New findings lend credence to concerns that ED-based brief motivational interventions for heavy drinking may be less effective in women and victims of violence. The latest evidence comes from a large, randomized clinical trial that tested a program that aimed to reduce incidents of excessive drinking and intimate partner violence (IPV) in women presenting to the ED. Investigators found that women who received a brief motivational intervention in the emergency setting followed by a reinforcing phone call did not experience fewer days of heavy drinking or incidents of IPV than women in control groups.1
While the new data conflict with some earlier studies that found brief interventions to be effective in reducing both alcohol consumption and preventing injuries among women who engage in hazardous drinking, the results suggest researchers should develop and test more comprehensive solutions, according to Karin Rhodes, MD, MS, the lead author of the study and director of the Center of Emergency Care Policy & Research in the department of Emergency Medicine at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
“Our study results clarify that identification and brief interventions alone will not be adequate to change the course of relationship violence and heavy drinking,” she observes. “Patients with multiple risk factors will likely need much more intensive interventions for longer periods of time.”
IPV, excessive drinking decline
The trial was conducted at two Philadelphia-based academic medical centers between January 2011 and November 2013. Out of a total of 600 eligible participants, 242 were randomized to receive a 20- to 30-minute motivational intervention delivered by masters-level therapists in the emergency setting. Investigators report the approach borrowed from ED interventions designed to target both drinking and risky driving, and that the goal of these sessions was to identify self-reported reasons for change and personal goals. Further, during the sessions therapists would attempt to get patients to draw the links between their alcohol use and incidents of IPV and help them move toward positive behavioral changes. The sessions were followed by a telephone “booster” call from the same therapist about 10 days after the original ED visit.
Both the intervention group and a second group of 237 participants who did not receive the sessions with therapists underwent interviews upon enrollment and weekly assessments for 12 weeks. Also, follow-up measures were recorded by telephone at three, six, and 12 months. Additionally, 121 participants in a third “no contact” control group were assessed at three months.
At 12 weeks, the researchers report that excessive drinking — or the consumption of four or more drinks per day — and incidents of IPV declined in both the intervention group and the control group in which participants were only referred to social service resources.
Further, over time, investigators found that incidents of IPV and heavy drinking declined significantly in the intervention group as well as both control groups. For example, at one year post-enrollment, nearly half (45%) of all the study participants reported no incidents of IPV in the previous three months, and the researchers found that 22% of all participants were consuming alcohol at safe drinking levels. However, there was no evidence that either the intervention or the frequent assessments that took place in one of the two control groups had any influence over these outcomes.
Patients have unmet needs
Why didn’t the intervention have more of an impact? Rhodes suggests part of the problem likely relates to the prevalence of psychosocial problems in the study participants.
“As an emergency physician, I have spent years trying to improve routine patient psychosocial screening and ED provider-patient communication about behavioral risks that impact patient health outcomes,” she explains. “I have identified that patients at urban academic medical centers have a high degree of unmet need.”
For instance, Rhodes notes that many of the patients screened at the study sites reported experiencing too much stress, depression, and use of tobacco. Additionally, nearly half reported one or more adverse financial circumstances, such as not having enough food, not being able to see the doctor, cost-related medication non-compliance, or housing instability.
“We found a significant graded relationship between the number of adverse financial circumstances and patients’ poor/fair self-rated health, depressed mood, high stress, smoking, and illicit drug use,” Rhodes notes.
“The findings from psychosocial health risk screening underscore the imperative for hospital-based social workers to design models of routine social health risk screening and system interventions that address patient financial and social well-being.”
A number of studies have examined the impact of having the medical providers themselves engage in motivational interviewing to help nudge patients toward changing a behavioral risk factor. Could involving the medical providers in the intervention in this case have made a difference in the study results? Rhodes suggests most of these earlier studies focused on a single risk factor and much less advice from the medical provider.
“The model for those interventions is ‘Ask-Advise-Refer,’ and even that is difficult to integrate into routine ED practice,” she says. “We tried to do a much more intensive, high-quality motivational interview (MI) targeted at both risk factors, and we recorded the interviews to make sure our therapists were doing an excellent job of motivational interviewing.”
Rhodes adds that emergency providers would need to undergo a lot of extra training to accomplish what the therapists, who were trained IPV-MI social workers, were able to do during the study. Further, even if medical providers wanted to provide the type of intervention that was provided during the study, it would be impractical for them to do so in the emergency setting.
“Emergency providers do not have the time for 20- to 30-minute motivational interviews,” Rhodes observes. “The flow and acuity of the ED makes this too difficult.”
However, Rhodes notes ED physicians, nurses, and administrators can establish routine screening to identify IPV and co-occurring psychosocial risk factors.
“Also, train social workers and IPV advocates to perform safety assessments and provide referrals for more intensive, evidence-based interventions that are tailored to the patient’s needs and goals,” she advises, suggesting there is room for improvement on many different levels.
“I am still interested in designing and testing new models of routine psychosocial screening and social worker response as one part of a broader system of interventions that address psychosocial health and mental health issues in vulnerable populations,” Rhodes adds.
-
Rhodes K, et al. Brief motivational intervention for intimate partner violence and heavy drinking in the emergency department. JAMA 2015;314:466-477.
-
Karin Rhodes, MD, MS, Director, Center of Emergency Care Policy & Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Email: [email protected].
