Session 3.


Intervening with Alcohol Problems


in Emergency Settings


Carlo C. DiClemente, PhD* 

Carl Soderstrom, MD 

Excessive alcohol consumption plays an important role in many of the 

medical conditions, accidents, and injuries that cause visits to emergency departments and trauma centers. Many studies have documented 

the presence of alcohol among patients admitted to emergency department1–5 and trauma center6,7 settings. Other studies have demonstrated 

that even blood alcohol concentration (BAC) determinations underestimate the extent of alcohol problems among the patients who are 

triaged and treated in emergency settings.4,7 The prevalence of this 

co-factor to the emergency admission, and the fact that alcohol is a risk 

factor both for the first visit and for a return visit to the emergency 

setting, have occasioned a call for an effective method of intervening 

with alcohol problems in these settings.8–12 Although there are problems 

with and barriers to intervening in these settings, a number of studies 

and a few controlled trials indicate that interventions focused on 

patients’ drinking can reduce the amount of drinking as well as injury 

episodes, including repeat re-admission for injury and other negative 

consequences of drinking. This review will examine the rationale for 

intervening, types of interventions and interveners, and barriers and 

concerns that need to be addressed. Then we will offer suggestions for 

research and practice related to intervening effectively with alcohol 

problems in emergency settings. 

Motivational considerations 

The rationale for interventions in the emergency setting is that the 

medical condition or injury prompting admission provides a “window 

of opportunity” when the individual may be more vulnerable and more 

open to seeing the connection between current consequences and his or 

her drinking or drug abuse and may be more motivated to change.13–15 

* Presenter 

Intervening with Alcohol Problems 89 
The presence of an adverse consequence that can be linked to drinking—such as gastrointestinal, vascular, renal, or other medical problem; 

an automobile crash; unintentional injury; or involvement in a violent 

incident—facilitates intervention among patients with alcohol problems 

encountered in the emergency setting. In an emergency department 

(ED) study of injured crash victims who had been drinking, Cherpitel 

found that more than one-third linked their drinking to being injured 

and thus were deemed good candidates for “brief intervention.”16 In 

another study by Sommers and colleagues15 involving two trauma 

centers, patients who were injured in vehicular crashes and had a 

positive BAC were asked, “To what extent do you believe your alcohol 

consumption was responsible for this injury?” Overall, 62% attributed 

being injured either “somewhat” (24%) or “mostly” or “totally” (38%) 

to be the result of drinking. This attribution may be less endorsed with 

medical conditions such as liver disease or pancreatitis. 

Whether this awareness is viewed as a “hitting bottom” phenomenon 

or in more traditional motivational terms, there does seem to be a 

connection between readiness to change and recognition that negative 

consequences can be directly linked to a behavior.

17 Reports from 

emergency staff and anecdotal descriptions of some interventions 

support the results of the above studies, indicating heightened motivation in the initial period of time in the emergency setting. However, 

it is not clear how long this initial openness to change lasts. There are 

also reports that after a couple of days, spurred by concerns about legal 

responsibility, family member advice, or rationalizations, patient 

openness to discuss drinking and other problem behaviors decreases 

dramatically. 

We do know that alcohol consumption changes for many problem 

drinkers after their visit to an emergency setting. Several studies have 

documented consumption changes not only in the intervention condition but also in the minimal intervention control groups.18,19 However, 

changes in alcohol consumption are often not sustained among participants in control conditions. After the emergency visit, there seems to be 

a reduction in drinking that gradually returns to baseline problematic 

levels for many untreated patients. Changes in drinking that are produced simply by the visit to the emergency department seem to dissipate 

without an alcohol-specific intervention.18 Although there may be some 

90 Alcohol Problems Among Emergency Department Patients 
natural or unaided salutary effect on drinking resulting from the medical emergency or injury and the ensuing visit to the emergency setting,

20 

that effect appears to be short-lived for many patients. 

Re-injury and readmission to an emergency or other medical setting is 

much greater for problem drinkers than for other emergency patients.12 

It is clear from the literature that without some intervention that can 

facilitate enduring reductions in drinking, simply giving medical treatment alone to the problem drinker admitted to the emergency setting 

will not reduce the rates of re-admission or prevent re-injury related to 

alcohol consumption. Although it is still not clear what the nature and 

extent of the intervention must be, some type of intervention specifically 

for drinking needs to be given. 

Interventions in the emergency department: a review 

Various types of interventions have been proposed and examined for the 

emergency medical setting (Figure 1). These range from brief interventions delivered by the physician to more extensive counseling during the 

admission that includes referral to intensive treatment after discharge. 

