Session 4.


Implementing Preventive Interventions in


Emergency Medicine: Strategic Considerations


Larry M. Gentilello, MD 

Individuals who may benefit from alcohol counseling are often unaware 

of their need for treatment. The provision of alcohol interventions in 

emergency departments (ED) may provide an opportunity to treat 

individuals who are currently not actively seeking such care. Due to their 

lack of awareness of their problem, these patients are unlikely to present 

for treatment on their own. 

Treatment does not need to be sought actively to be effective.1

 However, motivation can facilitate treatment. Studies suggest that physicians 

can opportunistically capitalize on the motivating effects of acute 

injuries or medical conditions that require emergency care to convince 

patients of the need for behavior change.2

 This process may identify 

patients who have not yet developed severe dependence, thereby preventing the development of more intractable stages of alcoholism. 

Finally, such interventions may have the potential to decrease repeated 

use of emergency department resources.3 

Randomized trials of inexpensive screening and intervention protocols that are feasible for use in the brief contact setting of the emergency 

department have been shown empirically to be effective when used in a 

variety of settings outside the ED.

2–6 A recent analysis of 12 randomized 

trials, each of which was limited to one session and consisted of less than 

one hour of motivational counseling, demonstrated that heavy drinkers 

were twice as likely to moderate their drinking when compared with 

those who did not receive an intervention.7 

Brief interventions were specifically designed to target patients who 

are drinking at hazardous levels but have not become dependent. Some 

patients treated in emergency departments need more intensive treatment such as inpatient or outpatient therapy or participation in selfhelp groups. Brief interventions may be used to motivate such patients 

to seek or accept a referral to more intensive treatment.

8 

Implementing Preventive Interventions 133 
As proven alcohol interventions emerge, a systematic effort is needed 

to incorporate them into emergency department practice. The public 

policy objectives of Healthy People 2010 include routine emergency 

department screening.

9 

The provision of such interventions is currently not routine. A variety 

of changes at the individual, system, and policy level will be needed to 

accomplish this goal. This paper describes the factors that have limited 

the provision of alcohol intervention and counseling in emergency 

departments and provides an agenda to foster their implementation. 

Knowledge and attitudes of emergency department staff 

Physician advocacy plays an important role in influencing screening 

practices by increasing awareness of the problem and by generating 

support for screening and intervention services. A survey of surgeons 

working in an emergency department found that the most significant 

predictor of screening was the attending physicians’ perception that 

their responsibilities included screening.

10 However, 81% did not 

routinely screen, and 75% did not believe that screening was the responsibility of emergency department staff. Routine screening and intervention will require engendering a sense of role responsibility among 

emergency department clinicians towards addressing substance abuse. 

This shift will require correcting misconceptions about the validity 

and generalizability of treatment research results and their relevance to 

the emergency department population.11,12 The literature suggests that 

these misconceptions are the result of a relative lack of physician education and training in substance abuse.10,13–18 

In the survey mentioned previously, 83% of respondents indicated 

that they had no prior training in screening or detection of alcohol 

problems, and more than 75% were not familiar with any of the commonly used alcohol screening questionnaires, such as the CAGE or 

MAST.

19,20 Another survey found that less than 25% of emergency 

medicine residency programs teach residents about the quantity/ 

frequency of alcohol use questions needed to establish an early diagnosis 

of an alcohol-related disorder.

21 A more recent survey of program 

directors found that the average emergency medicine residency program 

devotes only three curricular hours to substance abuse training.

22 

The lack of education about screening is illustrated by the fact that 

the most commonly cited reason for failure to screen is lack of time.10 

134 Alcohol Problems Among Emergency Department Patients 
However, an effective battery of screening tools that require minimal 

time and disruption to implement is already available. A screening blood 

alcohol level can be obtained easily when blood is drawn for other 

purposes. A simple questionnaire such as the CAGE can easily be 

incorporated into a routine history and physical examination. Detecting 

hazardous drinking in the absence of dependence can be accomplished 

by asking several questions about quantity and frequency of use 

(e.g., using the first three questions of the AUDIT), which are easily 

memorized.23,24 Lack of knowledge, rather than lack of time, is a more 

likely explanation for failure to screen. 

Many physicians do not screen because they believe that asking 

patients about substance use is intrusive. Physicians who do not screen 

are three times more likely to have this belief than physicians who 

routinely screen.10 Studies suggest that patients do not share this concern. Trials of alcohol screening in primary care, general medical clinics, 

trauma centers, and emergency departments demonstrate a high rate of 

patient acceptance.

2–4 

Some physicians are willing to detect alcohol use, but they believe that 

clinical judgment is reliable and formal screening is unnecessary.

25 

However, numerous studies document that physicians generally fail to 

diagnose alcohol problems unless a formal screening protocol is used. 

In one study, researchers screened 2,002 patients for alcohol problems, 

but the results were not provided to staff. The clinical detection rate for 

screen-positive patients ranged between 25% and 50%, depending on 

the type of service provider.

15 

Similar results were found in a study of injured patients treated in 

the emergency department. The staff was asked to subjectively determine if patients were intoxicated (BAC > 0.10 g/dl) or had a chronic 

alcohol problem. Although 45% of patients were intoxicated, sensitivity 

was only 77%, and sensitivity decreased to 63% among patients who 

were severely injured, endotracheally intubated, or brain injured.26 

Specificity was also poor. More than 20% of patients who were thought 

to be intoxicated had no alcohol in their blood. Patient’s age, income, 

and insurance status significantly influenced both sensitivity and 

specificity. Patients were also screened with the CAGE and SMAST. 

Staff identified fewer than 50% of screen-positive patients. Formal 

screening protocols are needed because clinical judgment is unreliable 

and subject to bias.15,27 

Implementing Preventive Interventions 135 
A key reason that screening is not performed is the widely held 

perception that treatment is not effective. In the trauma center survey 

mentioned previously, only 27% of respondents believed that “brief 

interventions are at least moderately effective.”10 Nearly half believed 

that “there are not enough treatment resources to make screening 

worthwhile.” An assessment of blood alcohol testing practices found 

that 91% of physicians who do not measure blood alcohol concentration 

believe the test is “not clinically important” because knowledge of the 

patient’s blood alcohol level does not benefit the patient.28 

Skepticism about treatment benefits is apparently widespread. One 

study of 2,500 randomly selected emergency department physicians 

found that only 55% believed that mental health professionals 

(psychologists and psychiatrists) can effectively address alcohol 

problems.29 Their perception of treatment efficacy provided by other 

staff (physicians and surgeons) was even lower, 23%. This confirms the 

lack of knowledge regarding the progress in alcohol treatment that has 

led to expert consensus recommendations that all patients at risk for 

alcohol problems should be screened and counseled or referred for 

counseling.

30,31 

Changing belief systems, clinical practices, and cognitive barriers is a 

slow process and a formidable challenge. Implementation will require 

increasing emergency department physicians’ knowledge in order to 

increase confidence in screening skills and to dispel myths about the 

futility of treatment. However, information alone may not change 

clinical practice. For example, only 21% of survivors of myocardial 

infarction are treated with beta-blockers by their primary care 

physician, despite the fact that expert consensus panels consider this 

omission a serious medical error.

