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Alcohol abuse and illicit drug use are common diagnoses in the ED, but providing follow-up care for these patients is often overlooked. "This tendency to "treat and street" patients is due to the attitudes and beliefs regarding the role of emergency physicians in substance abuse," says Edward Bernstein, MD, FACEP, associate professor of emergency medicine and vice chair person for academic affairs at the Boston University School of Medicine Department of Emergency Medicine (MA). "There is a need for adequate training of ED staff in how to make referrals for substance abuse," says Bernstein.
Studies have shown that less than a third of patients in the general population who are in need of treatment receive any form of help.1-3 In the ED, that percentage is often lower, says Bernstein.4,5 "Referrals and follow-up are often overlooked because of a lack of knowledge of appropriate referral sources in the community, and an overall lack of resources, staff, and time."
An internal study at Boston Medical Center's ED found room for improvement in referral rates. "We found that only about a quarter of patients who were substance abusers were detected, and out of that population, only a small percentage were referred," reports Bernstein.
To combat this problem, the ED developed a unique program, Project ASSERT (an acronym for improving Alcohol and Substance abuse Services and Educating providers to Refer patients to Treatment) to link ED patients to the substance abuse treatment system and to primary care and preventive services.
A cornerstone of Project ASSERT is the concept that brief counseling in the ED has an effect on substance abusers. "It can be effective as a treatment in itself and as a means to link substance abusers with treatment for addiction," says Bernstein.
The ED is an ideal time for intervention, says Bernstein. "The best time for early intervention is during the crisis that brings the patient into the ED," he notes. "Studies have shown that an ED visit appears to be a teachable moment."6-9
Project ASSERT began with a one-year study that screened more than 7000 adult ED patients. Substance abuse was detected among 41%, and a total of 1096 patients were enrolled in the study. "They were asked if they would discuss their drug use during a 'brief negotiation interview,'" says Bernstein.
Five "health promotion advocates" (HPAs) experienced in community outreach conducted the interviews, trained by ED personnel and consultants. "Many of them have been through recovery themselves, so [they] can act as role models for patients," says Bernstein. "They have a supportive approach and give unconditional support and respect to patients and help them to negotiate the system," says Bernstein.
Didactic presentations, role playing, and supervised bedside interviews are used. "The physicians are also trained in screening and interviewing patients, but because of time restraints and differences in motivation and commitment, they refer the patients to the health promotion advocate to continue the interview and complete the referral process," Bernstein explains. "They are often not experts in resources and do not have the time to actually call places and make initial contact."
The health promotion advocates then initiate further discussion, which may include an active referral process. A laminated, pocket-size card with sample questions is used to guide the interview, which lasts approximately 15 minutes. (See sample interview script, above.) "This is a special type of interview where patients are empowered to assist themselves rather than being told what to do or [being] shamed," says Bernstein. "It's very important to build a rapport with the patient."
After filling out a health needs history form (see form inserted in this issue), patients are referred to services as needed, including mammography, primary care, battered women's services, or HIV testing. If substance abuse is detected, patients are offered enrollment in Project ASSERT and asked about their frequency of drug or alcohol use.
Patients then mark on a "readiness ruler" scaled from 1 ("not ready") to 10 ("ready), to indicate their willingness to change their behavior. A variety of treatment options are presented, including inpatient, outpatient, detoxification, methadone clinics, and acupuncture. If the patient indicates they are ready to seek help, telephone calls are made to locate an available bed or appointment.
"Once the patient decides for themselves they want to seek treatment, facilities in our area are tapped to find an available bed," Bernstein explains. Taxi vouchers are provided to bring patients to treatment facilities. Patients are given a telephone number for contact with the health promotion HPA in case problems occur.
Active participation by the patient is a key component of the program. "The bed is found for them, and we provide the transportation, but the patient has to get on the phone and go through the intake process by themselves," says Bernstein.
The patient is fully informed about what to expect from treatment programs. "They have to be oriented to what detox is going to do for them and understand they need to plan beyond for aftercare or residential treatment," says Bernstein.
A "readiness to change" group meets weekly in the ED for patients who are not yet ready to commit to a behavior change. "Substance abuse is a recurrent, chronic condition that requires multiple attempts," says Bernstein.
Referrals are most effective when they involve the patient, says Bernstein. "Telling the patient, 'Don't you see what you are doing to yourself-you should go to detox immediately!' is not a quality referral," he explains. "We start the process by asking people if they are ready to start thinking about changing their lifestyle."
After one year, results showed that 50% of enrolled patients kept a follow-up appointment, and enrolled patients reported a 45% reduction in the severity of their drug problem, and 56% reported a reduction in alcohol use. The program is now a fully funded permanent part of the ED's operations.
Bernstein, a team of researchers at the Boston University School of Public Health, and the staff of the Boston Medical Center Urgent Care and Women's Health Clinic have received a five-year grant from the National Institute of Drug Abuse to study the efficacy of the Project ASSERT model among cocaine and heroin users in a randomized, controlled trial of the BNI/Active Referral Method conducted in the general medical setting. "We are going to compare the results of giving cocaine and heroin users a handout and telling them to follow up with this system," says Bernstein.
[Editor's Note: A video entitled The Emergency Physician and the Problem Drinker: Motivating Patients for Change is available for $39.95 plus $3 shipping and handling. The 30-minute video examines the doctor-patient interactions in the course of an ED visit and introduces interview techniques that have proved effective in negotiating change in drinking behavior and connecting individuals who are ready to change with appropriate treatment resources. For more information, contact Marino & Company, 8 Pleasant Street, South Natick, MA 01760. Telephone: (508) 650-9491. Fax: (508) 650-9071.]
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2. Harwood HJ, Zanzoia T. How Many People are in Need of Treatment? Paper prepared by Lewin-VHI for Office of National Drug Control Policy (Task No. 93H), July 14, 1993.
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8. Becker B, Woolard R, Nirenberg TD, et al. Alcohol use among subcritically injured emergency department patients. Acad Emerg Med 1995;2:784-790.