versus 20% of those not attending (not significant). 50% of those attending agency reported no intravenous drug use in previous 4 months versus 20% of those not attending (not significant)
Spirito et al, 2004, USA	152 ED patients aged 13 to 17 years with evidence of alcohol in blood/ breath/ saliva or self-report drinking 6 hours prior to ED attendance; consent/ assent; English-speaking; not suicidal, not in police custody; no serious injury requiring admission. 74 randomised to standard care (SC), 78 to brief motivational interview (MI) SC – 5min brief advice to stop drinking, handout on avoiding drinking and driving, list of substance abuse treatment agencies, recommendation to arrange follow-up with primary healthcare provider MI – standard care plus motivational interviewing: 35-45mins; emphasis on personal responsibility for change; exploration of motivation for drinking and review of potential negative consequences; personalised normative assessment feedback about pattern of alcohol use and risks; imagining their future if they continued to drink in same way versus if they change; establishing goals with regard to drinking and anticipating barriers to accomplishing the goals. Also additional handouts about negative effects of alcohol, effects of alcohol on driving abilities and a personalised feedback sheet	RCT	Alcohol use in past 3 months (frequency, quantity, high-volume drinking frequency) using ADQ (Adolescent Drinking Questionnaire)	Both groups had reduced drinking quantity at 12 months. Intervention group had significant decrease over time in quantity consumed (p<0.001) but not for frequency or high-volume drinking frequency. Among those with high ADI (Adolescent Drinking Inventory) score (positive for alcohol problems) those in intervention group had lower frequency of drinking (p<0.01) and lower frequency of high-volume drinking (p<0.01) at follow-up versus those in control group. No significant difference in quantity consumed	Questionable validity of adolescent self-report data; patients not blinded to treatment; high refusal rate (47%); only 31% of MI group and 21% of SC group attended for intervention; unable to assure sufficiency of sample size
			Drinking and driving in past 12 months using YADDQ (Young Adult Drinking and Driving Questionnaire)	Initial reduction in proportion drinking and driving in both groups at 3months (SC vs. MI 4% vs. 10%), returning to previous levels/ higher at 6 and 12months. Rates not significantly different between groups at any time
			Alcohol-related injury in past 12 months using AIC (Adolescent Injury Checklist)	Initial reduction in proportion with alcohol-related injury in both groups at 3months (SC vs. MI 1% vs. 12%), returning to previous levels/ higher at 6 and 12months. Rates not significantly different between groups at any time
			Alcohol-related problems in past 12 months using AHBQ (Adolescent Health Behaviour Questionnaire)	No time effects or differences between groups at any time. No differences when categorised by ADI scores
Monti et al, 1999, USA	94 ED patients aged 18 to 19 years with positive BAC (Blood alcohol concentration) or self-report drinking prior to ED attendance; consent/ assent; English-speaking; not suicidal, not in police custody; no serious injury requiring admission. 42 randomised to standard care (SC), 52 to brief motivational interview (MI) SC - 5mins; handout on avoiding drinking and driving and list of local treatment agencies MI - standard care plus motivational interviewing: 35-40mins; introduction and review of circumstances of event; exploration of motivation (pros and cons); personalised and computerised assessment feedback; imagining the future and establishing goals. Also additional handout on effects of alcohol on driving and a personalised feedback sheet	RCT	Alcohol use in past 3 months using ADQ	Significant reductions in alcohol use with time in both groups (p<0.001); no inter-group difference	Questionable validity of adolescent self-report data; patients not blinded to treatment; high refusal rate (33%); unable to assure sufficiency of sample size; randomisation procedure not described
			Drinking and driving using YADDQ	MI group significantly less likely to report drinking and driving versus SC group (62% vs. 85%, p<0.05)
			Traffic violations via DMV (Department of Motor Vehicle) records	MI group significantly less likely to have had traffic violation versus SC group (3% vs. 23%, p<0.05) at 6 months
			Alcohol-related injuries using AIC	MI group significantly less likely to report alcohol-related injury versus SC group (21% vs. 50%, p<0.01) at 6 months
			Alcohol-related problems using AHBQ at 6 months	MI group reported significantly fewer alcohol-related problems than SC group at 6 months (mean 0.89 vs. 1.44, p<0.05)
Tait RJ et al, 2005, Australia	As in Tait et al. 2004: 87 (69%) followed-up at 12 months: 38 intervention group, 49 usual care group	RCT 12-month follow-up	Attendance at treatment agency	Significantly more of intervention group than usual group attended agency (25% vs. 6%, p<0.005)	Questionable validity of adolescent self-reported data; questionable validity and completeness of record database; patients and interviewer not blinded to treatment allocation; higher loss to follow-up in intervention group (37% versus 27% in control); small sample size; AOD consumption analyses not performed by intention-to-treat
			Psychosocial indicators using GHQ and FAD	Both groups showed significant improvement in GHQ and FAD scores
			AOD consumption using DDUT and AUDIT-3	25% of those attending agency moved to 'safer' alcohol use versus 17% of those not attending (not significant). 25% of those attending agency reported no intravenous drug use in previous 4 months versus 16% of those not attending (not significant)
			Number of hospital AOD ED presentations using ED Information System or manual inspection of records	Fewer AOD ED events in intervention group versus usual group (not significant). Significant reduction in AOD ED events from pre to post-enrolment in intervention group (p=0.007) vs. no change in usual care group
Tait et al, 2005, Australia	As in Tait et al. 2004	RCT 12-month follow-up	Hospital events 12 months post-recruitment	Those receiving intervention had significantly more hospital events than usual care group (median 1 vs. 0, p=0.017)	Questionable validity and completeness of ED record database; relative severities of AOD repeat events unknown; small sample size
			AOD hospital events (as above)	Both groups had similar numbers of AOD-related events (p=0.161
			Survival to first AOD event	Both groups had similar survival times (intervention vs. control 1027 vs. 1141 days, p=0.441)
			Above re-assessed after categorising for type of drug 'alcohol alone' versus 'all other drugs'	Survival times similar for both categories of users in intervention group (p=0.97). In usual care group, those using 'all other drugs' had significantly shorter survival times than 'alcohol alone' group (p=0.0003)

