WASHINGTON, DC—The development of a new strategy is in the works to support Native Americans who find themselves in the the hospital emergency department for alcohol related injuries.
David Boyd, MD, the national trauma systems coordinator for the IHS Department of Emergency Services, believes that educating patients to connect their drinking with their current injury will motivate them to change their behavior, thus preventing future injuries.
IHS reports that alcohol-related deaths are seven times higher in Native Americans/Alaskan Natives than in the rest of the US population, and Native Americans/Alaskan Natives have the highest percentage of alcohol-related collisions.
Boyd developed the IHS Alcohol Screening and Brief Intervention (ASBI) to curtail the volume of patients that present themselves in IHS facilities with injuries due to alcohol misuse. “We spent a major part of 2007 and 2008 holding some train-the-trainer courses. We exposed maybe 900 IHS and tribal providers, physicians, emergency physicians, social workers, counselors, emergency people, and the like [to the program],” he said. “Now it is being implemented in the hospitals. What we are trying to do is develop a strategy in which we will approach the clinics.”
The targeted prevention program is directed towards the young, non-dependent drinker whose drinking is classified as “harmful” or “hazardous.” These are drinkers who are experiencing problems related to alcohol use, or their drinking is putting them at risk for injury, illness, or other social problems, but they are not dependent drinkers.
These are drinkers who may have gone out for a night with friends, had a few drinks, and then gotten behind the wheel. They then end up in the emergency room after getting hurt as a result of their impaired state.
The idea behind the ASBI technique is that if a patient with an alcohol-related injury presents to an acute care setting, the IHS provider would take advantage of a “teachable moment.” During this moment, the provider would engage the patient in a brief conversation about the patient’s drinking and then challenge the individual to modify his or her behavior. “It is a targeted intervention limited in time, limited in scope, and directed to the individuals who are in a hazardous drinking period of their life,” said Boyd.
The conversation that takes place between the provider and patient is based on the “Brief Negotiation Interview” (BNI) technology developed at Yale University by Gail D’Onofrio, MD, that is also used in programs such as SAMHSA’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention. The BNI consists of the provider raising the subject of the patient’s alcohol use with the patient and then helping the patient make the connection between their drinking and the injury.
The provider motivates the patient to modify his or her behavior by assessing how ready the patient is to change and negotiates a drinking behavior goal which is reinforced with a written drinking agreement. “It is a great way of bringing up a conversation regarding behavioral change and it can be used in all different populations,” said D’Onofrio. “The technique is about listening to the patient and finding what will motivate them to change.”
Intervention for Non Dependent Drinkers
ASBI takes limited time to conduct, Boyd said. Screening tools, such as the AUDIT-C questionnaire can be offered in written or verbal form and the brief negotiated interview may take as little as five to 10 minutes.
Boyd believes one of the “geniuses” of the IHS program is that the alcohol screening and the brief intervention can be completed at separate times, which may be helpful to providers in a busy hospital late at night who may not feel they have time to conduct the intervention. Boyd said that having to complete the process “at two in the morning will kill the enthusiasm of this program.”
The targeted prevention program is not proven to work for dependent drinkers and is not targeted to this category of drinkers, Boyd explained. “One of the problems was that when we presented this everyone said, ‘this will not work for Joe Smith, he has been in rehab six times.’ That’s right. This is not for that group.”
He also emphasized that the intervention is not counseling.
Developing the Program
Boyd’s background is in trauma care. He is credited with writing the clinically relevant parts of the EMS Systems Act of 1973 and was the national director of emergency medical services for the Ford, Carter, and part of the Reagan administrations.
In later years, he served for a time as the general surgeon at the IHS Blackfeet Community Hospital in Browning, MT. Here, he saw first hand how alcohol-related trauma can rattle a small American Indian community where everyone knows one another. “You saw the devastating effect that alcohol had on young people in a small community, especially when the community hospital is staffed by the aunts, the sisters, and brothers of the patients that are coming in. At Blackfeet Community Hospital we would have situations where a pick up truck would roll over and would kill two kids and maim three or four others. This caused such a convulsion in the community that with wakes, ceremonies, and grieving we would almost sometimes have to shut down our hospital because of the number of staff members that were involved with this.”
Boyd became national trauma systems coordinator for the IHS Emergency Services in 2006, and credits his development of the IHS ASBI to prevent these alcohol-related injuries on research by experts Carl Soderstrom, MD, Larry Gentilello, MD, and D’Onofrio, among others, that showed the value of brief interventions in influencing patients with alcohol-related injuries.
Research by Gentilello has shown that 12 months after an alcohol screening and brief negotiated interview in a trauma center, there was a reduction in alcohol intake by four drinks per week as well as a 47% reduction in repeat injuries, which lasted up to several years. If ASBI works for IHS as similar interventions have worked in the research, it would make a big difference. “The magnitude of healthcare delivery and the magnitude of dollar cost of savings we would have for this group that has hazardous behavior—is immense.”
While SAMHSA funds eligible grantees for SBIRT, ASBI is tailored to IHS facilities which are often sparsely staffed during weekends and evenings when many of these alcohol-related injuries arrive. “It is the ‘Model T’ of alcohol screening and brief intervention,” Boyd said. “It is honed down to the bare essentials.”