Seizing the Moment with Substance Abusers

“Treat ’em and street ’em.” For the overburdened urban hospital emergency room, this bluntly stated approach to patient management is geared toward speed and efficiency rather than long-term health goals. Stitch the wound, examine the back pain, medicate the headache, and wheel in the next patient. But new evidence collected by a husband-and-wife team at Boston Medical Center suggests that for substance abusers, a visit to the ER offers a valuable opportunity to help change harmful behavior that threatens patients’ health, disrupts their lives, and often causes repeated visits to the hospital.

At BMC, Edward and Judith Bernstein have been pioneering a simple but effective intervention that uses compassion, skilled listening, and the patient’s own desire to change. The Bernsteins have adapted SBIRT (screening, brief intervention, referral, and treatment), long recognized within the field of substance-abuse treatment as a relatively low-cost but effective strategy for promoting healthier behaviors, for use in emergency departments. The technique has yielded such promising results at BMC that in 2006, the Bureau of Substance Abuse Services at the Massachusetts Department of Public Health (MDPH) awarded a three-year, $2.25 million grant to the Bernsteins’ Brief Negotiated Intervention and Active Referral to Treatment (BNI-ART) Institute to train the staff of seven hospital emergency departments across the state.

“In the 10 years we have been doing this work, we have found that a guided series of questions — delivered to patients as part of routine health care — can help patients find the will to break the cycle of alcohol and drug abuse and dependency,” says Edward Bernstein, a professor and vice chair of academic affairs in the emergency medicine department at BU’s School of Medicine. “They are in the emergency department already, so why not take advantage of this moment to really improve their health?”

Bernstein, who is also a professor of social and behavioral sciences at the School of Public Health, and Judith Bernstein, an SPH associate professor of maternal and child health and a MED associate professor of emergency medicine, run the BNI-ART Institute in affiliation with SPH’s Youth Alcohol Prevention Center. The institute trains health-care professionals to screen patients, conduct brief interviews, and provide referrals to treatment. In the past decade, the Bernsteins have used the approach at BMC, in the emergency departments of public hospitals in New York City, and at 14 national demonstration sites for the National Institutes of Health.

“What we have done is create a different model for providers who are themselves in a very stressful setting,” says Edward Bernstein. “Even in as little as 15 minutes, people trained in the right approach can ask a series of questions that can help a patient take that next step toward treatment and recovery.”

Seven hospitals were chosen for SBIRT training last year, and teams from each hospital spent three days in the fall observing the operation of BMC’s emergency department and attending training sessions conducted by BNI-ART Institute staff. The training emphasizes changing the doctor-patient dynamic by putting the patient’s own health concerns at the center of the treatment plan.

“Emergency medical training is very focused on doing procedures, saving lives — immediate solutions,” Judith Bernstein explains. “Conducting person-to-person interviews on sensitive subjects is not a simple thing to do, especially for medical professionals, because a person who has been trained as an expert can find it hard to listen. And the time pressures can make it difficult to have an honest conversation that is clinically meaningful.”

In contrast, the SBIRT approach is patient-centered, which means listening for cues rather than forcing treatment. “When a physician says to a patient, ‘What is it about the drugs you are using that you like?’ the doctor is signaling a willingness to listen because what a patient thinks and feels is important,” she says. “The brief negotiated interview toolbox makes it easier for doctors and nurses to talk heart-to-heart with patients about changing behaviors that have an adverse effect on health.”

Under the guidance of the institute’s educational team, the seven hospitals chosen for SBIRT training last year are now setting up their own individual programs.

Check tomorrow’s BU Today for part two of “Seizing the Moment with Substance Abusers.”