Michael J. Mello

DIAL: A Telephone Brief Intervention for High-Risk Alcohol Use With Injured Emergency Department Patients

STUDY OBJECTIVE Brief interventions for high-risk alcohol use for injured emergency department (ED) patients have demonstrated effectiveness and may have a more pronounced effect with motor vehicle crash patients. We report on 3-month outcome data of a randomized controlled trial of injured patients, using a novel model of telephone-delivered brief interventions after ED discharge. METHODS ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, participants received by telephone an assessment of alcohol use and impaired driving and then were randomized to treatment (n=140) or standard care (n=145). Treatment consisted of 2 sessions of brief interventions done by telephone, focusing on risky alcohol use. At 3 months, both groups had an assessment of alcohol use and impaired driving. RESULTS Two hundred eighty-five patients were randomized and had a baseline mean Alcohol Use Disorders Inventory Test (AUDIT) score of 11.0 (SD=7.4). Three-month follow-up assessments were completed on 273 (95%). Mean AUDIT score decreased in both the treatment (mean change=-3.4; 95% confidence interval [CI] -4.5 to -2.3) and standard care group (mean change=-3.2; 95% CI -4.2 to -2.2). Measures of impaired driving decreased for the treatment group (mean change=-1.4 95%; CI -3.0 to 0.2) compared with standard care group (mean change=1.0; 95% CI -0.9 to 2.9; P=.04; d=0.31). Participants were stratified post hoc into 3 groups by baseline alcohol problem, with the treatment effect only being in the highest-scoring group (d=.30). CONCLUSION Telephone brief interventions decreased impaired driving in our treatment group. Telephone brief intervention appears to offer an alternative mechanism to deliver brief intervention for alcohol in this at-risk ED population.

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers.

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Project Reduce: Reducing alcohol and marijuana misuse: Effects of a brief intervention in the emergency department

STUDY OBJECTIVE Brief interventions (BI) for alcohol misuse and recently for marijuana use for emergency department patients have demonstrated effectiveness. We report a 12-month outcome data of a randomized controlled trial of emergency department (ED) patients using a novel model of BI that addresses both alcohol and marijuana use. METHODS ED research assistants recruited adult patients who admitted alcohol use in the last month, and marijuana use in the last year. In the ED, patients received an assessment of alcohol and marijuana use and were randomized to treatment (n=249) or standard care (n=266). Treatment consisted of two sessions of BI. At 3 and 12months, both groups had an assessment of alcohol and marijuana use and negative consequences of use. RESULTS 515 patients were randomized. We completed a 12-month follow-up assessments on 83% of those randomized. Measures of binge drinking and conjoint marijuana and alcohol use significantly decreased for the treatment group compared to the standard care group. At 12-month binge alcohol use days per month in the treatment group were (M=0.72:95% CI=0.36-1.12) compared to standard care group (M=1.77:95% CI=1.19-1.57) Conjoint use days in the treatment group (M=1.25.1:95% CI=0.81-1.54) compared to standard care group (M=2.16:95% CI=1.56-2.86). No differences in negative consequences or injuries were seen between the treatment and standard care groups. CONCLUSIONS BI for alcohol and marijuana decreased binge drinking and conjoint use in our treatment group. BI appears to offer a mechanism to reduce risky alcohol and marijuana use among ED patients but expected reductions in consequences of use such as injury were not found 12months after the ED visit.

Prescription opioid misuse among ED patients discharged with opioids

STUDY OBJECTIVES The purposes of this study were to determine the prevalence of prescription opioid misuse in a cohort of discharged emergency department (ED) patients who received prescription opioids and to examine factors predictive of misuse. METHODS This prospective observational study enrolled a sample of ED patients aged 18 to 55 years who were discharged with a prescription opioid. Participants completed surveys at baseline in the ED, then 3 and 30 days later. Follow-up surveys contained questions about opioid use and misuse, including screening questions from the National Epidemiologic Survey on Alcohol and Related Conditions. Patients were categorized as misusers if they (1) self-escalated their dose, (2) obtained additional prescription opioids without a prescription, or (3) used for a reason besides pain. RESULTS Of the 85 patients who completed follow-ups, 36 (42%) reported misuse at either 3 or 30 days. There was no difference in demographic variables, pain scores, analgesic treatment, or discharge diagnoses between misusers and nonmisusers. Self-escalation of dose was the most common category of misuse (33/36; 92%). Taking prescription opioids without a doctors prescription was reported by 39% (14/36), and taking pain medications for a reason other than pain was reported by 36% (13/36). The presence of disability, chronic pain, preexisting prescription opioid use, oxycodone use, and past 12-month risk of substance abuse were associated with misuse. CONCLUSIONS Prescription opioid misuse was prevalent among this cohort of ED patients. A heterogeneous mixture of behaviors was captured. Future research should focus on the etiologies of misuse with directed screening and interventions to decrease misuse.