32 

Studies of educational strategies to change physician behavior suggest 

that informational material and formal CME conferences have little 

impact, while outreach activities by professional organizations and 

opinion leaders conducting on-site educational programs produce 

positive change.33 However, many people become leaders of organizations because they reflect the needs and attitudes of members, and 

therefore they are not likely to radically change the culture of the 

organization. The majority of opinion leaders in emergency medicine 

reflect the current belief that alcohol problems are outside their practice 

136 Alcohol Problems Among Emergency Department Patients 
domain. Unless emergency medicine staff with an interest in integrating 

alcohol treatment services into emergency care assume greater prominence and leadership in their field, effecting change within this specialty 

will be slow and uneven. 

Implementation will, therefore, require the emergence of leaders who 

endorse the concept that alcohol screening and intervention is their 

responsibility. Funding for alcohol-related research needs to be provided 

to emergency department personnel on a priority basis because such 

funding will lead to their professional development, increase their 

national stature, lead to their advancement in professional societies, 

lead to association with policymakers, and enhance their opportunity 

to become opinion leaders. The development of credible opinion leaders 

who are emergency medicine clinicians, who will endorse and advance 

the concept of alcohol screening and intervention, is the best means of 

fostering attitudinal change within that specialty. Changes in a specialty 

practice are more likely to occur if they are supported by research 

conducted within that same discipline. Advances in one specialty do not 

necessarily affect the practice of another. Articles published in journals 

devoted to psychiatry or substance abuse will have little impact on the 

practice of emergency medicine. Traditionally, little interaction has 

occurred between emergency medicine physicians and substance abuse 

treatment providers. Each specialty operates within its own domain, 

with little integration of services across specialities, and they do not 

publish in common journals. This tendency for medical specialties to 

operate within their own discipline with little cross-dissemination of 

information suggests that ED staff must be involved in conducting 

intervention trials in order to popularize the concept within their own 

field. 

A MEDLINE search of papers published using the MESH terms 

“alcoholism AND treatment AND intervention” yielded 47 publications 

during the calendar year 2000. None of these were published in journals 

devoted to emergency medicine. None of the trials of alcohol interventions in emergency departments were published in journals likely to be 

encountered by emergency care providers.

2,34 It is, therefore, not surprising that emergency physicians and staff lack knowledge about substance 

abuse and have failed to embrace research advances in screening and 

intervention. 

Implementing Preventive Interventions 137 
Current funding sources are not structured to foster the development 

of leaders in emergency medicine who endorse the concept that addressing alcohol problems is their responsibility. Obtaining funds from study 

sections on emergency care is difficult because peer-reviewers do not 

view alcohol-related research as being vital. There are equally formidable 

obstacles when attempting to obtain funding from alcohol study sections. Reviewers may not be familiar with the characteristics of an 

emergency department as a unique clinical community. They also prefer 

the use of highly controlled diagnostic and demographic groups in order 

to obtain unambiguous answers to isolate the active ingredient of treatment efficacy. While this approach has led to great strides in understanding how treatment works, it may not be practical in the real-world 

setting of the emergency department and may generate studies with little 

external validity. 

We, therefore, have a dilemma. Grant applications submitted by emergency medicine specialists that do not use the methodologic processes 

preferred by alcohol research study sections are usually going to lose 

when competing against grants submitted by recognized alcohol 

research specialists. On the other hand, studies conducted by alcohol 

research specialists may not provide clinically relevant intervention 

protocols, are not likely to be noticed or considered credible by emergency medicine physicians, and will have little impact on practice. 

There is little point in funding research on interventions that are 

unlikely to be implemented. 

The design and peer-review of studies on alcohol interventions in the 

emergency care setting should be geared more towards embracing the 

perspectives of emergency medicine specialists. Such individuals are in 

the best position to understand what research questions are important 

and what type of interventions are feasible and generalizable. While 

their grant applications may not have the methodologic design that 

study sections composed of alcohol research specialists are accustomed 

to, funding such research will lead to the development of research 

methodologies appropriate to the emergency department setting. 

Research conducted by emergency medicine physicians will help 

establish a sense of role responsibility within the field, and this attitude 

will be disseminated within the specialty by the work product that is 

published and presented at practice-specific professional meetings. This 

138 Alcohol Problems Among Emergency Department Patients 
will foster the development of a culture of acceptance of role responsibility to screen and intervene, and develop lobbying pressure to do so 

within the field of emergency medicine. 

Emergency departments are frequently the only point of contact with 

the health care system for indigent patients.35 Emergency department 

interventions are consistent with the “No Wrong Door to Treatment” 

theme of the National Treatment Plan.36 Alcohol problems among 

emergency department patients consume an extraordinary amount of 

health care dollars. Studies on alcohol interventions in emergency 

departments should consume a proportionate amount of research 

dollars. 

Inadequate access to treatment/ineffective treatment 

Effective, low-cost interventions that require minimal additional staff to 

implement are already available. Due to emergency department time 

constraints, so-called “brief motivational interventions” are the intervention model most likely to be successfully implemented. No other 

existing model is likely to be useful in the real-world setting of the 

typical emergency department. 

The empirical support for brief interventions is excellent and does not 

need further conceptual verification. As suggested by the Institute of 

Medicine, the standards for forming a reasonable consensus leading to a 

recommendation to provide brief interventions have already been met.31 

Experts already recommend moving beyond clinical trials to national 

dissemination.30 There is no need to plow new ground and perform 

research to develop new interventions for emergency department use. 

A 1995 meta-analysis of 32 alcohol treatment modalities found that 

brief motivational counseling ranks near the top in four categories: 

1) total amount of research to investigate the modality, 2) methodological quality of research, 3) number of studies demonstrating improved 

outcomes, and 4) cost effectiveness.37 

Therefore, research should not focus on foundational and efficacy 

trials, but on the practical matter of successfully adapting proven intervention techniques to the emergency department setting. It is acknowledged that treatment must have documented efficacy in particular 

populations of patients. However, the emergency department is the 

entry point for medical care for a broad spectrum of problem drinkers. 

Implementing Preventive Interventions 139 
There is little reason to believe that intoxicated patients who present to 

the emergency department represent a special population to whom 

current research results do not apply. Patients with alcohol problems 

experience an average of 1.32 injury-related events requiring outpatient 

or inpatient care per year.

38 Visits to the emergency department are so 

common among substance-abusing patients that it is unlikely they 

represent a special treatment-resistant subgroup. 

The opposite may be the case. Alcohol-related medical problems, 

especially injuries, occur in the entire population of alcohol users. 

