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Three Part Question

In [Patients attending the emergency department for alcohol-related motor vehicle accident] is a [brief alcohol intervention better than standard of care] to [decrease future alcohol intake and/or risk of trauma recurrence]

Clinical Scenario

A patient is sent to the ER after being involved in a car accident while driving under the influence of alcohol. Basic trauma interventions and investigations are applied to rule out life-threatening injuries, and you keep him under surveillance until his alcohol blood level normalizes. Could a brief alcohol intervention or counselling be useful in order to decrease the risk of trauma recidivism and alcohol intake?

Search Strategy

Search performed on October 4th, 2017.

A. MEDLINE using the PubMed interface (1900 – Août 2017)

Terms used: Alcohol AND intervention AND emergency department AND motor vehicle accident  // 198 papers found

After reviewing the articles, 4 relevant papers were found

In addition, reference lists of relevant manuscripts were screened for potential studies. No new relevant studies were found. Studies on animal, cadaveric models and manikin were excluded.

B. Embase using the Elsevier interface (1966– August 2017)

Terms used: Alcohol AND intervention AND emergency department AND traffic accident OR driving under the influence // 113 papers found

After reviewing the articles, 1 relevant paper was found.

In addition, reference lists of relevant papers were checked for potential studies. No new relevant studies were found. Studies on animal, cadaveric models and manikin were excluded.

Search Outcome

Altogether 3 papers were found in Medline and 1 in EMBASE. No papers were found by scanning the references of relevant papers.
All 4 relevant papers are summarized in the table 1.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Marilyn et al. 2005 USA	Standard care (SC, n = 188) -Non-MVC n = 107 -MVC: n = 46 Brief motivational intervention (BI, n = 182) -Non-MVC: n = 95 -MVC: n = 53 Brief motivational intervention and booster (BIB, n = 169) -Non-MVC: n = 98 -MVC: n = 34 **Participants had an average baseline AUDIT score of 14.9 (SD=7.85)	Randomized controlled trial	Reduction of alcohol-related negative consequences (DrInC) at 12months	No significant difference between MVC vs non-MVC	Limited applicability due to the large amount of resources used during interventions No analysis made comparing BI and BIB in MVC groups
			Reduction of alcohol-related injuries (IBC) at 12 months	Significant difference in the MVC group between SC and BIB groups (p= 0.001) No significant difference in the non-MVC group between SC and BIB groups (p>0.05)
Carol R et al. 2006 USA	Patients involved in MVC receiving standard care (n = 62) Patients involved in MVC receiving brief intervention (n=64) ** all patients had either an admission BAC of 80 mg/dL or an Alcohol Use Disorders Identification Test (AUDIT) score of > or = 8	Randomized controlled trial	DUI arrest within 3 years of hospital discharge	Reduction of 10.6 % in BI vs SC group (11.3 % vs 21.9%) (p=0.11)	Potential selection bias since 25% of eligible patients declined study enrolment Possible underestimation of DUI arrest by the timing of follow-up and the limited information available that did not consider out-of-state arrests
			Odds of having a DUI arrest within 3-years after hospital discharge based on treatment allocation, prior DUI arrests, gender, AUDIT score, and baseline BAC	BI was the strongest protective factor for DUI arrest (OR: 0.32, [95%CI: 0.11-0.96])
Marilyn et al. 2005 USA	No intervention group (n=56) Simple advice (SA) group (n = 68) Brief counseling (BC) group (n= 63) (Included booster session after a month) *only alcohol-positive participants were enrolled while patients with a potential alcohol dependency were excluded	Randomized controlled trial	Difference in alcohol consumption 12 months after the MVC	Significant decline in alcohol consumption at 12-month follow-up in all groups No significant changes were found in alcohol consumption when the analysis was stratified by treatment condition	High number of participants lost to follow-up (47%) Participants who were excluded had a significantly higher BAC than those who were enrolled
			Difference in adverse driving events 12 months after the MVC	No significant changes were found for any of the driving event variables when the analysis was stratified by treatment condition
			Difference in injury or health status 12 months after the MVC	The BC group only had demonstrated significant decrease (34%) in reporting injuries limiting physical activity for > or = 1 days (p = 0.003
Baird J et al. 2017 USA	Brief behavioral intervention (BI, n = 204) Attention placebo, home safety intervention (HS, n = 203)	Randomized controlled trial	Changes in 6 impaired driving behaviours (IDS) at 12 months	No significant difference in IDS with group assignment Readiness to change alcohol use or ED visit being MVC-related at baseline did not result in greater changes in the IDS	Recruitment protocol included informing all participants that their drinking behaviors were being monitored
			Report of MVCs and traffic violations at 12 months	No statistically significant difference reported

Comment(s)

Although previous studies seem to have shown that a brief alcohol intervention could decrease alcohol use and adverse effects in patients with general alcohol-related injuries admitted to the ED, the impact on patients with a MVC-related visit hasn’t been clearly demonstrated. Most studies have failed to demonstrate that a brief alcohol intervention performed in the ED, with or without follow-up, modified significantly the alcohol drinking behaviours of this population. One hypothesis to explain these results is the MVC being, in itself, an incentive to change behaviours.

Clinical Bottom Line

Based on current evidences, a brief alcohol intervention in the ED does not decrease alcohol intake, risk of trauma recidivism or modify driving behaviour in patients attending the ED for alcohol-related motor vehicle accidents.

References

1. Michael J. Mello, MD, MPH Ted D. Nirenberg, PhD Richard Longabaugh, EdD Robert Woolard, MD Alison Minugh, PhD Bruce Becker, MD, MPH Janette Baird, PhD Lynda Stein, PhD Emergency Department Brief Motivational Interventions for Alcohol With Motor Vehicle Crash Patients Annals of Emergency Medicine 2005;45:6, 620-625
2. Carol R. Schermer, MD, MPH, Theresa B. Moyers, PhD, William R. Miller, PhD, and Lori A. Bloomfield, MSW Trauma Center Brief Interventions for Alcohol Disorders Decrease Subsequent Driving Under the Influence Arrests The Journal of Trauma Injury, Infection, and Critical Care 2006;60:1, 29 –34
3. Marilyn S. Sommers, PhD, RN, FAAN, Janice M. Dyehouse, PhD, RN, Steven R. Howe, PhD, Michael Fleming, MD, MPH, Jamison D. Fargo, PhD, and John C. Schafer, PhD Effectiveness of Brief Interventions After Alcohol-Related Vehicular Injury: A Randomized Controlled Trial The Journal of Trauma Injury, Infection, and Critical Care 2006;61:3, 523–533
4. Janette Baird, Eunice Yang, Valerie Strezsak & Michael J. Mello Examining motor vehicle crash involvement and readiness to change on drinking and driving behaviors among injured emergency department patients Traffic Injury Prevention 2017;18:5, 463-469