Field C., Walters S., Marti C.N. et al.
Annals of Surgery: 2014, 259(5), p. 873–880.
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US trauma centres dealing with serious and often alcohol-related injuries ought to offer an environment conducive to brief alcohol interventions, but this first multi-site trial found motivational counselling more effective than minimal advice only when combined with a follow-up ‘booster’ phone call.
Summary US trauma centres offering comprehensive regional emergency services (‘level I’) are required to provide brief interventions to injured risky drinkers, but what these should consist of remains unclear. The featured study aimed to clarify this issue by comparing the effectiveness of three kinds of brief interventions across several centres to test whether findings apply to different systems and caseloads.
Compared to emergency units, US trauma centres dealing with serious and often alcohol-related injuries are thought to offer a conducive environment for briefly counselling patients about their drinking.
This major US study tested whether in this environment a brief intervention based on motivational interviewing (with or without a ‘booster’ phone call a month later) would be more effective than minimal advice.
Without the booster there was little evidence of extra impact, but with it there were significant reductions in drinking but not in related problems.
Extra benefits were relatively small and generally did not persist to the final 12-month follow-up. It remains unclear whether doing more than the minimum is sufficiently well supported to justify extra cost.
Recent and/or risky drinkers among injured adult patients were recruited to the study at three trauma centres. Research and trauma centre staff identified patients with positive blood alcohol tests or who had drunk in the six hours before their injury, and used the AUDIT-C questionnaire to identify risky drinkers. Eligible patients who met any of these criteria were to be asked to join the study. Of 5895 who might have been screened for the study, 4727 were. Of these, 1335 met at least one of the criteria for recent or risky drinking. Less than half – 596 – were randomly allocated to the three interventions; most of the rest refused to join the study.
Typically they were white unmarried men without advanced educational qualifications. In the three months leading up to emergency admission they had averaged about 9 US drinks per week or around 126g alcohol or 16 UK units, and drank heavily on between 1 day in 5 and 1 in 4. Each drinking day they averaged about 10 UK units but peaked at around 18 UK units at a sitting.
All the patients in the study received alcohol handouts including strategies for cutting down and information on sources of help. In addition, they were randomly allocated to:
• minimal advice: on average about five minutes of face-to-face feedback on screening results, recommendations to quit or cut down, and information on hospital and community services;
• single-session motivational intervention: on average about 23 minutes of counselling based on the empathic and client-centre style of motivational interviewing, which also included feedback on screening results;
• boosted motivational intervention: as above, but followed a month later by an average 28-minute ‘booster’ phone call. More on the content of the call.
Counsellors were social workers or graduate students in helping professions who had demonstrated their competency in motivational interviewing after three days of training. Experts from the research team provided both training and weekly supervision.
To test the impact of the interventions, patients were re-assessed by research staff three, six and 12 months later. Of the 596 who started the study, 445 completed the final follow-up.
The general picture was that regardless of intervention, there were on average significant overall reductions in drinking three months later which then non-significantly bounced back, but not to pre-intervention levels. Relative to minimal advice, reductions were fairly consistently greater among patients allocated to the boosted motivational intervention, but effects were small compared to overall reductions. Without the booster the intervention was largely ineffective. Details follow.
Drinking over the past three months was assessed at baseline and then for the entire intervening periods (either three or six months) before or between each follow-up. Measures were:
• weekly consumption: average number of standard US drinks containing 14g alcohol consumed per week;
• heavy drinking days: proportion of days on which men consumed over 4 standard US drinks or women over 3 in a single drinking episode;
• peak consumption: maximum number of drinks consumed in a single drinking episode;
• average drinking-day consumption: average number of drinks consumed on days when the patient had drunk alcohol.
Each motivational intervention had 12 opportunities to prove superior to minimal advice – three follow-ups at each of which four indicators of drinking were recorded. At all 12 opportunities the boosted motivational intervention had been followed by greater drinking reductions than minimal advice, and seven of these differences were statistically significant. However, relative reductions were generally small and were not consistent across all measures and follow-up points. Relative to minimal advice, on none of the measures was reduced drinking recorded at all three follow-ups. By the final assessment, only peak consumption was significantly reduced – by about 2½ UK units.
Without boosters, at 10 of the 12 opportunities there was at least some reduction in average drinking levels. However, on just one measure at one follow-up was this sufficiently strong and consistent to meet the study’s criterion for a statistically significant result unlikely to have occurred by chance – about 14% fewer heavy drinking days at the final 12-month follow-up, equivalent to about a day a week.
Experience of alcohol-related problems was re-assessed at the last two follow-ups. Problems were significantly reduced across all patients, but on neither occasion were they reduced significantly more after a motivational intervention than after minimal advice.
Which of the three trauma units patients had been seen at, and whether they had been identified for the study on the basis of having been drinking shortly before admission, or by being screened for risky drinking patterns, made no difference to the impacts of the interventions. Just over half the patients scored as at least moderately severe drinkers at the start of the study. Among these, on average patients with the more severe drinking patterns responded best to the motivational interventions, making greater reductions in drinking relative to minimal advice.
