“At Risk” d - SGIM Library/SGIM/Meetings/Annual... · No Risk At Risk 4% Dependent 37% 24% Low Risk 35% 12 SECSAT HIGHEST rates of binge drinking are in: Males Age 25 – 34 Whites

SGIM WORKSHOP April 25, 2014

An Effective Method for Identifying and Helping Hazardous Drinkers in the Primary Care Setting:

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Kristy Barnes Le, MD David P. Miller, MD, MS, FAACP

Magdelena Greene, MD

Session Outline

Segment 1 (Kristy) Introductions

Epidemiology of “At Risk” drinking, and the evidence base for SBIRT

Segment 2 (Dave) Incorporating SBIRT into clinical practice: a systems approach

How to conduct an effective brief intervention (BI) with at-risk drinkers Video skills demonstration

Segment 3 (Kristy) Hands-on practice: BI with at-risk drinker

Segment 4 (Maggie) Time pressures

Added steps of a brief intervention with possibly-dependent drinkers Hands-on practice: BI with possibly-dependent drinker

Segment 5 (Kristy) Session Evaluation

Question and Comments

1

Funded by: www.sbirtonline.org

Kristy Barnes Le, MD David P. Miller, MD, MS, FACP


SGIM workshop

April 25th, 2014




Kristy Le, MD

Wake Forest UBMC IM Residency

Blanca Lopez, MD

Mercer University School of Medicine IM Residency

J. Paul Seale, MD

Mercer University School of Medicine FM Residency

Hunter Woodall, MD

AnMed Health FM Residency

Anderson, SC

Southeastern Consortium for Substance Abuse Training (NC, SC, GA)

Ann Barham, MD

Wake Forest UBMC FM Residency

Allen Tindol, MD

Memorial University IM Residency

Jill Mattingly, PA-C

Mercer University

Ed Evans, MD

Seneca Lakes FM Residency

Seneca, SC

J. Paul Seale, MD, Principal Investigator Department of Family Medicine

Mercer University School of Medicine Funded by Grant 1U79T1020278-01 Substance Abuse and Mental Health Services Administration (SAMHSA)

Objectives: By the end of the session, the attendee should be able to-

3

Explain the importance of screening for at-risk drinking in primary care settings.

Identify the components of an effective SBIRT system in the primary care setting.

Demonstrate a brief intervention with at-risk, and possibly-dependent drinkers.

SECSAT www.sbirtonline.org

2

What is SBIRT?

4

Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.

Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.

Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.


Background- started in 1980’s

5

Substance abuse screening tests developed (CAGE, MAST-Michigan Alcohol Screening Test, DAST-Drug Abuse Screening Test)

Seminal study by Russell et al. demonstrated the significance of physician advice to help patients quit smoking

Swedish research showed screening plus brief intervention in primary care setting could benefit risky drinkers

WHO expanded research initiative

Babor et al. FOCUS 2011 SECSAT www.sbirtonline.org

SBIRT - 25 years later

6

Overall > 100 trials have demonstrated efficacy and cost-effectiveness of SBIRT in emergency departments, primary care settings and trauma centers

Since 2008, SAMHSA has funded 17 medical residency cooperatives to disseminate SBIRT throughout graduate medical education

http://www.samhsa.gov/prevention/SBIRT/grantees/medres.aspx

Babor et al. FOCUS 2011


3

Benefits of Moderate Alcohol Consumption

Definition: 0.5-2 drinks/day

Benefits

Decreased risk of coronary heart disease

Decreased all-cause mortality

Thun et al, NEJM 1997

7 SECSAT www.sbirtonline.org

At-Risk Drinking

National Institute on Alcohol Abuse and Alcoholism. “Rethinking Drinking,” 2010.

MMWR 2012:61:14-19.