Gentilello and colleagues conducted a pilot intervention at a Houston 

emergency department that consisted of a substance abuse counselor 

mobilizing the family, and at times the employer, to intervene with the 

patient’s drinking and to arrange for immediate entry to a residential 

substance abuse treatment program after discharge. This program 

appeared to be successful in getting problem-drinking patients to 

treatment, but only with families who could be engaged and for patients 

who had resources or insurance.21 This and other seminal studies 

encouraged many professionals to call for some type of consultation 

service or brief intervention to be employed with patients in emergency 

rooms or trauma settings.13,22–25 

Many of the early studies that documented the efficacy of interventions with problem drinkers in emergency settings were evaluations and 

not controlled studies. Nevertheless, the documented outcomes have 

been impressive. Several studies have examined the outcomes achieved 

by substance abuse counselors or alcohol workers intervening with 

problem drinkers. A brief intervention in an emergency department by 

alcohol health workers demonstrated a mean reduction in drinking of 

43% for a subset of patients who were enrolled in the study.

26 The pilot 

Intervening with Alcohol Problems 91 
program in Texas described above demonstrated a 100% successful 

referral to alcoholism treatment for patients and families who agreed to 

be in the program.21 A substance abuse consultation team in a trauma 

center reported acceptance of referral for drug or alcohol treatment in 

62% of the 100 consecutive cases retrospectively evaluated.27 Hemphill, 

Bennett, and Watkins reported successful referral of patients to 

treatment with nearly half of the 440 patients referred for treatment 

remaining for the duration of the treatment program.28 Early reports 

of screening and referral of patients have been promising in terms of 

reduction in drinking or in successful connection with appropriate 

alcohol treatment programs.29,30 For the most part, these interventions 

have used blood alcohol concentration as one of the critical defining 

features in screening for the intervention. 

Interventions for drinking problems have also been successful in 

reducing re-injury. In a recent review of intervention trials for problem 

drinking that measured injury outcomes, Dinh-Zarr and colleagues 

identified 19 studies that measured injury outcomes among participants 

in a variety of settings. They reported that reductions in a variety of 

injuries, injury hospitalizations, and deaths ranged from a 27% reduction in “drinking-related injuries and accidents” to a 65% reduction in 

“accidental and violent deaths.”31 However, in this review there was no 

clear evidence that the mechanism of action of these interventions was 

reduced alcohol consumption. These interventions appeared to affect 

risk taking in addition to or instead of reductions in drinking and 

included individuals who had legal charges pending. Most of the studies 

reviewed were not well controlled and the numbers of participants and 

effect sizes reported in these studies were modest. 

Until recently, no well-controlled intervention studies have addressed 

whether interventions in emergency settings would reduce alcohol 

consumption and consequences. Several current publications have 

begun to remedy this lack of prospective, randomized trials. Gentilello 

and colleagues at the Harborview Medical Center in Seattle, Washington, 

conducted a randomized controlled trial in a Level I trauma center. 

Patients who screened positive on a combination of blood alcohol 

concentration (BAC), serum gamma glutamyl transpeptidase (GGT), 

and SMAST scores, and who agreed to a follow-up study, were randomized into an intervention or control procedure. The intervention was a 

single motivational interview that lasted approximately 30 minutes with 

92 Alcohol Problems Among Emergency Department Patients 
a doctoral-level psychologist trained and certified in motivational 

interviewing techniques. A letter was sent summarizing this session 

one month later. A total of 366 patients were randomly assigned to 

the intervention condition, but nearly 15% of these patients were 

discharged before the intervention could be given, and nearly 2% 

refused the intervention. At the 12-month follow-up, the intervention 

group demonstrated an average reduction in drinking of 22 drinks per 

week compared with a reduction of 7 drinks per week for the control 

group. Most of the drinking reduction occurred among the patients 

with mild to moderate alcohol problems and not in the heaviest drinking subgroup. There were also significant reductions in new injuries 

of about 50% at one year and a reduction in inpatient hospital readmissions for injury treatment of 50% at the three-year follow-up. 

The authors suggest that this type of intervention alone is insufficient 

for patients with more chronic and severe alcohol dependence. Another 

limitation of this seminal study is that 50% of participants were lost to 

follow-up at 12 months. However, this trial demonstrates that a rather 

brief intervention delivered by a trained professional in the emergency 

setting can produce significant reductions in drinking and repeat 

injury episodes. 

A controlled trial of a similar motivational intervention with older 

adolescents ages 18 to 19 years treated in an emergency room following an alcohol-related event randomly assigned 94 of the 184 eligible 

patients.19 Patients were assigned to a motivational intervention or a 

standard control of a handout about drinking and driving and a list 

of alcohol treatment agencies. The intervention, which lasted 30 to 

40 minutes, was delivered in the emergency department either immediately or within a couple of days of the visit. About 25% of the eligible 

patients were discharged before the intervention and another 25% 

refused to participate. Nevertheless, drinking and driving, moving 

violations, alcohol-related injuries, and alcohol-related problems were 

significantly reduced at the six-month follow up, with the intervention 

group experiencing one-third to one-half fewer events than the control 

group. Although drinking decreased over time for both intervention and 

control groups, their drinking levels were not significantly different. 

Bachelor’s or master’s level staff with one to two years’ of experience and 

extensive motivational interview training delivered this intervention. 