Moderate, and even light drinkers, often require emergency care because 

many alcohol-related events are not related to total alcohol consumption, but rather to the activities the patient engages in while drinking 

and to where, when, and with whom alcohol is consumed. Patients with 

severe dependence have a disproportionate share of alcohol-related 

medical consequences, but it is estimated that such patients generate 

only a fraction of all alcohol-related problems.39 

Alcohol-related problems occur at lower rates, but in much greater 

numbers, among patients with mild to moderate alcohol problems 

because such patients constitute the greatest proportion of the drinking 

population. Thus, if all patients with severe problems stopped drinking, 

a substantial number of patients with alcohol-related problems would 

still present to the emergency department. For example, driving while 

intoxicated overlaps with alcoholism, but it constitutes an important 

issue in its own right because surveys consistently show that a substantial number of individuals who do not meet diagnostic criteria for 

alcohol abuse or dependence admit to having driven an automobile 

while intoxicated. For many of these patients, brief interventions demonstrate significant effects on subsequent alcohol intake and emergency 

department resource utilization when used as stand-alone treatment.40 

Other patients may require more extended treatment. Brief interventions may play an important role in motivating such patients to accept a 

treatment referral or can be used to establish motivation while waiting 

for access to publicly funded treatment.41,42 One trial, Project Assert, 

provided brief interventions and used an active referral process to gain 

access to the marginal capacity of the substance abuse treatment system 

for those who needed additional care.43 Its success led to its adoption by 

140 Alcohol Problems Among Emergency Department Patients 
Boston Medical Center as a value-added service in the emergency 

department. Patients without insurance may also be referred to community resources and self-help groups. Those with insurance have at least 

some access to treatment services to which they can be referred. 

Emergency department physicians may obtain the training necessary 

to perform the intervention, but in most hospitals, staffing constraints 

will prevent them from being the primary providers of this service.44 

Furthermore, instilling this knowledge and sense of responsibility 

throughout the field will require too broad a change in service culture 

for this approach to be readily adopted. Time demands and current 

practice standards are likely to limit the role of emergency department 

physicians to “setting the stage” for an intervention. 

Data suggest that few patients comply with a simple referral to seek 

treatment after emergency department discharge.45 Therefore, emergency departments should have dedicated staff on-site who can provide 

interventions. This places the responsibility to perform the intervention 

in the hands of individuals who are already committed to providing the 

service and avoids dependence on physicians who are unlikely to acquire 

such commitment until significant attitudinal changes occur. 

Two decades of mental health services research in primary care 

settings support the concept that the most effective method of delivering 

psychosocial services is through collaboration between mental health 

consultants and primary care providers.

46–48 A collaborative model using 

emergency department physicians to screen and mental health professionals to perform the intervention is the approach that is most likely to 

be widely adopted.

49 

Alcohol use among emergency department patients is not likely a 

problem that can be tackled by a single discipline. Interdisciplinary 

research is more likely to facilitate the development and implementation 

of emergency department interventions that work in the real world. 

Collaborative care has the potential to benefit both emergency department and mental health professionals. Data suggest that substance abuse 

counselors may find that a medical or surgical crisis increases patient 

motivation.50 As a result, their services may be more effective when 

conducted in the emergency department environment. To date, all 

published studies on emergency department or trauma center interventions have used the collaborative care approach.

2,3,34,51 

Implementing Preventive Interventions 141 
Financial considerations 

Despite the prevalence of alcohol use disorders, hospital administrators 

are likely to raise concerns about hiring additional staff to conduct 

interventions because they do not consider addressing alcohol problems 

as part of their mission. Social workers and similar individuals are 

available, but shifting the burden to these individuals will still require 

hiring additional employees. It will be necessary to provide evidence that 

hiring staff to perform interventions is in the best interests of stakeholders and is fiscally responsible. Therefore, studies are needed to assess the 

nominal costs of implementation and any cost offsets that occur. This 

has already occurred in family medicine, which is currently the medical 

service with the highest screening rate. 

There is reason to believe that cost-effectiveness can be demonstrated. 

For insured patients, counseling services are billable under existing CPT 

(current procedural terminology) codes when delivered by qualified 

staff. Studies on brief interventions conducted in other settings demonstrate that a substantial portion of the reduction in costs is related to a 

reduction in use of emergency department and hospital resources.2–4,40 

Studies of cost-effectiveness should include not only direct medical 

costs, but also societal costs. Federal, state, and county sources fund 

many emergency departments, particularly those in urban areas. It is 

estimated that direct medical costs constitute only 15% of total costs 

related to substance abuse, with the remainder being related to problems 

such as property damage, crime, absenteeism, and unemployment. 

Study outcomes should be multi-dimensional and assess a broad array 

of outcomes because the true stakeholders are society at large. Research 

that covers multiple outcomes in addition to medical ones addresses 

audiences with different needs and priorities and encourages their 

support for provision of intervention services and financial resources. 

Studies should, therefore, use a variety of databases, including not 

only emergency department records, but also general medical record 

reviews and insurance and Medicare/Medicaid claims to detect outpatient visits. Although claims data provide the most accurate information 

about health care use, ensuring adequate follow-up for purposes of 

obtaining information from patient self-report is important because 

many people do not report alcohol-related events to insurance companies.40 In order to interest other stakeholders, such as policymakers and 

health care providers, additional databases should be used to assess other 

142 Alcohol Problems Among Emergency Department Patients 
outcomes: for example, motor vehicle records to detect crashes; police 

records to assess criminal activities; and state vital statistics registries, the 

Social Security Death Index, and the Fatal Accident Reporting System 

(FARS) to detect mortality. 

Health care policy 

Physicians have voiced a common concern about alcohol screening: the 

potential denial of reimbursement for medical services provided to 

patients if they have a positive blood alcohol or drug screen. The 

Uniform Individual Accident and Sickness Policy Provision Law 

(UPPL), a model law drafted by the National Association of Insurance 

Commissioners (NAIC) in 1947, provides insurers with this right. The 

NAIC is an organization of insurance regulators from the 50 states, the 

District of Columbia, and the 4 U.S. territories. It provides a forum for 

the development of uniform policy and addresses the need to coordinate 

regulation of multi-state insurers. 

The model law states, “The insurer shall not be liable for any loss 

sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on the 

advice of a physician.” Thirty-eight states adopted the law, and four 

others have adopted it with provisional restrictions that apply only to 

narcotics, or to injuries sustained while committing a felony. However, it 

is obvious that if screening is not performed, the provision cannot be 

applied. Physicians are unlikely to screen if it affects their legitimate 

expectation for financial remuneration for patient care. The main effect 

of this law has not been to decrease insurance claims, but to discourage 

physicians from screening for alcohol problems.52 

In practice, the UPPL applies to only a fraction of patients treated in 

the emergency department. Many patients are uninsured or carry 

policies that do not enforce this provision. However, emergency physicians do not engage in analysis of insurance contracts before providing 

care and are therefore unaware of the type of coverage, if any, carried by 

the patient. As a result, fear of financial loss generally prompts physicians to treat all patients as if the UPPL applies to them. 

The NAIC recently adopted an amendment to the UPPL which states 

(1) “This provision may not be used with respect to a medical expense 

policy” and (2) “For purposes of this provision, ‘medical expense policy’ 

means an accident and sickness insurance policy that provides hospital, 

Implementing Preventive Interventions 143 
medical and surgical expense coverage.” The National Conference of 

Insurance Legislators (NCOIL), an organization of state legislators 

whose main area of public policy concern is insurance legislation and 

regulation, recently passed a resolution asking states to repeal the UPPL. 