“binge drinking”


Binge Drinking 12.5% among adult women • Women 18 – 24: 24% binge • Women 25 – 34: 20% binge

Current alcohol use in high school

girls: 38% • 55% of girls who drink, binge

drink

Vital Signs MMWR. Jan 11, 2013 9


4

10

“At-risk”

Alcoholic


Beer: 12 oz = 1 16 oz = 1 1/3

22 oz = 2 40 oz = 3 1/3

Malt Liquor:

12 oz = 1 1/2 16 oz = 2

22 oz = 2 1/2 40 oz = 4 1/2

Wine: 5 oz = 1 750 ml bottle = 5

Liquor: 1.5 oz shot = 1 Mixed drink = 1 or more

Pint = 8 1/2 Fifth = 17

11

What is a Standard Drink?

NIAAA, 2010

7.4% Alcohol

CAUTION

2 pints = 4 standard

drinks!


Drinking Patterns in the U.S.

http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA

2009; MMWR 2012:61:14-19.

No Risk

At Risk

Dependent 4%

37%

24%

Low Risk

35%

12

HIGHEST rates of binge drinking are in:

Males

Age 25 – 34

Whites

Educated (some college or more)

Higher income (≥ $75,000)


5

DUI’s

Injuries (intentional & unintentional)

Other substance use

Alcohol use disorders

Liver disease

Impaired physical health

Impaired mental health

Impaired cognition/ADL’s

Obesity/overweight

School problems

Unsafe sex/STD’s

Unintended pregnancy

Sexual victimization

13

Most Morbidity & Mortality is from Binge Drinking (NOT Chronic Daily Drinking)

SECSAT www.sbirtonline.org http://www.collegedrinkingprevention.gov

Why is Management of Alcohol Misuse Important to Primary Care Physicians?

14

Prevalence

Morbidity and mortality

Barrier to treatment of chronic conditions

Potential functional impairment

High associated cost


Moore et al, 2003 Bouchery et al, 2011

But, few physicians address it!

15

CDC survey data from 2011 (166,753 US adults)

only 16% of patients overall report ever discussing alcohol use with their physician

only ~25% of binge drinkers report ever discussing alcohol use with their physicians

McKnight-Eily et al, MMWR 2014


6

Brief Intervention Works!

16

SBIRT meta-analyses & reviews:

More than 34 randomized controlled trials

Focused primarily on at-risk and problem drinkers

Result in 10-30% reduction in alcohol consumption at 12 months

Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005; Kaner

et al, 2009 SECSAT www.sbirtonline.org

2013 USPSTF Review

17

23 randomized controlled trials reviewed (11 U.S.)

In general, show that primary care interventions reduce binge drinking Meta-analysis 7 trials

12% fewer patients reported no risky drinking episodes at 1 year follow-up

Meta-analysis 10 trials Reduced average weekly consumption from 23 to 19 drinks

Meta-analysis 3 trials (younger/ college-age) Reduced frequency of heavy drinking days by one per month at

6-month follow-up

Moyer, Annals 2013; USPSTF 2013


US Preventive Services Task Force: SBIRT Recommended for All Adults Over 18 yo

18

Recommended since 2004

“…adequate evidence that numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity”

“…adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes…. These interventions also reduce weekly alcohol consumption…”

Moyer, Annals 2013; USPSTF 2013


7

SBIRT Can Be Effectively Implemented in Primary Care

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Effective models exist for implementing screening and brief intervention in residency training.

Trained clinicians typically intervene with more than 70% of patients.

Seale et al, 2005; Adams et al, 1998


Key to Implementation: Systems Approach Targeting Both The Clinicians & Office System

20

Train clinicians & clinic staff in SBIRT

Create office system that will support SBIRT Screening & prompting system

Assessment instruments

Intervention materials

Reminder system for re-assessment & reinforcement


5 Basic Components of an Effective SBIRT System

21

Prescreening (nurse screening questions) Screening (Alcohol Use Disorders

Identification Test =AUDIT) Clinician Intervention for all screen-positive

patients Referral as appropriate for patients with higher

levels of risk or possibly dependent Follow-up assessment/reinforcement at future

visits


8

Prescreen is routinely performed

every 6-12 months

Nursing questions:

1. “Do you sometimes drink beer, wine, or liquor?”