Intervening with Alcohol Problems 93 
Follow-up was limited to six months, so this study would have missed 

any rebound back to baseline at later time points, and the refusal rate 

was rather high in this study. However, the evidence was strong for a 

harm reduction effect across various indicators of risk and re-injury. 

Who delivers what type of intervention 

Most of the interventions described previously were conducted by 

specialists trained in alcohol or substance abuse counseling or in motivational interviewing techniques. These interventionists met with the 

patient, discussed drinking and substance use openly and directly, and 

offered some advice and assistance. Substance abuse counselors typically 

offered advice and referrals to treatment facilities or self-help programs. 

Motivational interview counselors typically discussed the perceived 

consequences, readiness to change, pros and cons of change, and plans 

to reduce drinking and avoid alcohol-related injuries in the future. 

Substance abuse specialists of one type or another typically delivered 

drinking interventions in emergency settings with a few exceptions.29,30 

No studies have compared different types of intervention providers in 

these settings. 

In contrast, physicians or nurses in a variety of primary care settings 

have delivered brief alcohol-focused interventions. These interventions 

also appear to be effective in reducing drinking and risky behaviors.20,32,33 

One recent study demonstrated that a brief, patient-centered alcohol 

counseling intervention delivered in the context of a regularly scheduled 

internal medicine visit produced significant reductions in alcohol 

consumption among both male and female high-risk drinkers.34 Based 

on these interventions in other medical settings, a number of researchers 

have recommended the involvement of the physician in the emergency 

setting in the alcohol intervention.9,26,35,36 However, few studies of 

physician-delivered interventions in an emergency setting exist. Clearly, 

none of the extant studies could be done without the support and 

involvement of emergency medicine physicians and trauma surgeons. 

However, it may be difficult to get physicians to deliver these alcoholfocused interventions for a variety of practical, philosophical, orientation, and training reasons. 

To some degree, all interventions described in the emergency setting 

are motivational. Each intervention attempts to highlight problematic 

alcohol consumption, the connection between injury and drinking, 

94 Alcohol Problems Among Emergency Department Patients 
and patient plans to address excessive drinking. Prototypic substance 

abuse interventions focus on motivation to enter treatment because 

the patients are severely dependent, heavy drinkers. Referral to “appropriate” treatment is the critical end point of this type of intervention 

and compliance with the referral the important outcome. Change of 

drinking and risky behaviors is left to the treatment program, and 

almost always, abstinence from alcohol is the goal of these treatment 

programs.37 On the other hand, motivational interviewing approaches 

view change as the province and responsibility of the individual and 

work with the individual at whatever level of motivation or stage of 

change is appropriate to promote consideration of change and an 

individualized plan of action that does not necessarily include additional treatment or self-help groups like Alcoholics Anonymous. Brief 

motivational interventions have been used with a wide range of problem 

drinkers and have been found to be effective in reducing drinking and its 

consequences.38 Goals for this treatment are articulated by the client and 

can include reduction as well as abstinence from alcohol. 

Nearly all interventions delivered in emergency settings consist of a 

single intervention visit. It is difficult to prescribe multiple visits unless 

the patient is admitted to the hospital from the emergency department 

or has an extended stay in a trauma center. Some researchers have 

suggested that the follow-up visit to the clinic for extended treatment 

would be the best place for alcohol interventions.25 However, postponing 

intervention to the follow-up visit poses great logistical problems. 

Scheduling of follow-up visits depends on type of medical problem or 

injury. Moreover, these visits are not consistently attended by the patient 

or delivered by the same physician who saw the patient in the initial visit 

to the emergency setting. Although many single-visit alcohol interventions in medical settings have been effective,32 the context of the emergency setting does increase the importance of considering follow 

through after the initial contact. Gentilello and colleagues sent a letter 

home one month after discharge as a reminder of the intervention 

conversation.

18 A currently funded trial at the University of Maryland 

Shock Trauma Center in Baltimore is using a feedback letter and two 

or more follow-up phone calls to extend the intervention beyond the 

emergency setting interview. This extension into the post-discharge 

period is most relevant for interventions that do not rely completely 

Intervening with Alcohol Problems 95 
on referral to treatment. However, post-discharge follow-up could also 

be used to solve problems related to treatment recommendations and 

enhance compliance with the recommendations. 

Issues and challenges for interventions in emergency settings 

Substantial evidence indicates that interventions with problem drinkers 

in emergency settings can produce significant change in drinking 

behavior and/or reduce risk of re-injury. The number of studies that 

have demonstrated effects either with volunteer or randomized 

participants is modest but increasing, and the effects range from 

minimal to very sizeable reduction in risks that have significant public 

health importance. Evaluation and referral interventions have been 

able to get a number of emergency department and trauma center 

patients into alcoholism treatment.29,30 It is not always clear whether 

there were long-term positive outcomes from these trials since referral 

has been the outcome variable most often studied. However, one can 

assume that some patients referred to treatment had very positive 

outcomes in terms of reductions in drinking and of risk profiles. 