This study suggests that rather than simple advice/information and single-session interventions, brief interventions in trauma centres should feature motivational interviewing plus a telephone booster based on feedback on the patient’s assessment results. Benefits were seen despite the fact that the minimal-advice option bettered by the boosted motivational intervention was itself a viable intervention, the minimum recommended for US trauma centres.
Importantly, the impacts of the interventions did not significantly differ between the three centres, despite substantial differences in their patients. The implication is that, when adequately standardised through rigorous training and supervision, brief motivational interventions can have robust effects across a range of patient populations. The study was one of the few such trials to include participants with more severe alcohol problems probably amounting to dependence, a feature which perhaps partly accounted for impacts on drinking not seen in some other trials.
Substantial reductions in drinking and related problems seen across all three sets of patients suggest that trauma centre admission may significantly influence subsequent drinking, and constitutes a window of opportunity to successfully engage at-risk drinkers whether or not they were drinking at the time, and even if their drink problems are severe.
Among the limitations which might affect the generalisability of the results to all adult trauma patients are that many injured patients did not meet criteria for joining the study, and many who met these criteria refused to join.
commentary Unlike the fleeting contacts typical in emergency departments dealing mainly with minor conditions, US trauma centre patients have suffered life-changing events and injuries often associated with drinking. Typically they are admitted for several days to the centre, which organises ongoing care. More so than in an emergency department, the situation might in any event prompt a rethink about drinking, and offers opportunities for intervention and for building therapeutic relationships with staff which may affect drinking. These influences seemed evident in the plummeting consumption of all three sets of patients in the three months after admission.
Despite the relatively conducive setting and some positive findings, the study’s results do not offer a consistent vindication of doing more than minimal advice. A well crafted, single-session motivational intervention from relatively intensively trained and supervised counsellors essentially made no significant difference to drinking or related problems. Extra drinking reductions due to the boosted intervention were minor compared to the overall reductions and generally not significantly present at the final follow-up, and there were no indications that they fed through to related problems. The gains the study did find resulted from an intervention unlikely to be matched in normal practice, and findings can only be assumed to apply to the minority of injured drinkers who completed the study.
The authors saw their results as supporting the most extended intervention they tested, but their report offers no direct proof that the boosted intervention was superior to the un-boosted version. Instead the results may be seen (like the English SIPS emergency department trial) as supporting the least extended, least expensive and least sophisticated of the interventions. Since un-boosted motivational counselling improved little if at all on minimal advice, it seems possible that had minimal advice also been boosted a month later, it would have proved just as effective as the boosted motivational intervention. More about the featured study.
Booster calls – at least those not from the original counsellor – do not necessarily reinforce drinking reductions following brief interventions in emergency departments. Extra reductions were also absent in a US trauma unit study, though in this study the boosted intervention did reduce drink-related problems, including injuries. But like the featured study, this earlier study conducted no direct test of whether adding a booster improved outcomes relative to the initial motivational session alone. Also like the featured study, it found the interventions worked no better when patients had been drinking at the time of the injury than when they had not.
Arguably the most convincing study to find drinking reductions from a practically feasible intervention among injured patients was a UK study conducted in Cardiff in circumstances similar to that of a trauma unit – a jaw and face clinic to which patients had been referred from a local emergency department. The distinctive set of patients were mainly young men facially injured in assaults. The study seems to suggest that when the setting is relatively conducive (a clinic insulated from the disruptions of an emergency service and whose patients attend for lengthy periods) and the patients relatively receptive (recently reminded that drinking can result in serious injury, but not distracted by the immediate aftermath of that injury), intervention can not just be effective but also practical, being in this study conducted by the clinic’s own nurses while they treated the patient’s injuries. It may be relevant that the study did not even offer minimal advice to comparison patients, that all the patients had been drinking heavily immediately before admission, and that its seems very likely that drinking had contributed (and was seen as having done so) to the incident which led to emergency care.
Like the featured study, the major UK emergency department trial to date from the SIPS study found no added benefits from adding a motivational intervention to minimal advice. Despite some benefit in the featured trial from adding a booster session, together these trials may be seen as justification for doing just the minimum, though in both cases this also included consenting to join a study, screening, and baseline and follow-up research assessments.
Though the authors of the featured study stress the quality of the intervention as a determinant of desired outcomes, an emergency department study of how closely staff implemented the motivational style and techniques of a brief alcohol intervention found no relation to later drinking.
As mentioned above, emergency departments seem a less conducive setting for brief interventions than trauma units. Apart from patchy evidence of efficacy in conditions approximating normal practice, emergency department alcohol interventions are difficult to implement in the department, and appointments made for later intervention are often not kept. Together these limitations raise doubts over whether emergency department brief interventions – though they can work – actually will work in normal practice and be implemented widely enough to appreciably improve public health.
For more on brief interventions and UK policy see this Effectiveness Bank hot topic. The US government has provided a guide for trauma departments on how to plan, implement and monitor a programme to identify risky drinking among their patients and to offer appropriate advice and referral.
Thanks for their comments on this entry in draft to Dr Cheryl Cherpitel of the Alcohol Research Group at the Public Health Institute in California, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 06 October 2015. First uploaded 28 September 2015