2. “How many times in the past year have you had more than x drinks in a day?”

X = 4 for men

X = 3 for women

22 SECSAT www.sbirtonline.org Smith et al, 2009

Patterns of alcohol use among U.S. at-risk drinkers: 28% of population at-risk

Exceed only daily limits (> 3 OR 4

drinks/day)

Exceed only weekly limits

(>7 or 14 drinks/wk)

2%

http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/ Rethinking_Drinking.pdf, NIAAA 2009;

http://www.collegedrinkingprevention.gov/; NESARC Wave 1 study

Prevalence is higher in college students: 44%

23

16%

10%


When Prescreen is Positive,

Administer AUDIT

Patient is given the Healthy Lifestyles Screen (AUDIT)

Patient completes the AUDIT and gives it to his/her clinician

Physician performs brief intervention (BI)


9

25

Healthy Lifestyles Screen (AUDIT)

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and

treatments, it is important that we ask some more questions about your use of alcohol. If we find that you are drinking more than you or we feel is good for you, we have some services right here that can help you

take better care of yourself. Your answers will remain confidential so please be honest.

Place an X in one box that best describes your answer to each question.

QUESTIONS 0 1 2 3 4

1. How often do you have a drink containing alcohol?

Never Monthly

or less

2-4 times a

month

2-3 times a

week

4 or more

times a

week

2. How many drinks containing alcohol do you have on

a typical day you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more

3. How often do you have four or more drinks on one

occasion? Never

Less than

monthly Monthly Weekly

Daily or

almost daily

4. How often during the last year have you found that

you were not able to stop drinking once you had

started?

Never Less than


Daily or

almost daily

5. How often during the past year have you failed to do

what was expected of you because of drinking? Never

Less than


Daily or

almost daily

6. How often during the past year have you needed a

drink first thing in the morning to get yourself going

after a heavy drinking session? Never

Less than

monthly

Monthly Weekly

Daily or almost daily

7. How often during the past year have you had a

feeling of guilt or remorse after drinking? Never

Less than


Daily or

almost daily

8. How often during the past year have you been unable to remember what happened the night before because

of your drinking? Never

Less than monthly

Monthly Weekly Daily or

almost daily

9. Have you or someone else been injured because of

your drinking? No Yes, but

not in the

past year

Yes, during

the past year

10. Has a relative, friend, doctor, or other health care

worker been concerned about your drinking and

suggested you cut down?

No Yes, but

not in the

past year

Yes, during

the past year

Adapted from World Health Organization

3 quantity & frequency questions (1-3)

3 questions probing signs of dependency (4-6)

4 questions about alcohol-related problems (7-10)

Score Range: 0 - 40

SECSAT www.sbirtonline.org Babor et al, 2001.

SECSAT Risk Zones


High

Risk

At Risk

Low/No Risk

1-13

≥ 14

AUDIT Score:

Intervention

Clinician identifies level of intervention based on Healthy Lifestyles Screen (AUDIT)

Clinician conducts the intervention using the intervention card as a guide

27

Intervention card adapted from Oregon Health & Sciences University

SBIRT Primary Care Residency Initiative

Not at all Extremely 0 10 5 6 7 8 9 2 3 4 1

cm

Lower Risk Drink Limits

No drinking/using if driving, pregnant, possibly dependent or otherwise

contraindicated

What is a standard drink? Do you sometimes drink beer, wine or liquor?

How many times in the last 12 months have you had X or

more drinks in one day?

Men: X = 5 Women: X = 4

How many times in the past year have you used an illegal

drug or used a prescription medication for nonmedical

reasons?

The percent of “pure” alcohol expressed here as alcohol/volume varies by beverage.