Comment(s)

Tait et al. (2004) and follow-up study (Tait et al. 2005) demonstrated that brief intervention significantly enhanced attendance at a treatment agency, significantly improved psychosocial well-being and resulted in non-significant reductions in alcohol consumption in those attending a treatment agency. Although follow-up at 12 months (Tait & Hulse 2005) demonstrated significantly more hospital events in patients receiving the intervention, the number of AOD hospital events was similar in both groups and there was a significant reduction in AOD ED attendances pre- to post-enrolment in the intervention group (Tait et al. 2005). The US-based trial in attendees aged 13-17 years (Spirito et al.) demonstrated a significant reduction in alcohol consumption in the intervention group over time, but no significant inter-group differences in consumption, drinking or driving, alcohol-related injury or problems. Conversely, an earlier trial in 18-19 year olds (Monti et al.) showed that at 6 months, those in the intervention group were significantly less likely to commit traffic violations, to drink and drive, and to experience alcohol-related injuries or problems.

Clinical Bottom Line

Brief psychotherapeutic intervention is worthwhile in adolescents and children who attend emergency departments after an alcohol related episode

References

1. Tait RJ, Hulse GK, Robertson SI. Effectiveness of a brief intervention and continuity of care in enhancing attendance for treatment by adolescent substance users. Drug Alcohol Depend 2004;74(3):289-96.
2. Spirito A, Monti PM, Barnett NP et al. A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department. J Pediatr 2004;145(3):396-402.
3. Monti PM, Spirito A, Myers M et al. Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. J Consult Clin Psychol 1999;67(6):989-94.
4. Tait RJ, Hulse GK, Robertson SI et al Emergency department-based intervention with adolescent substance users: 12-month outcomes Drug Alcohol Depend 2005,79(3):359-63.
5. Tait RJ, Hulse GK. Adolescent substance use and hospital presentations: A record linkage assessment of 12-month outcomes. Drug Alcohol Depend 2005;79(3):365-71.