The primary instruments of public policy for NCOIL and the NAIC 

are model laws and guidelines. Model legislation forms a uniform basis 

from which all states can deal with regulatory issues. The basic legislative 

structure of insurance regulation requires some degree of uniformity 

throughout the states. However, states are free to maintain their own 

insurance codes. They may either adopt the models intact, modify them 

to meet their specific needs, or ignore them. Emergency physicians 

should provide their legislative representatives and insurance regulators 

with information about how the UPPL adversely affects their ability to 

implement alcohol intervention programs and encourage them to 

implement the changes recommended by the NAIC and NCOIL. 

A serious concern expressed by physicians is that documenting 

alcohol use in the medical record has the potential to abridge patient 

confidentiality about sensitive issues.53 Patients with substance abuse 

disorders may face stigmatization and other potentially serious consequences if screening results are not protected. Fear of stigmatization 

gave rise to federal regulations and laws protecting information related 

to substance abuse. The intent of these regulations is to encourage 

individuals to seek treatment for substance abuse by reducing the risk 

that they will be stigmatized. The laws are contained in the Code of 

Federal Regulations (42 C.F.R. Part 2), Confidentiality of Alcohol and 

Drug Abuse Patient Records. 

The regulations apply to hospitals that have either an identified unit 

that provides substance abuse treatment or medical personnel whose 

primary function is the provision of alcohol and other drug abuse 

diagnosis, treatment, or referral for treatment (C.F.R. Part 2 2.11). The 

law specifically states that records generated by emergency and trauma 

physicians are not covered because their primary function is not to 

provide substance abuse counseling. Presumably, this would not harm 

the congressional intent of attracting people to treatment because 

patients do not come to the emergency department with the intention 

of receiving substance abuse treatment. 

If an emergency department hires staff whose primary function is 

screening and intervention, the application of this law will need to be 

144 Alcohol Problems Among Emergency Department Patients 
reconsidered by emergency physicians and hospitals. If a blood alcohol 

level is obtained to facilitate treatment of an illness or injury, it is not 

under special protection. However, if it is obtained in order to engage 

the patient in treatment, the information is protected under the above 

federal regulations that require the express, written permission of the 

patient before it can be shared with others.54 A special “Consent for the 

Release of Confidential Information” form must be signed in order for 

this information to be released.55 Under federal regulations, a general 

medical consent form is not sufficient. 

Recommendations 

1. Emergency medicine physicians should increase their knowledge, 

skills, and confidence in alcohol screening and intervention. To accomplish this and change current practice patterns, studies on alcohol interventions should be framed, focused, and performed by emergency 

medicine physicians. 

2. Given the magnitude of alcohol problems and the ability of emergency departments to identify patients who might not otherwise seek 

treatment, funding agencies should give high priority to research on 

alcohol problems in EDs. 

3. Research support should be primarily for services research, not 

the development of new intervention models or prototypes. Translational studies that develop methods of adapting already validated 

interventions into emergency department practice are needed. Data 

obtained from practically oriented translational studies will help to 

develop guidelines for optimal resource allocation by determining the 

sub-population of patients for whom brief interventions are most 

effective. They will also provide a framework for future investigations 

that target non-responsive patients in need of more extensive services. 

Studies should be conducted using a collaborative process that involves 

mental health specialists and other appropriate professionals. 

4. Research is needed on referral strategies for more severely impaired, 

non-responsive patients, to assist them in gaining access to resources 

already available in their communities. This research should include 

studies on the use of no-cost services such as self-help or 12-step 

Implementing Preventive Interventions 145 
programs using, for example, abbreviated forms of the “Twelve Step 

Facilitation Therapy Manual” developed for use in Project MATCH.56 

The 12-step arm of Project Match had the best outcomes in the study, 

regardless of “matching” considerations. 

5. Research studies of cost-effectiveness are needed to convince 

physicians and administrators that having staff available to address 

alcohol problems is an integral component of the practice of medicine 

and part of their mission. Since cost-benefit analysis is critical to overcoming resistance to implementation, research groups should include 

health care economists or health services researchers. 

6. Emergency and trauma physicians, their respective professional 

organizations, and alcohol advocacy groups should contact their state 

insurance regulator, state department of health and human services, and 

legislators involved in insurance issues to urge amending state insurance 

codes that financially penalize hospitals and physicians who screen for 

alcohol. 

7. Emergency departments should designate specific individuals to 

assume the role of obtaining and interpreting screening results and to 

provide interventions. This is the most immediately available policy to 

protect patients with federal confidentiality regulations and alleviate 

legitimate concerns about the right to privacy. 

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37. Hester RK, Miller WR. Handbook of Alcoholism Treatment Approaches: 

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38. Blose JO, Holder HD. Injury-related medical care utilization in a problem 

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39. Gerstein DR, editor. Toward the Prevention of Alcohol Problems: Government, 

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intervention and referral. SAEM Substance Abuse Task Force. Society for 

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150 Alcohol Problems Among Emergency Department Patients 
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Implementing Preventive Interventions 151 
Response to Dr. Larry Gentilello’s Presentation 

Stephen M. Hargarten, MD, MPH 

I am honored to have the opportunity to participate in this timely 

conference. It is my belief that our deliberations and discussion should 

greatly assist the articulation of a focused, thoughtful research agenda 

for addressing alcohol-related problems in the emergency department 

(ED) setting. 

My comments are intended to link this research agenda with the 

unique, strategic position of the emergency department and to reflect 

on the new partnership of the federal agencies and care providers 

represented here today. I think this effort reflects the philosophy of 

emergency medicine, which seeks out collaborators, partners, and 

advisors for all of the problems that may arise in the ED. 

I feel strongly that the ED-based research agenda should address the 

spectrum of problems that present daily to the ED. Screening and 

interventions for alcohol-related problems must be integrated into the 

practice of emergency medicine and all of the emergency department’s 

clinical activities. The research agenda’s translation to practice should 

reflect the spectrum of alcohol use and related problems as well, given 

that the ED is inundated with patients who have alcohol-related problems. A series of carefully structured, single questions needs to be 

developed that can identify at-risk users, alcohol abusers, and alcoholics. 

When I first began practicing, the extent of screening consisted of the 

question, “Are you a drinking man?” 

Exciting research now is pinpointing which intervention (really brief, 

brief, short-term, long-term) is most effective as well as where it is most 

effectively delivered (emergency department, hospital, and/or treatment 

center). While all of the answers are not yet known, the progress is 

encouraging. 

It is evident that additional research is needed to 1) refine the set of 

single questions that improve efficacy and efficiency; 2) identify highrisk groups, essential to focused, effective screening; and 3) match the 

alcohol-related problem to the intervention. 

This is the essence of the traditional biomedical research model. I look 

forward to the day when the next Joint Commission hospital visit 

includes the requirement to demonstrate our ED and hospital-based 

152 Alcohol Problems Among Emergency Department Patients 
screening and intervention “toolbox” that addresses this patient population with alcohol problems. 

Health care settings should be considered safe, effective, patientcentered, timely, efficient places of equitable care. These descriptors of 

health care quality from the recent Institute of Medicine report

1

 should 

be applied to all patients with alcohol-related problems. 