~5% ~7 % ~12% ~40%

12 oz

Beer

8-9 oz

Malt

Liquor

5 oz

Wine

1.5 oz/

1 shot

liquor

Your Risk Level: AUDIT

≥ 14

1-13

0

DAST

3-10

1-2

0

Per

Day

Per

Week

Healthy

Men

4

14

Healthy

Women

3

7

All ages

>65

3

7


10

Intervention Guide

Intervention card adapted from Oregon Health & Sciences University

SBIRT Primary Care Residency Initiative

Zone I: At Risk

AUDIT 1-13 (≥ 1 binge); DAST 1-2

Zone II: High Risk, Possibly Dependent

AUDIT ≥ 14; DAST 3-10

www.sbirtonline.org

Rev. Mar 2012

Funded by:

Ask Permission “I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”

Provide Feedback Refer to pyramid & provide patient’s AUDIT/DAST score & risk level(s). [As your physician] “Drinking/using at this level can be harmful to your health and possibly responsible for the health problem for which you came in today. What do

you make of that?”

Enhance Motivation

& Elicit Change Talk

“What are the good things/not so good things about your alcohol/drug use?” (Decisional balance)

“On a scale of 0-10, how important is it that you cut back or quit your alcohol/drug use?”

If >0, “Why that number and not a lower one?” [Use rulers to also ask about confidence, readiness]

“Have you ever considered cutting back or quitting?” If so, “Why?” If not, “What would have to happen for you to

consider cutting back/quitting?”

Provide Advice Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines (or offer advice to quit or cut back

drug use).

Zone II Additional Steps:

Ask: “If you go a day or 2 without drinking/using do

you ever get sick, shaky, have

tremors/seizures/cramps, or see/hear things that are

not there?”

Offer menu of options for more help:

► Medication (naltrexone, acamprosate,

disulfiram, methadone, Suboxone)

► Referral

•Counseling/Brief treatment •Support group (e.g., AA, NA, Celebrate

Recovery)

•Treatment or substance abuse program

Discuss Next Steps “If you were to make a change, what would be your first step?”

Close on Good

Terms

Summarize, emphasize patient strengths, highlight change talk and decisions made. Arrange for follow-up as appropriate.


Motivational Interviewing - Definition Collaborative, goal-oriented method of

communicating with patients.

Intended to strengthen patient’s personal motivation.

promote commitment to their own goal for behavioral change

Uses patients ambivalence and own feelings about their behavior to help them move forward, rather than physician being directive.

Miller & Rollnick, 2008


The MI Shift

From feeling responsible for changing

patients’ behavior to supporting them in thinking & talking about their own reasons and means for behavior change.

30 MI Basic Training


11

Stratified Intervention Protocols: Zone I: At Risk Drinker/User

At risk drinker with limited or no consequences (AUDIT score 1-13)

Brief intervention Ask permission

Provide feedback

Enhance motivation

Provide advice

Discuss next steps

Close on good terms


Step 1: Ask for Permission

32

“I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”


Step 2: Provide Feedback from Prescreen and AUDIT questionnaire

Refer to graph & provide patient’s AUDIT score

“Drinking at this level can be harmful to your health.”

“What do you make of that?”

AUDIT

≥ 14

1-13

0


12

34

Step 3: Enhance Motivation: Decisional Balance

Ask, “What are some of the good/not-so-good things about your alcohol/drug use?”

Summarize both sides of their thinking On the one hand… and on the other hand…


Step 3: Enhance Motivation: Rulers

35

“On a scale of 0 to 10, how important is it for you to cut back or quit your alcohol/drug use?” [Clarify whether discussing quitting or cutting back.]

If > 0, ask “Why that number and not a lower one?” [N-2]

May also use rulers to ask about confidence and readiness

0

10


Step 4: Provide Advice

36

Low-Risk Drinking (NIAAA Guidelines) Healthy men ≤ 65 years old No more than 4 per day or 14 per

week

Healthy women of all ages No more than 3 per day or 7 per

week

All healthy individuals >65 years of age No more than 3 per day or 7 per

week

Per Week

Per Day

Men

14

4

Wome

n

7

3

All

ages >65

7

3

Per Week

Per Day

Men

14

4

Wome

n

7

3

All

ages >65

7

3

Lower Risk Drink Limits

No drinking if driving, pregnant or possibly dependent

7 3 All ages >65

7 3 Healthy Women

14 4 Healthy

Men

Per Week

Per Day


13

Step 5: Discuss Next Steps

37

“If you were to make a change, what would be your first step?”