Injuries in youth football: national emergency department visits during 2001-2005 for young and adolescent players.

OBJECTIVES Limited research exists describing youth football injuries, and many of these are confined to specific regions or communities. The authors describe U.S. pediatric football injury patterns receiving emergency department (ED) evaluation and compare injury patterns between the younger and older youth football participants. METHODS A retrospective analysis of ED data on football injuries was performed using the National Electronic Injury Surveillance System-All Injury Program. Injury risk estimates were calculated over a 5-year period (2001-2005) using participation data from the National Sporting Goods Association. Injury types are described for young (7-11 years) and adolescent (12-17 years) male football participants. RESULTS There were an estimated total of 1,060,823 visits to U.S. EDs for males with football-related injuries. The most common diagnoses in the younger group (7-11 years) were fracture/dislocation (29%), sprain/strain (27%), and contusion (27%). In the older group (ages 12-17 years), diagnoses included sprain/strain (31%), fracture/dislocation (29%), and contusion (23%). Older participants had a significantly higher injury risk of injury over the 5-year study period: 11.0 (95% confidence interval [CI] = 9.2 to 12.8) versus 6.1 (95% CI = 4.8 to 7.3) per 1,000 participants/year. Older participants had a higher injury risk across all categories, with the greatest disparity being with traumatic brain injury (TBI), 0.8 (95% CI = 0.6 to 1.0) versus 0.3 (95% CI = 0.2 to 0.4) per 1,000 participants/year. CONCLUSIONS National youth football injury patterns are similar to those previously reported in community and cohort studies. Older participants have a significantly higher injury risk, especially with TBI.

Usefulness of computerized pediatric motor vehicle safety discharge instructions

OBJECTIVES To determine whether providing child motor vehicle safety recommendations on computerized discharge instructions (CDIs) were useful to parents and modified their use of child-restraint devices (CRDs). METHODS The subjects were guardians of children seen in an urban pediatric emergency department (ED). An intervention group was given computerized ED discharge instructions that included the National Highway Traffic Safety Administration recommendations for motor vehicle CRDs. A control group was given CDIs without the recommendations. All subjects were subsequently called within four days of the ED visit and asked questions about their knowledge and use of CRDs. They also were queried if the recommendations affected their knowledge or changed their behavior. RESULTS There were 52 subjects in the control group and 58 in the intervention group. Fifty-seven percent of the intervention group remembered reading a safety tip (p < 0.001, 95% confidence interval [CI] = 0.32 to 0.62), and 82% of that subset correctly identified it pertaining to motor vehicle safety. Forty-five percent (n = 33) of those who remembered the safety recommendation in the intervention group supported it being educational (p = 0.067, 95% CI = 0.28 to 0.64). Ten percent of the subjects in the intervention group said the CDIs changed their behavior regarding buckling-up their child, compared with 0% of the control group (p = 0.473, 95% CI = 0.05 to 0.32). CONCLUSIONS Including CRD information on CDIs is a convenient method of educating guardians of patients about motor vehicle safety in a pediatric ED setting. The data suggest that parents find it educational and a smaller subgroup change their behaviors after receiving them.

DIAL: a randomised trial of a telephone brief intervention for alcohol.

Background Decreasing Injuries from ALcohol (DIAL) is a randomised control trial of a telephone brief intervention (BI) with injured emergency department (ED) patients with high-risk alcohol use. Here the authors examine 12-month outcomes of the interventions effect on alcohol use, alcohol-related injuries and alcohol-related negative consequences. Methods ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, all participants received by telephone an assessment of their alcohol use, alcohol-related injuries, and alcohol-related negative consequences and then were randomised to treatment or standard care. Treatment consisted of two telephone sessions of BI focusing on risky alcohol use. Both groups were reassessed after 12 months. Results At 12 months, 249 (89%) participants completed follow-up assessments. After using a log transformation, the difference in alcohol-related injuries between baseline and 12-month follow-up was greater in the BI group than the standard care group (p=0.04); this is an effect size of Cohens d=0.21. No difference between groups was found when comparing change in alcohol consumption and other alcohol-related negative consequences at 12 months. Conclusions These findings suggest that a telephone BI with injured ED patients may decrease alcohol-related injuries. Identifying patients with risky alcohol use in the ED and then subsequently delivering the intervention by telephone after discharge has promise as a model for BI and deserves further study.