I think Dr. Gentilello’s presentation nicely outlined the elements of the 

biomedical model and approach. Dr. Gentilello has made a significant 

contribution to the insurance industry’s policies toward alcohol-related 

problems. Many trauma surgeons and emergency physicians oppose 

alcohol screening in the current environment because of concerns 

about non-payment for services. I appreciate the advances being made 

to integrate screening into emergency departments, and I agree with 

Dr. Gentilello’s assessment of the barriers to making screening a reality. 

Physicians’ and other providers’ knowledge, skills, and attitudes can all 

create barriers. 

At this point, I want to depart from the biomedical research model to 

discuss the importance of an epidemiologic shift towards population 

health. I feel that the research agenda should also integrate the public 

health model. The ED is in a strategic position to inform the public and 

policymakers about the scope and nature of alcohol-related problems in 

the ED. An epidemiologic shift from screening to surveillance, from 

individual patients inside the ED to populations of patients outside the 

ED, will serve to understand at-risk behaviors of groups of patients, the 

agent/vehicle of morbidity and mortality, alcohol, and the environment 

in which these groups interface with alcohol. 

Policy-relevant studies are needed to address the marketing, distribution, and sale of alcohol to high-risk groups and environments. Research 

that examines pricing schemes and marketing strategies that are associated with college-based binge drinking is needed. A set of single policyrelevant questions should be routinely asked such as, “Where did you 

buy the alcohol?” and “Where were you drinking before you were 

injured?” Linking the abuse/individual behavior questions to when and 

where the alcohol was consumed has important implications. Research 

that evaluates policy interventions linked with reliable, accurate surveillance information can influence policy changes such as lowering the 

legal limit of a driver’s BAC or extending DWI laws to cover snowmobile 

driving. 

Implementing Preventive Interventions 153 
Research on changing social norms for alcohol use and abuse is 

needed for practitioners and patients, given that alcohol-related problems are still largely viewed as a social issue, not a medical problem. 

Addressing emergency medicine training will be very challenging since 

emergency medicine professionals might have their own social norms of 

at risk alcohol usage that will influence their effectiveness and interest. 

The emergency department-based research agenda need not be 

limited to the biomedical model. It should be extended to include health 

services research and access to matched, therapeutic interventions. It 

should also use the public health model (addressing behavior, the agent/ 

vehicle, and the environment), and the injury control model (prevention, acute care, and rehabilitation). By using different models, the 

research agenda can address treatment and policy issues and develop and 

evaluate prevention strategies at the primary, secondary, and tertiary 

levels. Ultimately, this multiple approach will help us to reach our 

shared goal of fewer alcohol-related deaths and injuries. 

Reference 

1. Committee on Quality of Health Care, Institute of Medicine. Crossing the 

Quality Chasm: A new health system for the 21st century. Washington (DC): 

National Academy Press; 2001. 

154 Alcohol Problems Among Emergency Department Patients 
Comments on Implementing Preventive 

Interventions in Emergency Medicine: 

Strategic Considerations 

Linda C. Degutis, DrPH 

Dr. Gentilello has raised many important issues in his paper. Many of 

them point to the lack of knowledge of the evidence that screening and 

intervention for and treatment of alcohol problems can be effective in 

decreasing morbidity and mortality. This is certainly an area where we 

can be proactive in highlighting the evidence that these strategies work, 

and for those who are practitioners, in modeling behaviors that include 

screening, intervention, and referral for patients who have alcoholrelated problems. 

Other areas also need to be addressed, and some definitions need to be 

clarified. For example, Dr. Gentilello performed a MEDLINE review 

using the term “alcoholism.” While this term may refer to the patients 

who are dependent on alcohol, it does not necessarily capture at-risk 

drinking or hazardous drinking patterns. It will not capture the patient 

who drinks six or eight drinks a few times a month, drives a motor 

vehicle, and is injured in a crash. Using the term “alcohol” and searching 

the indexes of two of the primary emergency medicine journals, Annals 

of Emergency Medicine and Academic Emergency Medicine, 121 citations 

were selected for the years 1990–2000. Of these, 61 were original articles 

that either had “alcohol” in the title or were clearly examining alcoholrelated problems. There was also a trend toward an increasing number 

of articles published in the later years. Only one article appeared in 

1990, while nine were published in 2000. Several other articles published 

in 2000 discussed alcohol as a risk factor for particular injuries or 

disease. In 1998, Academic Emergency Medicine, which is published by 

the Society for Academic Emergency Medicine, published two papers 

that included recommendations for screening and intervention for 

alcohol problems in the emergency department.1,2 So, it does not seem 

that editorial boards are not accepting articles about alcohol problems. 

Perhaps the issue is that the number of researchers in this area is small, 

and therefore few papers are submitted. 

Implementing Preventive Interventions 155 
Dr. Gentilello makes several recommendations in his paper. He states 

that the studies need to be framed, focused, and performed by emergency medicine physicians using a collaborative process. It is necessary 

that emergency physicians perform research in this area, but the contribution of other researchers should not be negated, nor should other 

researchers be discouraged from working in this area. What is important 

is that a team approach be taken to build upon the strengths of alcohol 

research methodologists, epidemiologists, economists, social workers, 

nurses, and others who have specific contributions to make. 

Focusing research support on health services researchers is important, 

but the opportunities to develop new methods of intervention should 

not be eliminated. Translational studies will help in the adaptation of 

interventions in emergency medicine practice, but interventions evolve 

over time, and new methods are developed and tested. Emergency 

medicine should participate in this research. Researching strategies for 

engaging emergency department patients in treatment, especially those 

with high recidivism rates, would be of tremendous benefit to the field 

of emergency medicine. Examining cost-effectiveness is also important, 

as practitioners are constantly asked to do more with less, and patients 

face the threat of cuts in essential services in order to trim budgets. 

With respect to policy, Dr. Gentilello deserves a great deal of credit 

for the work that he has done with the National Association of Insurance 

Commissioners (NAIC) and the National Conference of Insurance 

Legislators (NCOIL). He has been very effective in convincing them 

that it is necessary to change their policies so that practitioners would 

not fear that screening for alcohol problems could place their patients 

in jeopardy of losing insurance coverage. Other policy questions need 

to be answered as well. Would reimbursement for screening and brief 

intervention increase screening and intervention, and subsequently, 

decrease morbidity and mortality? To what extent do emergency department patients have coverage for alcohol and other drug problems, and 

how does this affect their ability to enter treatment when they are 

referred? Have state substance abuse parity laws decreased the number 

of people who need to seek treatment through the ED rather than other 

facilities? What degree of confidentiality can be assured with respect to 

records of alcohol screening and intervention in the ED, and how does 

this affect screening and intervention rates? 

156 Alcohol Problems Among Emergency Department Patients 
As we already know, this is a complex problem that probably does not 

have simple solutions. I think that some clarifications are necessary to 

ensure we are using common language and common definitions. In the 

field of injury epidemiology and injury control, we try to avoid the use 

of the term “accidents” and instead use terms such as “injury events.” 

When describing patients who have manifested problems with alcohol, 

we should use definitions such as “at-risk drinking,” “abuse,” and 

“dependence” to define the continuum of alcohol problems that we see. 