Step 6: Close on Good Terms

38

Summarize

Emphasize patient strengths

Highlight change talk

List decisions made regarding next steps

Arrange for follow-up as appropriate



Video: BI for At-risk Drinking

Clinician Intervention for At-risk Drinker

14

Practice At-Risk Brief Intervention

40

PATIENT: María Lopez

REASON FOR

VISIT: Sore throat

HISTORY: 47 years old

No current medical problems

PHYSICAL

EXAM FINDINGS: Height 5'7"

Weight 130 lbs.

BP 140/90

Pulse 70 and regular

DRINKING

INFORMATION See Prescreen and Screen

• Mrs. Lopez replied that she has never smoked. • She replied that several times a week she has

four or more drinks. • She indicates that she has never used any other

substances.


41


PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask

some more questions about your use of alcohol. If we find that you are drinking more than you or we feel is good for you, we have some services right here that can help you take better care of yourself. Your answers will remain confidential so please be honest.


QUESTIONS 0 1 2 3 4


Never Monthly

or less

2-4 times a

month

2-3 times a

week

4 or more

times a

week




occasion? Never

Less than


Daily or

almost daily



started?

Never Less than


Daily or

almost daily



Less than


Daily or

almost daily




Less than

monthly

Monthly Weekly




Less than


Daily or

almost daily

8. How often during the past year have you been unable

to remember what happened the night before because of your drinking?

Never Less than


Daily or

almost daily



not in the

past year

Yes, during

the past year




No Yes, but

not in the

past year

Yes, during

the past year

PROVIDER USE ONLY

1. On average, how many days a week do you have an alcoholic drink?_____ X

2. On a typical drinking day, how many drinks do you have?______ = ________(weekly average)

3. How many times in the past year have you used an illegal drug or used a prescription medication for non-medical

reasons? None__ 1 or more__ Which ones?______________________ Any others? _____________

__________________________________________________________________________

Total

ZONE I (1-13) ZONE II (≥ 14)

BI performed Blue brochure given

BI performed Red brochure given

W/D precautions discussed

Medication (naltrexone, acamprosate or disulfiram)

Referral (check all that apply)

Counseling/BT

Support group

Tx/SA program

Physician signature: ____________________________________

Provider Name: ________________________________________

Description of plan:

Lopez, Maria

47 F SECSAT www.sbirtonline.org

Dealing with Time Pressure

42

An ounce of prevention is worth a pound of cure.

Benjamin Franklin


15

Dealing with Time Pressure Do your brief intervention over multiple visits At the first visit, use 1 minute to cover the first

three steps Ask permission to discuss alcohol use Provide feedback on patient’s risk level Offer advice to reduce drinking at least to low risk

levels Invite the patient to discuss alcohol use at a future

visit

Investing a few minutes now may avoid a greater problem later


Zone II: 3 Added Steps for Those Patients with Possible Dependence & Polysubstance Abuse

Advice is to stop

Assess withdrawal risk

Discuss other resources available if patient is interested


Intervention Steps for Possibly Dependent Patients (AUDIT ≥ 14)

45

Brief intervention Ask permission

Provide feedback

Enhance motivation

Provide advice encouraging abstinence

Assess & address possible withdrawal risk

Discuss next steps including information about getting help

Close on Good Terms


16

Withdrawal Assessment:

46

“Some people have the following after a day or two without drinking/using. Have you ever had these symptoms?” Felt sick or shaky

Tremors

Nausea

Heart racing

Seizures

Seen or heard things that were not there

“When did you last quit drinking? For how long?”