Motivational interventions in emergency settings have more recently 

demonstrated important clinical outcomes in terms of risk-taking, 

negative consequences of drinking, and, at times, reductions in drinking.

18,19 The number of participants who were not screened, who 

refused, who were discharged early, or who were ineligible was large in 

some studies. However, when the intervention was delivered to patients 

in emergency settings and compared with standard or minimal interventions, intervention patients had significantly better outcomes on 

relevant measures. It is important to note that minimal interventions 

are not insignificant since they include, of necessity, an assessment of 

drinking behavior and a follow-up contact, and they are often much 

more than ordinarily occurs in the emergency setting. Screening or 

assessment alone, however, does not appear to be as effective as some 

type of specific intervention. 

Bringing research to practice 

This review of interventions, focused on addressing alcohol problems 

among patients in various medical settings, highlights several important 

issues and offers a perspective on the challenges to creating sustained, 

effective intervention programs in the emergency setting. Strategies and 

96 Alcohol Problems Among Emergency Department Patients 
insights from clinical trials should be gathered and made available to 

practitioners to help every emergency department and trauma center 

implement a coordinated, effective, and feasible program of screening 

and intervention for problem drinkers. However, several conceptual 

and practical issues need to be clarified so they can be resolved in a 

future research and implementation agenda. 

Although an opportunity exists to intervene with patients who have 

alcohol use problems, and there are published guidelines for emergency 

department and trauma centers concerning intervention, that opportunity has not been seized.8,9,35,39 Gentilello and colleagues noted that 

although “trauma centers are uniquely positioned to implement programs of alcohol screening, intervention, and referral,” and “despite 

emphasis on injury control and prevention, little has been done to 

incorporate alcohol intervention programs into care of the injured 

patient.”10 This observation was based in part on the results of a national 

survey of trauma centers which revealed that blood alcohol testing, 

which is often a precursor for any intervention, was routinely conducted 

at only 64% of centers despite a published guideline by the Committee 

on Trauma of the American College of Surgeons indicating that testing 

was an “essential” characteristic for those centers.

40 The survey also found 

that although 59% of the centers had substance abuse counselors, only 

5% used screening questionnaires to identify patients with alcohol use 

problems. 

Although we know of no studies assessing clinical practices regarding alcohol problems in emergency departments, a survey of 

1,055 emergency medicine physicians by Chang and colleagues found 

that most physicians favored testing and reporting injured, alcoholimpaired drivers.41 However, ambivalent attitudes were revealed concerning alcoholics and alcoholism. On a scale of 0 (strongly disagree) 

to 7 (strongly agree) the statement “alcoholics are difficult to treat” 

received a mean score of 6.25, and the statement “alcoholism is a treatable disease” received a mean score of 5.27. In an earlier report, Chang 

and Astrachan documented low BAC testing rates for intoxicated drivers 

by emergency department physicians.42 One of the reasons they cited 

was “defeatism about alcoholism management.” In a recent survey of 

emergency medicine physicians, 78% agreed that alcohol abuse/dependence is a “treatable disease,” but more than 90% indicated that there 

was a lack of time to perform interventions, and only 51% supported 

Intervening with Alcohol Problems 97 
emergency department interventions.43 These attitudes and practices are 

similar to those found in a national survey of physicians practicing 

internal medicine, family medicine, obstetrics-gynecology, and psychiatry.

44 Most physicians reported asking about alcohol use but few used 

recommended screening protocols or offered formal treatment. 

The first challenge for implementing recommended screening and 

interventions for problem drinking in emergency settings involves 

convincing staff of the importance and efficacy of such interventions. 

Although the research to date supports the efficacy of these interventions, clinical trials are needed to confirm these findings and to set the 

stage for the next logical step of effectiveness studies. Feasibility and 

successful dissemination must be demonstrated. Prototype interventions 

that can reach the majority of problem drinkers, motivate them to 

change drinking patterns or enter appropriate treatment, and produce 

positive long-term outcomes should be introduced into several emergency settings of differing size and staff composition. These multi-site 

effectiveness studies can then be used to promote change in standard 

practice in all emergency settings. 

What we have learned from the research to date gives us some direction as to how to implement interventions in emergency settings to 

reduce drinking and alcohol related risks. The first step to developing 

an effective and efficient intervention program would be to create a 

screening procedure integrated into the admission and triage system of 

the emergency settings. Alcohol problems can be identified along a range 

of alcohol use and consequences. However, it is important to clarify 

what type of problem interveners are attempting to address. The screening procedure can have a net with larger or smaller mesh that can be 

set for more or less severe alcohol problems. However, whatever the 

titration of the screen, the procedure must be clearly delineated and 

uniformly applied to every patient admitted to the emergency department or trauma center. The primary screen must be integrated into the 

standard intake procedure of the emergency setting and must be the 

responsibility of the staff to administer to all patients. 

