Experts: Despite time constraints, motivational interviewing techniques can have lasting impact on drinkers, drug abusers
The Brief Negotiation Interview (BNI) can lead patients toward healthy changes, but effective implementation requires training and practice.
Emergency providers are trained to deal with crises, but it can be frustrating to see the same patients rotating through time and time again. “When you are in the trauma room for months at a time and you are taking care of gunshot and stab wounds, and heaven knows what else, you rapidly learn that most of this is caused by substances,” observes Gail D’Onofrio, MD, FACEP, chair of the Department of Emergency Medicine at Yale University School of Medicine in New Haven, CT.
Not content to just keep placing a bandage on the situation, D’Onofrio has spent the past decade working with colleagues to fine tune a method for intervening with these types of patients so they stand of chance of actually making the kind of changes that will prevent a repeat visit to the ED. Her tool, the Brief Negotiation Interview (BNI), uses motivational interviewing techniques to try and elicit from patients reasons why they need to drink less, stop using harmful drugs, or to admit to themselves that they need to get help for an addiction.
This is the kind of thing that many emergency providers feel is beyond the scope of their practice to provide, but a research team led by D’Onofrio has shown use of the BNI by practitioners in the in the ED can bring about positive changes in problem drinkers.1 And D’Onofrio says the same approach can be used with respect to drug abuse and other harmful behaviors that have health consequences.
D’Onofrio has, in fact, been using the technique for years, and she is well aware of the constraints that emergency physicians face. She is also accustomed to objections from busy providers that they simply don’t have the time to conduct the BNI, which takes about seven minutes to carry out.
“One of the strengths that I have is that I work in an ED that is horribly busy and chaotic, and people can see me do my job well and also be able to integrate some intervention into my care,” she says. “I am very reasonable. There are times when you can’t do the whole intervention. There are times when you can only do 30 seconds or a minute, but you can do part of it, and then you give patients referrals or handouts.”
Furthermore, D’Onofrio sees attitudes changing among emergency physicians who want to do more than just patch people up without making any attempt to address the underlying issues. “Emergency physicians like myself see this revolving door of problems,” she says. “And if you can do anything to get people into treatment or just raise their awareness that these things could be resulting from alcohol or drug use, then in the end, it is a benefit to emergency physicians. I think more and more people are learning that, and we are finding creative ways to deal with this.”
Ask for permission
It takes practice to engage in effective motivational interviewing, but D’Onofrio has observed that providers become adept at the practice relatively quickly. “Emergency physicians learn incredibly complex skills like putting chest tubes in, intubating people, and putting in central lines,” she says. “This is a skill like any other.”
The payback is that you can see patients start to switch on and listen to what the provider has to say, says D’Onofrio. To give an example of how motivational interviewing works, D’Onofrio uses the case of a patient who has been involved in a car wreck. The first step for the provider is to ask the patient for permission to discuss his alcohol use. “When you ask for permission, the patient almost always says yes — even if they say it grudgingly,” she says. The conversation can then proceed something like this:
Provider: Do you see a connection between your car crash today and your drinking?
Patient: Look how bad the weather is tonight. See how bad it is?
Provider: It is a bad night, so you can imagine what would happen if there is anything that is distracting you. Do you know that one drink for anybody decreases your reaction time? Is it possible that you didn’t see that car coming because of this?
Patient: Well it is possible, I guess.
Provider: OK, on a scale of 1 to 10, how likely are you to change any aspect of your drinking?
Patient: I would say 3 or 4.
Provider: That’s great. Thirty percent ready to change. Tell me some reasons why you didn’t choose a lower number? You must have had some reason to change.
Patient: Because I got in this crash.
Provider: This must be difficult for you with no car and a broken hand. What other reasons do you have to change?
Patient: I am spending a lot of money on alcohol, and my girlfriend is mad at me. Also, when I am drinking I yell at my grandmother. I don’t like to yell at her. It upsets me.
Look for opportunities to engage
Once the patient unveils his or her own reasons for changing, the provider can then lead the conversation toward meaningful steps the patient can take toward positive change. “We know that 7% of the time just having a physician advise a patient to do something will prompt that patient to do it, so just offering advice has some effect,” says D’Onofrio. “However, the key to this is asking the patient to identify reasons to change.”
Sometimes you will have patients tell you that they have no reason to change, but there is usually something you can use to focus the conversation, says D’Onofrio. “You listen to the patient and then you turn it around,” she says. “Sometimes people come in with a sexually transmitted disease, and my resident will ask them if it is possible that they didn’t use a condom because they were drinking. The reply is usually “of course.” This gives the resident an opening to discuss some reasonable limits that will enable the patient to make better choices, she explains.