We also need to be clear about the disease processes that we are interested in studying. To many health care practitioners, the term “trauma” 

means something very different than the term “injury.” “Trauma” often 

connotes injuries of significant severity to require treatment by specialized care providers, whereas “injury” often is perceived as meaning 

relatively minor physical injury. The term “injury” is more inclusive and 

should be used, as “trauma” is a subset of injury. If we cannot converse 

with and understand one another, there is little hope that we can effectively deliver our message outside of our field. 

There are additional complexities to doing research in the emergency 

department setting, created by the physical environment, the practice 

environment, the ever-increasing demand for emergency care as evidenced by increases in ED visits, and the financial constraints that affect 

the type of real-world interventions that can be implemented and 

evaluated. In addition, we often have difficulties with Institutional 

Review Board (IRB) approvals, as alcohol problems are still viewed as 

sensitive issues, and some IRBs are uncomfortable approving this type 

of research. 

The field of emergency medicine is young and evolving and developing its evidence base for clinical practice. This is leading to much debate 

among emergency physicians about their role in providing preventive 

services. The Society for Academic Emergency Medicine is addressing 

these issues through its Public Health Task Force, as well as through 

sessions at its annual meeting and articles in Academic Emergency 

Medicine. Research in this area is in its very early stages. 

Because the field of emergency medicine is young, large numbers of 

established researchers do not exist. To increase research capacity, we 

need to teach people how to do the research through fellowships, faculty 

development programs and grants, mentored research awards, and other 

programs that foster the development of new researchers. 

Implementing Preventive Interventions 157 
Translational research, as well as the communication of findings to the 

community and evaluation of implementation, is another challenge. 

Funding for translational research has been inadequate, as has a focus on 

sustainability of interventions that are implemented, once an evaluation 

has ended. Along with encouraging the implementation of effective 

interventions in the ED setting, it is also necessary to develop strategies 

to ensure sustainability of those interventions. 

One area of research that has not received much attention in our 

discussions over the past two days is that of policy research. This type of 

research tends to focus on population impact, rather than on impact on 

the individual patient or practitioner. Often, policies are created and 

implemented with no study of their effectiveness or the unintended 

consequences that arise from their implementation. Dr. Gentilello has 

highlighted one specific policy area, but there are many other policy 

directions that must be evaluated. These policies may be public or 

private and may be implemented on the institutional, local, state, or 

national level. For example, in Connecticut, we recently lost funding for 

transporting patients to substance abuse treatment services. It is not 

hard to imagine the impact of this, but it was only in examining the cost 

to referring institutions that a movement to reinstate the funding began. 

Now our task is to identify more cost-effective ways of providing the 

needed services before funding is cut yet again. 

We are currently involved in the evaluating Connecticut Public Act 

98-201, which has several provisions.3

 The primary goal of this legislation is to implement universal screening for alcohol and other drug 

problems among injured patients admitted to acute care hospitals. Other 

provisions include development of model continuing education standards for health professionals and plans for including training about 

alcohol and other drug problems in the standard curricula for health 

professionals attending institutions of higher learning. The original law 

signed by the governor required screening of all injured patients admitted to an acute care hospital as well as injured patients who required the 

activation of a trauma team response or who were transferred to or from 

an acute care institution. Many emergency physicians in the state 

interpreted the law to mean that they would have to perform screening 

of injured patients presenting to the emergency department. They 

vehemently objected to this policy and were able to have the legislature 

include a technical correction that clarified that screening is required 

158 Alcohol Problems Among Emergency Department Patients 
among injured patients who are admitted to acute care hospitals as 

inpatients, rather than implying that all injured patients presenting to 

the ED be screened. Given this reaction by physicians, are we ready to 

ask for broader implementation of these policies? 

The lack of acceptance of screening as a routine part of practice is only 

one of the barriers that we face. Policies have been developed on the 

basis of evidence that treatment for addiction is effective. Several states 

have passed substance abuse treatment parity legislation that requires 

insurers to cover treatment for alcohol and other drug (AOD) problems 

to the same extent that they cover treatment for other diseases. There is 

no federal legislation to this effect so the result is that in states that have 

parity laws, many people are still not guaranteed comparable coverage 

for AOD treatment because their insurance plans are governed by 

federal law under the Employee’s Retirement Income Security Act 

(ERISA). In addition, some insurance plans do not offer any coverage 

for AOD problems so the parity statutes do not apply to them. Of 

course, people who lack health insurance have even more limited access 

to treatment. 

Many people who are under the jurisdiction of the criminal justice 

system have AOD problems. In addition, evidence exists that treatment 

of these problems leads to a decrease in crime. But, little has been done 

to ensure that people involved in this system receive necessary treatment 

for their disease. Instead, there is often a tendency to criminalize addiction and to “treat” the problem through arrests and prison terms. Some 

states, such as Connecticut, require that anyone who is incapacitated by 

alcohol be transported to an acute care facility rather than jail. The 

intent of this law was to bring people into the treatment system and to 

avoid the consequences of unrecognized severe problems with alcohol. 

Currently, emergency departments in Connecticut see many patients 

with acute alcohol intoxication on a daily basis, but funds for treatment 

are limited. 

The education of practitioners in the process of screening and brief 

intervention is another area that needs study. To promulgate a standardized approach to patients with cardiac problems, the Advanced Cardiac 

Life Support course was developed. Similarly, the Advanced Trauma Life 

Support course provides a standardized approach to the initial care of 

the injured patient. Both of these courses, as well as others such as 

Advanced Pediatric Life Support and Prehospital Trauma Life Support 

Implementing Preventive Interventions 159 
combine didactic sessions with skill-building sessions to improve 

practitioner knowledge and skills in these areas. Perhaps we need to 

develop a similar approach for screening and intervention—an 

Advanced Alcohol Problem Identification and Intervention course. 

Despite the evidence of the relationship between alcohol and injury, 

we still do not have strong support for screening and intervention from 

our colleagues who deliver trauma care. In the most recent version of the 

American College of Surgeons monograph Optimal Care of the Injured 

Patient, which describes standards of care for verification of trauma 

centers, the requirement that trauma centers be able to perform blood 

alcohol testing was eliminated.4

 The message this sends may be interpreted in several ways: a) there is not a sufficient relationship between 

alcohol and injury to justify testing for alcohol use in injured patients; 

b) issues of alcohol use among injured patients are not in the purview of 

the trauma team; c) nothing can be done to address the issue of alcohol 

problems among injured patients so testing does not help; or d) not 

testing protects the patient and the practitioner from various legal 

issues. 

Dr. Gentilello recommends the development of an ED alcohol 

research center. While his idea of highlighting this area of research holds 

great merit, operationalization is problematic. If there is an ED alcohol 

research center, will there also be a primary care alcohol research center, 

a trauma alcohol research center, and a critical care alcohol research 

center? His proposal, rather than bringing the field together, can lead 

to fragmentation within the small group of researchers who are doing 

work in this area. 

The importance of developing partnerships with public health 

researchers and practitioners, alcohol researchers, community-based 

organizations, and others has been discussed. It is important that we 

look at the impact of interventions not only in the academic environment that is populated by students, residents, and faculty, but also in 

community practice and rural settings. We need to explore the impact 

of interventions in settings such as the Indian Health Service that serve 

distinct populations. 