This preliminary screen should trigger a more in-depth assessment 

and a brief intervention that can be delivered either separately or as a 

package (Figure 2). The assessment is critical for evaluating motivation 

98 Alcohol Problems Among Emergency Department Patients 
and decisional considerations and for determining the need for and 

appropriateness of referrals to treatment. The success of motivational 

and patient-centered approaches seems to indicate that it is critical to 

take into account the motivation of the patient and his or her readiness 

to change.24,25 Once motivated, the patient may need a variety of options 

depending on the nature of the alcohol problem and the needs of the 

patient. Many treatment providers believe that intensity of treatment 

should be determined by level of alcohol problem, although controlled 

trials do not always support the assumption. Greater dependence and, 

particularly, greater support for drinking in the environment, may 

indicate a need for more intensive treatment, such as detoxification, 

inpatient or residential treatment, or intensive day treatment. Self-help 

groups like Alcoholics Anonymous, Women for Sobriety, or Rational 

Recovery; outpatient treatments; and guided self-change45 may also be 

appropriate for a wide range of drinking problems. In any case, the 

broader the net cast by the screening instrument that identifies individuals with alcohol problems, the more flexible and wide-ranging 

should be the referral and post-discharge options. 

The assessment and intervention could be delivered by a variety of 

trained professionals who have some expertise in motivational interventions, understand alcohol problems, and are armed with a series of 

viable options to assist the patient.35 The intervention, by necessity, 

needs to be brief and limited in contact consisting of 10 to 40 minutes 

of interaction. Interventions and the staff who conducts them need to 

be flexible and creative in adapting to situations created by the injuries 

and the noisy and often chaotic nature of emergency settings. Communication rather than confrontation, concern rather than condemnation, 

and facilitation rather than force or law enforcement should mark the 

interventions. If there is a legal aspect to the case, it should be separated 

from the clinical intervention as much as possible. Multiple, feasible 

referral options that vary in intensity and scope should be available as 

part of the intervention. Since data from other studies indicate that 

facilitating the referral and making the connections increase compliance, 

the intervention ideally should have a component of compliance 

enhancement if it includes referral to community treatment programs. 

Intervening with Alcohol Problems 99 
Next steps 

Research is needed to confirm and extend the findings to date about 

interventions in emergency settings. Unresolved questions about the 

nature and format of the intervention that could use input from research 

are enumerated below. 

1. Should there be several types of interventions for differing levels of 

severity? Individuals with less severe alcohol problems may benefit from 

a brief intervention with little or no follow-up or referral.10 Are there 

subpopulations that benefit more from motivational or brief interventions?46,47 Should we triage the most severe problem patients into a more 

intensive intervention in the emergency setting? What are the long-term 

outcomes (12 months or more) of various interventions with patients of 

differing levels of severity? 

2. Who can best deliver the intervention? How involved should the 

patient’s attending physician in the medical treatment be in the intervention for alcohol problems? Most emergency department physicians 

do not believe that physicians or nurses would be the best persons to 

provide effective treatment.42 There are a variety of professionals that 

could be trained to deliver the intervention including physicians, nurses, 

psychologists, social workers, and substance abuse counselors. However, 

it may be more a matter of skill and ability to work in this setting and 

deliver the needed type of intervention rather than of profession that 

should determine who should deliver the intervention. 

3. Should the intervention include the family? Are family members a 

help or hindrance in the intervention? Family members and partners 

can be of significant assistance in the intervention.48 However, they can 

also interfere with the interview by suggesting non-cooperation, interfering with the candidness of the self-report, and trying to protect the 

patient from the intervention in some misguided attempt to help. 

Including family should be done carefully and thoughtfully, if at all. 

4. What are the constraints regarding the timing of the intervention? 

Must the intervention occur in the first 24 hours or can it be included in 

discharge planning and delivered after discharge? We need to know more 

about the closing of this “window of opportunity” and whether delay 

interferes with motivation. 

100 Alcohol Problems Among Emergency Department Patients 
5. How can emergency staff be trained to facilitate the screening and 

intervention? Would particular approaches to training be more effective 

in reaching emergency physicians and nurses? 

6. How does extent of injury or severity of illness affect the intervention? It is clear that some injuries create barriers to intervention in the 

emergency setting. Is a separate protocol needed for individuals who are 

admitted to the hospital for surgery or other medical treatments that 

necessitate a hospital stay? 

7. Should all interventions triage and intervene based on patient 

readiness to change? The perspective of the stages of change model 

appears to be an appealing one to help staff and interventionist understand the process of change for addictive and health behavior.

49,50 

Incorporating this perspective into interventions in the emergency 

setting has been suggested by several researchers.24,25 

8. Are there significant policy issues that must be resolved to make 

interventions for alcohol problems more feasible? For example, many 

clinicians do not routinely obtain a BAC test because of a fear of denial 

of payment for medical care by third-party payors for injured patients 

who test positive. This fear is well grounded. Rivara and colleagues in 

a survey of insurance commissioners found that 26 of 31 respondents 

indicated that intoxication at the time of injury allowed for exclusion 

of coverage.