Such conversations can generally be completed in a just a few minutes, says D’Onofrio, noting that providers need to take advantage of opportunities. “If you are putting a splint on or suturing, that is a great time to start talking to them while you are doing the procedure,” she says. “You can double-dip on your time.”
D’Onofrio realizes that there are times when the practitioner may have to make judgment calls about which patients to engage in this type of questioning, but she stresses that the goal should be to make it a routine task. “We want to normalize the fact that providers are asking about substance use and doing brief interventions as much as they would ask about tetanus [shots],” she says. “That is such a normalized process that it is embedded in [an emergency provider’s] everyday life.”
There is no question that emergency providers are overwhelmed with responsibilities. “We are the front line, and the health care system is broken, so we do everything,” acknowledges D’Onofrio. “So one of the huge barriers [to implementing BNI-style interventions] is that physicians will say that if they identify something and it is really bad, they won’t have time to deal with it, so it is almost better not to bring it up.”
To counter such arguments, EDs need to have resources in place that providers can rely on to help with patients who have severe problems, says D’Onofrio. For example, the ED at Yale New Haven Hospital has health promotion advocates available who can help to connect patients directly with the care and services they need. “Physicians can do tons of this themselves when someone is harmful and hazardous, but not severe. When the patients are severe, you need someone who can help get them into a specialized treatment center, which is not easy,” says D’Onofrio. “You have to know what is available in your community, and you have to partner with these centers.”
Kerry Broderick, MD, FACEP, a staff physician in the ED at Denver Health Medical Center, and medical director of Screening Brief Intervention & Referral to Treatment (SBIRT) Colorado, has championed use of the BNI by both nurses and physicians, and she notes that having one or two health educators on hand is extremely helpful, especially if there is not a social worker involved or strong buy-in from the nursing staff and leadership. “Providers are afraid to get into [the BNI] without having someone to hand-off to,” she says. “Practicing a ‘tight’ BNI is also very important. Two minutes of some feedback may be all you can get from staff.”
Emergency providers commonly complain that there are no specialized centers in their community to deal with substance abuse problems, says D’Onofrio, noting that she has heard this specific argument often in her own ED in New Haven, CT. But she insists there are always some resources. “We have tons of centers in New Haven. People just need to get out there, and that is what health promotion advocates can help with,” she says. “Everyone has Alcoholics Anonymous and Narcotics Anonymous, at the very least. It is just a matter of trying to find them.”
Provide continuous reinforcement
Motivational interviewing techniques are not just useful with respect to substance abuse; they can be used effectively to discuss almost any type of behavior with patients, says D’Onofrio. Instead of scolding a diabetic who is not adhering to his medical routine, physicians might have more success asking the patient about his reasons for non-adherence, she says. “Then it will get better,” adds D’Onofrio.
However, for a BNI-based intervention to remain in place in the ED, there needs to be constant reinforcement. “Until it becomes normalized you need great opinion leaders and role models that do it,” observes D’Onofrio. “You always need those, no matter what. It is true of anything you do in the ED.”
Broderick agrees that delivering education and training in how to use the BNI is just a first step. “Initially we conducted two- to three-hour training sessions, but they were not sustainable, so then we built a web-based module that we could assign to people,” she says. “We also do booster training for the nurses on a semi-annual basis.”
Emergency department leaders that are interested in making use of the BNI should first make sure they have an acceptable screening tool in place for substance use first, says Broderick. “Having an [electronic medical record] that has [the screening tool] built in would be the easiest way to do this,” she says.
Editor’s note: For training videos and more information on Screening Brief Intervention & Referral to Treatment — a process that includes use of the Brief Negotiation Interview (BNI), visit the Yale School of Medicine Web site at: medicine.yale.edu/sbirt/index.aspx.
- D’Onofrio G, Fiellin D, Pantalon M, et al. A Brief intervention reduces hazardous and harmful drinking in emergency department patients. Ann Emerg Med. 2012;60:181-192.
- Kerry Broderick, MD, FACEP, Staff Physician, Emergency Medicine, Denver Health Medical Center, Denver, CO, and Medical Director of Screening Brief Intervention & Referral to Treatment (SBIRT) Colorado. E-mail: email@example.com.
- Gail D’Onofrio, MD, FACEP, Chair, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT. E-mail: firstname.lastname@example.org.