Seizing the Moment with Substance Abusers

Click here to read part one of “Seizing the Moment with Substance Abusers.”

In the early 1990s, when emergency-medicine clinicians Judith and Edward Bernstein were working in Albuquerque, N.M., they had a sudden insight into treating substance abusers. They began working with middles school students from pueblos and rural communities to test the benefits of a standard anti–drug and alcohol curriculum compared with a personal, interactive experience. With guidance from nursing and medical students, the middle schoolers talked to emergency department patients who had problems with alcohol and drugs, asking them questions about their lives, their hospital experiences, and their substance problems.

“We watched as these kids interviewed the patients, people from their own communities,” says Judith Bernstein. “They showed so much concern for the patients — so much interest in their lives — and spoke to them so much more respectfully than did the staff. We had to ask ourselves, ‘What is missing in the interaction between professionals and patients?’”

That question has been the foundation of the couple’s work, at Boston Medical Center and in other hospitals, for the past decade. Judith Bernstein, an associate professor of maternal and child health at the School of Public Health and an associate professor of emergency medicine at BU’s School of Medicine, and Edward Bernstein, a MED professor and vice chair of academic affairs in the emergency medicine department, run the Brief Negotiated Interview and Appropriate Referral to Treatment (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 — an approach known as SBIRT.

The idea is that an ER visit by substance abusers allows a provider to seize the moment and help them take an opportunity to treat their addiction problems. 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.

And all of the programs evolved from the student-patient interactions the Bernsteins observed in New Mexico, including SBIRT, the BNI-ART Institute, and Project ASSERT, an intervention and treatment program launched by the Bernsteins at Boston Medical Center in 1994.

In a recent example of the patient-centered approach, Project ASSERT team member Ludy Young talked with an emergency room patient in his mid-40s complaining of a stomachache. Young introduced herself as a health promotion advocate and asked a few ice-breaker questions, with the goal of getting him to open up about his health concerns. Following the program’s tenets of speaking in a nonjudgmental tone and making eye contact, she asked the man how much he drank and what type of drugs he took.

“In our conversation it came out pretty quickly that this gentleman had a serious drinking problem that was bothering him, unrelated to the stomachache,” Young says. After the doctor’s examination, she continued talking with the patient, who confided that his drinking had spiraled out of control after his brother had been murdered and his mother had become ill.

“Once I was sure he was open to the idea of treatment, I offered him a number of options,” she says. “He asked to go into treatment that night, and right then and there we found him a detox bed.”

In these encounters, health promotion advocates use a one-page medical survey as a guide to begin an open-ended conversation with a patient.

“We might start with ‘How about taking a break?’” says Moses Williams, another Project ASSERT staff member. “Then we continue with questions that relate more directly to their current health status.” To find out the patient’s own sense of well-being, the advocates also ask, “In the last month, how often have you felt there is nothing to look forward to?”

Once they have worked through the questionnaire, the advocates will actively help a patient with the details of a treatment plan, which can include finding a bed in a rehab facility or making a follow-up doctor’s appointment, and will touch base with the patient four weeks later. The Project ASSERT team also runs a weekly support group and offers help to former patients on a drop-in basis.

Nancy O’Rourke, director of emergency services and acute care at Heywood Hospital in Gardner, Mass., says the SBIRT program has the potential to change the entire emergency department atmosphere.

“Before, all we were doing was handing our at-risk patients a piece of paper with some telephone numbers on it,” O’Rourke says. “When options are limited, patients who become hostile and verbally abusive can create an atmosphere that reduces the quality of patient care for everyone else in the emergency department.”

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 BNI-ART Institute to train the staff of seven hospital emergency departments across the state. The fact that 26 Massachusetts hospitals submitted applications to participate does not surprise Edward Bernstein, who sees a growing desire among medical professionals to receive this kind of training. According to the 2004 National Survey on Drug Use and Health by the Substance Abuse and Mental Health Services Administration, Massachusetts ranks second of 50 states in alcohol use among residents age 12 and older. And while an estimated 8 percent of emergency room patients in Massachusetts are drug- or alcohol-dependent, 26 percent are estimated to be using substances at levels that put their health at risk. Also, as other statistics suggest, the need for services takes a heavy toll on the medical system: at Springfield’s Mercy Hospital — one of the seven regional hospitals that have implemented the SBIRT program this year — 6.9 percent of emergency visits were substance-abuse related; those patients occupied nearly 20 percent of the hospital’s beds.

Over the years, the SBIRT approach has been proven to benefit these issues. A study of Project ASSERT patients from 1995 to 1996 conducted by the Bernsteins showed a 65 percent reduction in alcohol and drug consumption among patients who had participated in the program. The results of another study, conducted by the Academic Emergency Department SBIRT Collaborative (a group of trained practitioners at 14 sites around the country), also were promising: three months after intervention, 39 percent of emergency patients considered at high risk for dependent behavior were drinking within the low-risk guidelines established by the National Institute on Alcohol Abuse and Alcoholism, compared to 19 percent of the control group.

Other studies have shown improvements for drug-dependent patients as well. In a randomized control trial conducted by the Bernsteins among cocaine and heroin users through ASSERT’s Project Link, 22 percent of cocaine users in the intervention group were abstinent at six months, compared to 17 percent of the control group; among heroin users, it was 40 percent of the intervention group compared to 30 percent of the control group. After the results were published, Nora Volkow, director of the National Institute on Drug Abuse, wrote in an NIDA publication, “This type of intervention provides true benefits in reducing cocaine and heroin abuse; it also suggests that peer interventionists can play an important role in busy clinical environments.”

“We believe there is a natural process of change in people, and when people have a chance to talk about their use of drugs and alcohol, that opens the door to change,” says Edward Bernstein. “You might say that we are giving these patients a prescription for change.”