51 A review of state statutes, including those of the District 

of Columbia, revealed that 38 states have a provision that allows thirdparty payors to issue policies that deny payment for injuries sustained 

while intoxicated. While Rivara and associates note, “this option seems 

to be enforced rarely by most companies,” we are aware of anecdotal 

reports of emergency departments and trauma centers that have ceased 

testing because of the fears of non-payment. However, our inquiry to 

billing department staff at the Maryland Shock Trauma Center, which 

admits nearly 6,000 patients annually, revealed not a single case of 

denial of payment. 

9. There is also a need for health services research to examine technology transfer and explore ways to disseminate research findings to 

emergency settings of differing size and complexity. Implementation is 

as important as the intervention in these settings. Unless screening and 

Intervening with Alcohol Problems 101 
intervention becomes an integral part of the emergency triage and 

treatment system, it will be an appendage that will be inconsistently 

applied or tried and discarded. An intervention template with options 

incorporating the alcohol problem intervention into the various settings 

should be developed and evaluated. 

10. As we have indicated, guidelines and best practices have been 

published that deal with alcohol dependence and abuse and emergency 

medicine. The challenge now is to discover how government agencies 

and professional organizations can promote adoption and implementation of intervention guidelines. 

The opportunity 

A combination of basic research, program implementation and evaluation studies, and policy and procedure evaluations are needed to resolve 

the issues outlined previously. Twenty years ago, Joseph Zuska, a surgeon 

with an interest in alcohol problems among injured patients noted: 

“The crisis that brings the alcoholic to the surgeon is an opportunity 

for intervention in a progressive, often fatal disease.”52 More recently, the 

Substance Abuse Task Force from the Society of Academic Emergency 

Medicine led by D’Onofrio and colleagues emphasized that in the 

emergency department setting, “Early intervention and appropriate 

referral of patients with alcohol problems have the potential to reduce 

alcohol-related morbidity and mortality.”9

 An accumulating body of 

evidence supports these calls for intervention. However, systemic and 

practical barriers must be overcome and additional research conducted 

to take full advantage of this opportunity. 

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Epidemic increases in concaine and opiate use by trauma center patients.


J Trauma 2001;51:557–64.


25. Smith AJ, Shepherd JP, Hodgson RJ. Brief interventions for patients with


alcohol-related trauma. Br J Oral Maxillofac Surg 1998;36:408–15.


26. Wright S, Moran L, Meyrick M, O’Connor R, Touquet R. Intervention by an


alcohol health worker in an accident and emergency department. Alcohol Alcohol


1998;33(6):651–6.


27. Fuller MG, Diamond DL, Jordan ML, Walters MC. The role of a substance


abuse consultation team in a trauma center. J Stud Alcohol 1995;56:267–71.


104 Alcohol Problems Among Emergency Department Patients 
28. Hemphill C, Bennett BE, Watkins, BL. Alcoholism: the response of a public 

hospital. Urban Health 1984;13(7):14–6. 

29. Bernstein E, Bernstein J, Levenson S. Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance 

abuse treatment system. Ann Emerg Med 1997;30(2):181–9. 

30. Hungerford DW, Pollock DA, Todd KH. Acceptability of emergency 

department-based screening and brief interventions for alcohol problems. 

Acad Emerg Med 2000; 7:1383–92. 

31. Dinh-Zarr T, Diguiseppi C, Heitman E, Roberts I. Preventing injuries 

through interventions for problem drinking: a systematic review of randomized 

controlled trials. Alcohol Alcohol 1999;34:609–21. 

32. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief 

physician advice for problem alcohol drinkers: a randomized controlled 

trial in community-based primary care practices. JAMA 1997;277:1039–45. 

33. Walsh DC, Hingson RW, Merrigan DM, Levenson SM, Coffman GA, Heeren 

T, Cupples LA. The impact of a physician’s warning on recovery after alcoholism 

treatment. JAMA 1992;267(5):663–7. 

34. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician and 

nurse practitioner-delivered counseling for high risk drinkers. Arch Intern Med 

1999;159:2198–2205. 

35. Dunn CW, Donovan DM, Gentilello LM. Practical guidelines for performing 

alcohol interventions in trauma centers. J Trauma 1997;42:299–304. 

36. Reyna TM, Hollis MW, Hulsebus RC. Alcohol-related trauma: the surgeon’s 

responsibility. Ann Surg 1985;201:194–7 

37. Miller WR. Alcoholism: toward a better disease model. Psychology of 

Addiction Behaviors 1993;7:129–35. 

38. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: 

a review. Addiction 1993;88:315–36. 

39. Center for Substance Abuse Treatment, Substance Abuse and Mental Health 

Services Administration. Alcohol and Other Drug Screening of Hospitalized 

Trauma Patients, Treatment Improvement Protocol (TIP), No. 16. Rockville (MD): 

Department of Health and Human Services; 1995. DHHS Publication No. 

(SMA) 95-3014. 