Finally, I would like to address the issue of funding. Much of the 

research that is being done in this area is not supported by the National 

Institutes of Health, but by other federal agencies such as the Centers for 

Disease Control and Prevention, the National Highway Traffic Safety 

160 Alcohol Problems Among Emergency Department Patients 
Administration, the Substance Abuse and Mental Health Services 

Administration, and the Health Resources and Services Administration. 

We need to consider the impact of the funding policies of these agencies 

both in promoting research and in growing the field of alcohol research 

in emergency medicine. The smaller agencies often include indirect costs 

as well as direct costs within the budget cap for a particular project. 

While this may not be problematic in an institution with an indirect rate 

of 25%, it is very difficult for a researcher at an institution with an 

indirect rate of 60% or higher to compete, as much of the budget is 

taken up by indirect costs. In addition, this type of funding policy 

discourages the research community from collaborating with academic 

centers because the researchers perceive that the bulk of the budget is 

going to some administrative group with whom they have no interaction 

and who has no interest in what the researchers are doing. 

In summary, alcohol problems are a significant issue for emergency 

department patients. A growing body of evidence demonstrates that 

interventions in the emergency department are effective and that treatment referral can work. The opportunities for research in this area are 

great, and we need to work to develop research capacity. There is a need 

for interdisciplinary teams of researchers who can draw on one another’s 

knowledge and strengths. Although funding strategies can be improved, 

funding is available for this work. We have already come a long way, and 

much is left to do. 

References 

1. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 2: 

intervention and referral. SAEM Substance Abuse Task Force. Society for 

Academic Emergency Medicine. Acad Emerg Med 1998;5(12):1210–7. 

2. D’Onofrio G, Bernstein E, Bernstein J, Woolard RH, Brewer PA, Craig SA, 

Zink BJ. Patients with alcohol problems in the emergency department, part 1: 

improving detection. SAEM Substance Abuse Task Force. Society for Academic 

Emergency Medicine. Acad Emerg Med 1998;5(12):1200–9. 

Implementing Preventive Interventions 161 
3. An Act Concerning Substance Abuse Emergency Room Screening and Training 

and Education for Health Care Professionals, 1998. Connecticut General Statutes, 

P.A. 98-201. 

4. Committee on Trauma, American College of Surgeons. Optimal Care of the 

Injured Patient: 1999. Chicago (IL): American College of Surgeons; 1998. 

162 Alcohol Problems Among Emergency Department Patients 
General Discussion 

Jeffrey Runge agreed with Larry Gentilello that health economists 

should be part of the research team. He noted that we must demonstrate 

the value of interventions to hospital administrators if we want extra 

staff for interventions. He also echoed Gentilello’s comment about the 

need to individualize interventions. In his multi-center study, interventionists felt restricted by a standard intervention, sensing that variation 

was needed to meet different clients’ needs. 

Gentilello said that research methodologists want interventions to be 

standardized so that they know why a treatment is working. However, 

if they cannot use those interventions in their clinical setting, the 

interventions are of no use. 

Elinor Walker commented that something about an intervention must 

be standardized in order to assess its cost-effectiveness. 

Gentilello suggested that the salaries of full-time employees could 

provide cost data and blood alcohol tests and admission rates could 

provide effectiveness data. 

Linda Degutis added that interventions have to be monitored. If a 

standardized intervention is not used, audio tapes can at least give 

an idea of how it works. 

Carl Soderstrom agreed with Gentilello that alcohol-related research 

must be published not in substance abuse journals, but in publications 

read by emergency and trauma surgery staff. For example, he noted that 

the American College of Surgeons’ Resources for Optimal Care of the 

Injured Patient: 1999, which contains guidelines for the certification of 

trauma centers, omitted the requirement to test patients’ blood alcohol 

content for the first time in 20 years. He admitted that many times a 

positive blood alcohol test in patients with head injuries can be troublesome. However, when he explored the reasons for the omission, he 

found that the group that wrote the latest version of the American 

College of Surgeons resource guide did not have access to data that 

proved that treatment had any value. Regarding the issue of nonpayment for services provided to alcohol-impaired patients, he observed 

Implementing Preventive Interventions 163 
that insurance companies rarely take advantage of their current legal 

right to deny payment due to alcohol use. 

Stephen Hargarten said that screening for alcohol applies not only to 

the potential for interventions, but also to the patient’s overall quality 

of care, including safety from injury due to alcohol impairment or from 

alcohol withdrawal during the acute phase of treatment for medical or 

surgical conditions. 

Gentilello observed that his publications in trauma journals have earned 

him a great deal of attention and have raised awareness. He said that 

changes in emergency medicine practice will require publication of 

studies in journals that reach emergency medicine practitioners. 

Phillip Brewer noted that at annual meetings of the Society for 

Academic Emergency Medicine (SAEM), papers dealing with substance 

abuse were spread over other categories such as geriatrics and injury. 

One of the goals of the Substance Abuse Interest Group of SAEM was 

to authorize a substance abuse category for abstracts and sessions at the 

annual meeting. To date, SAEM has not agreed to a separate category. 

The idea of prevention in emergency medicine has taken root for injury 

and domestic violence, he said, but not yet for substance abuse. 

Peter Rostenberg agreed that forsaking the BAC prevents good management and good medicine. At his hospital, attending physicians are 

responsible for dealing with the results of alcohol screens and they 

receive a letter when they fail to do so. He observed that this system 

had been effective largely because physicians had seen patients recover. 

Richard Longabaugh urged that collaborative studies include health 

services researchers. He noted that there is an R-01 interactive project 

that allows for great collaboration across disciplines. He also encouraged 

researchers to continue publishing in journals about their own areas of 

expertise. Although he, too, had concerns about standardized manuals, 

he noted that studies show that such manuals do not result in poorer 

treatments. He suggested the use of decision trees in the manuals, which 

can lend more flexibility to clinical applications of research. Depending 

on the patient and the setting, paths can be traveled very quickly and 

adapted quickly as well. 

164 Alcohol Problems Among Emergency Department Patients 
Gentilello agreed that we should all keep publishing in our various 

disciplines. However, he reiterated that if we do not publish in trauma 

and emergency medicine journals, practices will not change. He said it 

is easier to change a field from within than from the outside. He also 

emphasized the importance of funding emergency medicine specialists, 

not just alcohol researchers, to conduct this research. 

Richard Brown observed that although the grant review process at NIH 

can be difficult, the experience of re-submitting grants has strengthened 

his work. The process can be a learning opportunity and result in more 

sound research. He speculated that if many dependent patients can have 

spontaneous remissions, then research on whether brief interventions 

could help them seems warranted. However, he thought that guidelines 

to require screening in emergency departments were premature, particularly without funding to support required changes. Instead, he 

advocated implementing demonstration projects that use different 

models. Consistent evaluation across the models would determine if 

they actually make a difference. He thought that without this type of 

research, requirements would cause a rebellion against practice changes. 