Two Options for Addressing Potential Withdrawal

47

Higher risk Arrange withdrawal treatment immediately

Follow institutional protocols

Lower risk Tell patient what to do if these symptoms occur

Arrange outpatient SA treatment

Document what you do in the patient’s chart


Red Zone Offers Information on Getting Help

48

Menu of options

Medication: (naltrexone, acamprosate, or disulfiram for alcohol, buprenorphine or methadone for opioids)

Referral to Treatment Self-help/support group (e.g., AA/NA, Celebrate Recovery, etc.)

In-house counseling (brief treatment)

Treatment or substance abuse program

Offer menu of options for more help:

► Medication (naltrexone, acamprosate,

disulfiram, suboxone, methadone)

► Referral

•Support group (e.g., AA, NA, Celebrate Recovery)

•In-house counseling (Brief treatment)

•Treatment or substance abuse program


17

Practice Possibly-Dependent BI

49

PATIENT: Robert Johnson

REASON FOR VISIT: Routine physical

HISTORY: 42 years old

Several previous visits because of falls w/sprains

PHYSICAL

EXAM FINDINGS: Height 5'10"

Weight 178 lbs.

BP 142/96

Pulse 84 and regular

DRINKING

INFORMATION: See Prescreen and Screen

ADDITIONAL

INFORMATION: Patient has no symptoms of withdrawal.

Patient is not yet ready to quit drinking but may consider cutting back.

• Mr. Johnson replied that he is a current smoker. • He replied that he drinks more than 5 drinks most

days. • He indicated that he does not use any other

substances.


50


PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask

some more questions about your use of alcohol. If we find that you are drinking more than you or we feel is good for you, we have some services right here that can help you take better care of yourself. Your answers will remain confidential so please be honest.


QUESTIONS 0 1 2 3 4


Never Monthly

or less

2-4 times a

month

2-3 times a

week

4 or more

times a

week




occasion? Never

Less than


Daily or

almost daily



started?

Never Less than


Daily or

almost daily



Less than


Daily or

almost daily




Less than

monthly

Monthly Weekly




Less than


Daily or

almost daily

8. How often during the past year have you been unable

to remember what happened the night before because of your drinking?

Never Less than


Daily or

almost daily



not in the

past year

Yes, during

the past year




No Yes, but

not in the

past year

Yes, during

the past year

PROVIDER USE ONLY

1. On average, how many days a week do you have an alcoholic drink?_____ X

2. On a typical drinking day, how many drinks do you have?______ = ________(weekly average)

3. How many times in the past year have you used an illegal drug or used a prescription medication for non-medical

reasons? None __ 1 or more __ Which ones?______________________ Any others? _____________

__________________________________________________________________________

Total

ZONE I (1-13) ZONE II (≥ 14)

BI performed Blue brochure given

BI performed Red brochure given

W/D precautions discussed

Medication (naltrexone, acamprosate or disulfiram)

Referral (check all that apply)

Counseling/BT

Support group

Tx/SA program

Physician signature: ____________________________________

Provider Name: ________________________________________

Description of plan:

Johnson, Robert

42 M


All materials can be found at:

Questions ?

& Comments 51

http://www.sbirtonline.org/

18

References:

52

See distributed list

SGIM WORKSHOP April 25, 2014



Kristy Barnes Le, MD David P. Miller, MD, MS, FAACP


References

1. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Kazi A, Bray, J. Screening, Brief

Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to

the Management of Substance Abuse. FOCUS 2011; 9:130-148.

2. www.samhsa.gov/prevention/SBIRT/grantees/medres.aspx

3. Thun MJ, Peto R, Lopez AD, Monaco JH, Henley SJ, Heath CW, Doll R. Alcohol

Consumption and Mortality among Middle-Aged and Elderly U.S. Adults. N Engl J Med

1997; 337:1705-1714

4. Rethinking Drinking. NIH Publication No. 13-3770, Published 2010. Available at

http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

5. Payne, Cathy. CDC: Binge drinking is serious problem for girls, women. USA Today. Jan

8, 2013

6. Centers for Disease Control and Prevention (CDC). Vital signs: Binge drinking among

women and high school girls--United states, 2011. MMWR. 2013; 62:9-13.