Intervening with Alcohol Problems 105 
40. Soderstrom CA, Dailey JT, Kerns TJ. Alcohol and other drugs: an assessment 

of testing and clinical practices in U.S. trauma centers. J Trauma 1994;36:68–73. 

41. Chang G, Astrachan BM, Weil U, Bryant K. Reporting alcohol-impaired 

drivers: results from a national survey of emergency physicians. Ann Emerg Med 

1992;21:284–90. 

42. Chang G, Astrachan BM. The emergency department surveillance of alcohol 

intoxication after motor vehicular accidents. JAMA 1988;260:2533–6. 

43. Graham DM, Maio RF, Blow FC, Hill EM. Emergency physician attitudes 

concerning intervention for alcohol abuse/dependence in the emergency 

department. J Addict Dis 2000;19:45–53. 

44. Friedman PD, McCullough D, Chin MH, Saitz R. Screening and interventions 

for alcohol problems: a national survey of primary care physicians and psychiatrists. J Gen Intern Med 2000; 15:84–91. 

45. Sobel MB, Sobel LC. Problem Drinkers: Guided Self-change Treatment. New 

York (NY): Guilford Press; 1993. 

46. Heather N. Interpreting the evidence on brief interventions for excessive 

drinkers: the need for caution. Alcohol Alcohol 1995;30(3):287–96. 

47. Poikilainen K. Effectiveness of brief interventions to reduce alcohol intake 

in primary health care populations: a meta-analysis. Prev Med 1999; 28(5): 

503–9. 

48. McCrady BS, Epstein EE. Marital therapy in the treatment of alcoholism. 

In: Gurman AS, Jacobson N, editors. Clinical Handbook of Marital Therapy 1995. 

2nd ed. New York (NY): Guilford Press; 1995. p. 369–93. 

49. DiClemente CC, Prochaska JO. Toward a comprehensive, transtheoretical 

model of change: stages of change and addictive behaviors. In: Miller WR, 

Heather N, editors. Treating Addictive Behaviors. 2nd ed. New York (NY): 

Plenum; 1998. p.3–24. 

50. Zimmerman GL, Olsen CG, Bosworth MF. A “stages of change” approach 

to helping patients change behavior. Am Fam Physician 2000;61(5):1409–16. 

51. Rivara FP, Tollefson S, Tesh E, Gentilello LM. Screening trauma patients for 

alcohol problems: are insurance companies barriers? J Trauma 2000;48:115–8. 

52. Zuska JJ. Wounds without cause. Bull Am Coll Surg 1981;66:5–10. 

106 Alcohol Problems Among Emergency Department Patients 
Figure 1

Types of Emergency Setting Interventions 

◆ Brief Advice (and Referral)


◆ Substance Abuse Evaluation and Referral


◆ Motivational Enhancement (and Referral)


◆ Personalized Feedback (New)


◆ Post-Discharge Contact (New)


Figure 2

Points of Intervention


Screening 

Evaluation 

Referral Counseling 

Follow-up 

Intervening with Alcohol Problems 107 
Response to Dr. Carlo DiClemente’s Presentation 

Gail D’Onofrio, MD 

I am honored to be a discussant following Dr. DiClemete’s comments 

about interventions for patients presenting to the emergency department (ED) with alcohol problems. We have just heard compelling 

evidence regarding the efficacy of brief intervention in a variety of 

settings including primary care, inpatient trauma centers, and emergency departments, and for multiple populations, ranging from 

adolescents to adults. 

We now know several truths. First, screening and brief intervention 

(SBI) does work. A recent evidence-based review of the literature on 

SBI, conducted by Dr. Linda Degutis and me, revealed 39 studies 

(30 randomized controlled and 9 cohort) with a positive effect demonstrated in 32 of these studies.1 We also know that the ED visit offers a 

potential “teachable moment” due to the possible negative consequences 

surrounding it and that in essence we, as emergency physicians, have a 

captive audience. In addition, we know that patients presenting to the 

ED are likely to need our help more than those who present to primary 

care. Cherpitel recently compared patients presenting to an ED with 

those presenting to primary care in the same metropolitan area. She 

found that ED patients were one and one-half to three times more likely 

than primary care patients to report heavy drinking, consequences of 

drinking, alcohol dependence, or history of treatment for an alcohol 

problem.

2 

It is now time for us to adapt the information we have learned from 

these efficacy trials to the ED setting and move on to effectiveness trials. 

In doing so, we face unique challenges. These include time pressures, 

competing priorities, few formal follow-up protocols, negative attitudes 

of the staff, and a multitude of systems problems in an environment that 

at best can be described as controlled chaos. Perhaps the largest hurdle is 

the fact that ED practitioners have not yet bought into the idea that SBI 

is part of their role or responsibility. 

To be effective, our research strategies must be brief and clear. In real 

life, there is not a cadre of researchers to screen and administer lengthy 

interventions. Therefore, protocols must be capable of being integrated 

into existing systems with available resources. 