Alcohol-Related Visits to the Emergency Department by Injured Adolescents: A National Perspective

PURPOSE Alcohol use is a risk factor for injury in adolescents. Many injured adolescents require treatment in emergency departments (EDs). The present study was intended to explore this association between adolescent alcohol use and injury-related ED visits using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative probability sample of visits to EDs. METHODS This was a retrospective, cross-sectional study using data from NHAMCS for 2001 through 2004. ED visits by injured adolescents aged 13-20 years whose visits were determined by NHAMCS coders to be related to alcohol were compared with visits by those whose visits were determined not related to alcohol. Specific variables of interest included demographic and medical characteristics of visits. RESULTS Our analyses indicated that there were several visit-related characteristics that were associated with alcohol-related ED visits, including time of visit, type of health insurance, and geographic location of the ED. Similarly, there were a number of patient-related characteristics that were also associated with alcohol-related visits to the ED, including patient acuity and injury intentionality. CONCLUSIONS Our findings suggest that injured adolescents are more likely to present to the ED with an alcohol-related visit during the early hours of the morning, that the injury is more likely to be assault related and of higher acuity than non-alcohol-related visits. These findings suggest the ED as a potential site for alcohol prevention interventions with younger adolescents. However, these interventions will need to take into account when such adolescents will present to the ED and will need also to recognize that factors such as violence and aggression, in addition to alcohol use, may be important issues to address in the intervention.

Adolescents' preference for technology-based emergency department behavioral interventions: does it depend on risky behaviors?

Objectives This study aimed to (1) determine the prevalence of technology use and interest in technology-based interventions among adolescent emergency department patients and (2) examine the association between interest in an intervention and self-reported risky behaviors. Methods Adolescents (age, 13–17 years) presenting to an urban pediatric emergency department completed a survey regarding baseline technology use, risky behaviors, and interest in and preferred format for behavioral health interventions. Questions were drawn from validated measures when possible. Descriptive statistics and &khgr;2 tests were calculated to identify whether self-reported risky behaviors were differentially associated with intervention preference. Results Two hundred thirty-four patients (81.8% of eligible) consented to participate. Almost all used technology, including computers (98.7%), social networking (84.9%), and text messaging (95.1%). Adolescents reported high prevalence of risky behaviors as follows: unintentional injury (93.2%), peer violence exposure (29.3%), dating violence victimization (23.0%), depression or anxiety (30.0%), alcohol use (22.8%), drug use (36.1%), cigarette use (16.4%), and risky sexual behaviors (15.1%). Most were interested in receiving behavioral interventions (ranging from 93.6% interest in unintentional injury prevention, to 73.1% in smoking cessation); 45% to 93% preferred technology-based (vs in person, telephone call, or paper) interventions for each topic. Proportion interested in a specific topic and proportion preferring a technology-based intervention did not significantly differ by self-reported risky behaviors. Conclusions Among this sample of adolescent emergency department patients, high rates of multiple risky behaviors are reported. Patients endorsed interest in receiving interventions for these behaviors, regardless of whether they reported the behavior. Most used multiple forms of technology, and approximately 50% preferred a technology-based intervention format.

Emergency department charges for evaluating minimally injured alcohol-impaired drivers

STUDY OBJECTIVE The literature on the costs of treating alcohol-impaired motor vehicle crash victims is largely based on inpatient data. Less is known about the more frequent emergency department (ED) evaluations for those who are discharged home. Our objective is to measure the difference in charges and length of stay between alcohol-impaired and nonimpaired drivers in this population. METHODS This was a retrospective study of charts and billing data for all drivers in motor vehicle crashes, aged 21 to 65 years, treated at an urban Level I trauma center in 2005 and discharged home from the ED. Patients were divided into alcohol-positive and -negative groups according to alcohol level, documentation of recent alcohol use, or clinical intoxication. Itemized charges were tabulated and compared across groups. RESULTS Of 1,618 eligible patients, median charges were higher for alcohol-positive patients by