7. Grant BF, Dawson DA, Stinson FS, Chou SP, Dufour MC, Pickering RP. The 12-month

prevalence and trends in DSM-IV alcohol abuse and dependence: United states, 1991-

1992 and 2001-2002. Drug Alcohol Depend. 2004; 74(3):223-234. Available at

http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm

8. Kanny D, Liu Y, Brewer RD, Garvin WS, Balluz L. Vital signs: Binge drinking prevalence,

frequency, and intensity among adults – United States, 2010. MMWR 2012;61:14–19

9. http://www.collegedrinkingprevention.gov

10. Moore AA, Endo JO. Is there a relationship between excessive drinking and functional

impairment in older persons? J Am Geriatr Soc. 2003; 51(1): 44-49.

11. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic Costs of Excessive

Alcohol Consumption in the U.S., 2006. Am J Prev Med. 2011; 41(5): 516-524.

http://www.samhsa.gov/prevention/SBIRT/grantees/medres.aspx

http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf


http://www.collegedrinkingprevention.gov/

12. McKnight-Eily LR, Liu Y, Brewer RD, Kanny D, Lu H, Denny CH, Balluz L, Collins J. Vital

Signs: Communication Between Health Professionals and Their Patients About Alcohol

Use — 44 States and the District of Columbia, 2011. MMWR 2014; 63:16-22

13. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol

problems: A meta-analytic review of controlled investigations in treatment-seeking and

non-treatment-seeking populations. Addiction. 2002; 97(3):279-292.

14. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J, U.S. Preventive Services Task

Force. Behavioral counseling interventions in primary care to reduce risky/harmful

alcohol use by adults: A summary of the evidence for the U.S. preventive services task

force. Ann Intern Med. 2004;1 40(7):557-568.

15. Bertholet N, Daeppen JB, Wietlisbach V, Fleming M, Burnand B. Reduction of alcohol

consumption by brief alcohol intervention in primary care: Systematic review and

meta-analysis. Arch Intern Med. 2005; 165(9):986-995.

16. Kaner EF, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F, Saunders JB,

Bernand B, Heather N. The effectiveness of brief alcohol interventions in primary care

settings: A systematic review. Drug Alcohol Rev. 2009; 28(3):301-323.

17. Moyer VA. Screening and behavioral counseling interventions in primary care to reduce

alcohol misuse: U.S. preventive services task force recommendation statement. Ann

Intern Med. 2013; 159: 210-218.

18. USPSTF, 2013. United Stated Preventive Services Fact Sheet. Available at

http://www.uspreventiveservicestaskforce.org/uspstf12/alcmisuse/alcmisusefact.pdf

19. Seale JP, Shellenberger S, Boltri JM, Okosun IS, Barton B. Effects of screening and brief

intervention training on resident and faculty alcohol intervention behaviours: a pre-

post-intervention assessment. BMC Family Practice. 2005; 6:46

20. Adams A, Ockene J, Wheeler E, Hurley T: Alcohol counseling: Physicians will do it. J Gen Intern Med 1998, 13:692-698

21. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009; 24(7):783-788.

22. Alcohol Use and Alcohol Use Disorders in the United States: Main Findings from the 2001-2001 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). NIH Publication No. 05-5737, Published 2006. Available at http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm

23. Babor T, Higgins-Biddle J, Saunders J, Monteiro M. AUDIT, the Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. 2nd ed. World Health Organization, Geneva. 2001.

24. Rollnick S, Miller WR, Butler CC: Motivational Interviewing in Health Care: Helping Patients Change Behavior (Applications of Motivational Interviewing). New York: Guilford Press; 2008

http://ovidsp.tx.ovid.com/sp-3.10.0b/ovidweb.cgi?&S=OACHFPDGBADDKDDCNCNKOBIBBLDPAA00&Complete+Reference=S.sh.55%7c2%7c1




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