Hargarten noted that it has not been long since the Joint Commission 

on Accreditation of Healthcare Organizations (JCAHO) mandated 

policies and procedures to enhance domestic violence screening and 

intervention in every ED in the country. He thinks screening for alcohol 

problems in EDs is on the horizon. In order to get reasonable requirements and uniform adherence in the 5,000 EDs in the country, it will be 

necessary for an external body like JCAHO to be thinking about this 

now. In the meantime, we need to be doing research that will make sure 

that appropriate requirements are adopted. With respect to the methodological issues, we must balance rigorous follow-through and long-term 

studies with studies that are germane to emergency departments. 

Collaboration with rigorous methodologists is important, but those 

collaborations have to focus on what can be accomplished specifically 

in the ED setting. 

Gentilello clarified that he had not criticized the peer-review process, 

but that panels reviewing alcohol interventions in EDs should include 

representatives of emergency medicine. Grant review panels should 

consider proposals from the perspective of the emergency physician, 

not the perspective of the psychiatrist, who probably has not been in 

Implementing Preventive Interventions 165 
an ED for many years. Since alcohol interventions in the ED cut across 

different disciplines, the peer-review group should embrace multiple 

perspectives. Methodologies that work in the emergency department 

come from deciding what is feasible in that environment and adapting 

interventions that have been shown effective in other clinical settings. 

Results from such studies will be used. 

David Fiellin recommended using current mechanisms like the Robert 

Wood Johnson Clinical Scholars program to train physicians in methodology, clinical epidemiology, and health services research so that review 

committees will include members who are knowledgeable about the ED 

setting and clinical research. 

Hargarten endorsed that idea, but added that there was little funding for 

training in clinical research in emergency medicine. 

Gentilello agreed that lack of funding was a problem. Many young 

surgeons become interested in alcohol interventions and write grants, 

but when their studies are not funded, they lose interest and move on to 

other subjects. 

Ronald Maio cautioned that we should not abandon the randomized, 

controlled trial (RCT). Gentilello’s results had a powerful impact on 

trauma surgeons because his study was an RCT. When we adapt proven 

interventions to new settings, we change many factors so we need to have 

an RCT. He recalled the 1970s, when many ED procedures were adapted 

for use in the field by EMS without appropriate evaluation. Now, it is 

difficult to justify many of those changes. Regarding collaboration, he 

mentioned that partnering with specialists in substance abuse gave him 

a greater understanding of that specialty and increased the quality and 

credibility of subsequent proposals. He said an NIAAA fellowship is one 

way of getting further training. 

Daniel Pollock wondered how we could use research as a force for 

positive change in the clinical setting. He recounted that Gentilello’s 

goal for research was to modify interventions that work in other settings 

for use in EDs rather than creating new ones. He asked what types of 

outcomes would indicate successful adaptation. Would they be patient 

outcomes or process measures? 

166 Alcohol Problems Among Emergency Department Patients 
Gentilello replied that the outcome depends on the audience. For 

addiction specialists or psychiatrists, an outcome of reduced drinking 

would probably be appropriate. Surgeons would probably be influenced 

more by an outcome of reduced readmissions to the trauma service. He 

surmised, therefore, that reduction in recidivism might be a suitable 

outcome for emergency physicians. 

Pollock asked how to differentiate that type of study from doing a 

clinical trial. 

Gentilello suggested that clinical trials are important because they 

change practice. He thought a successful multi-center trial could lead 

to the creation of a standard of care. 

Edward Bernstein observed that one site cannot address all the questions raised at this conference. He suggested that National Alcohol 

Screening Day, an NIAAA-sponsored event, is an opportunity for EDs 

in many institutions to collaborate in evaluating the AUDIT screening 

instrument in the ED. It could be the first step toward multi-center 

studies. He also believed that research should have policy implications 

and that funding sources should require this applicability. He suggested 

that NIAAA reclaim indirect grant costs from institutions that did not 

implement positive findings from their research. 

Richard Ries responded to Bernstein’s indirect cost proposal by endorsing a doubling of indirect costs for institutions that adopted positive 

findings as standard operating procedures after the grant period was 

over. This would reward institutions for putting clinical preventive 

services into practice. He reasoned we should prefer motivational 

strategies. He observed concern during the conference that control 

groups in intervention studies get much alcohol-related assessment, 

which can act as an intervention. He also agreed with Gentilello that 

decreased alcohol intake might not be as important an outcome to ED 

staff as decreased re-visits to the ED. Since brief interventions only lead 

to modest changes in alcohol intake, perhaps studies should focus on 

re-injury or health care use as the primary outcome. Then follow-up 

interviews would have to do less alcohol intake assessment, and that 

would mean less intervention effect on the control group. 

Implementing Preventive Interventions 167 
Gentilello concurred, commenting that insurance claims data can be a 

useful source of follow-up data, as can a simple phone call to inquire 

whether a patient has returned to the doctor recently. 

Cheryl Cherpitel related difficulties as a non-MD publishing in medical 

journals. She wondered if articles by non-MDs would be taken seriously 

by physicians who work in clinical areas. If they would, medical journals 

might need to be educated to accept articles from non-MDs. If non-MD, 

alcohol methodologists could publish more easily in these journals, they 

could have a bigger impact on practices in the ED. 

Gentilello remarked that the attitudes of reviewers for surgical journals 

vary considerably. He once submitted an article with 95% confidence 

intervals and it was rejected because it had no p values. He related 

that his alcohol studies used to be returned without being reviewed. 

Reviewers have become more accepting. They no longer require him to 

strike any references that show alcohol treatment is effective. He believes 

that trauma research requires multi-disciplinary input and that research 

by non-MDs is taken seriously. However, getting that work published 

requires persistence. Submitting this work helps educate editors and 

reviewers. 

Hargarten observed that the impediments to publishing seem to be 

lessening, and that the work of Cherpitel and others is vital. 

Soderstrom noted that large grants provide a great deal of data. Papers 

that are clinically applicable to functioning practice in the emergency 

department and the trauma center belong in those journals. He asserted 

that papers on methodology or more complex areas need to be included 

in other appropriate journals. 

Brewer commented that having a paper published is different from 

having an impact on clinical practice. Most patients in emergency 

departments are seen in non-academic centers. Physicians in these 

environments may doubt the applicability of research done in academic 

centers. He suggested we need research on how to get physicians to 

screen in the emergency department. One of the ways we get physicians 

to do this is to get JCAHO to require it. 

168 Alcohol Problems Among Emergency Department Patients 
Daniel Hungerford observed that the Richmond-Kotelchuck model 

suggests that changes in practice result from effort applied to all three 

elements of the model—political will, social strategy, and knowledge 

base. It might seem that research activities apply only to the knowledge 

base aspect of the model. However, important research activities need 

to be carried out in all three elements of the model. 

Robert Woolard favored continuing intervention research in EDs. 

He believed that the realities of our practice settings help drive the 

development of new ways of delivering counseling, for example, 

computer-based methods. While emergency physicians may not 

have the time or interest, the patients do. He suggested that research 

in trauma centers and EDs can help alcohol researchers learn more 

about the interventions they have already developed and can even 

lead to novel interventions. 

Implementing Preventive Interventions 169