108 Alcohol Problems Among Emergency Department Patients 
I am going to show you a clip from a video entitled The Emergency 

Physician and the Problem Drinker: Motivating Patients for Change.

3 

Actual ED scenarios are used to demonstrate common problems or traps 

that arise when physicians attempt to counsel patients about their 

alcohol use. The intervention featured, the brief negotiation interview, 

includes establishing rapport, raising the subject of problem drinking, 

providing feedback, and assessing the patient’s readiness to change. 

Specific strategies to intervene, based on the patient’s readiness to 

change, are demonstrated to help the patient start the process of finding 

his or her own solutions to change. Two versions of a physician/patient 

interaction are depicted: one that is likely to be unsuccessful, and one 

that is likely to be successful. 

To be successful in developing effectiveness trials in the ED setting, 

researchers must be very clear about a number of issues when developing their proposals. These issues include: 

Who should be screened? 

Should we target certain populations—the injured or non-injured; the 

at-risk, harmful, or hazardous drinker; or the dependent drinker? 

Should we concentrate on the life cycle, from adolescence to older age, 

or should we concentrate first on more defined populations? It is 

unrealistic to assume that one intervention will work for everyone. 

What should the intervention include? 

The message of the intervention is vital. It should be brief, scripted, and 

reproducible. Exactly what constitutes brief? The exact time of the intervention should be recorded. What is included in the intervention 

should be clearly stated. Should we be sure to include the acceptable 

components of brief intervention as outlined in the acronym FRAMES: 

feedback, responsibility, advice, menu of strategies, empathy, and selfefficacy?4 Is making a connection between drinking and the ED visit 

important? Is there a prescription or recommendation given to the 

patient? Does the message include advice or add a component of motivational enhancement therapy? Does the research protocol monitor 

adherence to the message, and how? 

Intervening with Alcohol Problems 109 
Who should provide the screening and intervention? 

Which provider actually screens for problems and provides the 

intervention? Different sites can be creative about who conducts the 

interventions. Is it best done by nurses, physicians, or health promotion 

advocates?5

 Is it possible that patients can be screened by completing 

computer programs while waiting in the ED, with results then relayed 

to the physician?6 

How can we motivate practitioners to change? 

What can be done to motivate physicians and other health care providers to change their behaviors and incorporate SBI into their practices? 

What are the motivators? Are they patient driven so that documentation 

of a decrease in recidivism and morbidity and mortality must be proven 

to convince practitioners? Or are they tied to reimbursement? Are 

emergency physicians more likely to include counseling in their practice 

if it is a billable service? What other barriers must be removed or systems 

changes made before SBI is successful in an ED? Available resources are 

essential, as well as perceived support and role models.7

 A great deal of 

time is spent developing continuous quality improvement projects in 

EDs for problems with far less prevalence. Return visits and deaths are 

often tracked. Why not include patients with alcohol problems in this 

process? 

What exactly is included in educational programs for providers? 

Standard didactic educational programs have not been shown to change 

physician behavior and subsequently improve patient care.8

 However, 

evidence indicates that skills-based interactive sessions can change 

practice.

9,10 

How do we measure success? 

What outcomes are we measuring? Do they include a decrease in alcohol 

consumption or decreases in negative consequences, such as drinking 

and driving violations or school and work problems? A decrease in 

morbidity and mortality may be more difficult to measure and require 

a lengthy follow-up period, but it provides much more meaningful data 

to the practicing emergency physician. It is also possible that tracking 

110 Alcohol Problems Among Emergency Department Patients 
referrals to primary care or specialized treatment programs may be an 

important outcome. Rates of enrollment in treatment programs and 

compliance with appointments may be meaningful outcomes. 

How long one brief intervention may affect patients’ behavior is 

unclear. ED providers have no formal relationships with the patients 

beyond the index visit, and it is entirely plausible that the effect of the 

brief intervention may be short lived. Therefore, certain outcomes may 

need to be measured early at one or three months. However, one may 

also argue that it is possible that there may be a “sleeper effect,” or 

delayed emergence of treatment efficacy, as described by O’Malley and 

Carroll,

11,12 making it imperative that assessments be continued for one 

year or more. 

All of these questions need to be answered in future studies if we are 

to prove that SBI is effective in the ED setting. It is crucial that researchers are clear on all aspects of their research protocols so that future 

projects can either replicate or build on past experiences. These aspects 

include exclusion and inclusion criteria, the specifics of the intervention 

(i.e., what, how, and by whom), and the specific outcomes to be measured. Adherence to the protocol should also be assured. 

In conclusion, there is no “silver bullet,” or one exact intervention that 

will work for everybody. We must focus on small, incremental steps and 

realize that the entire process will be a long one. Fortunately, the number 

of ideas and research questions are endless, allowing for multiple studies 

and a great deal of creativity on the part of the researchers. 

References 

1. D’Onofrio G, Degutis LC. Preventative care in the emergency department: 

screening and brief intervention for alcohol problems in the eergency department: a systematic review. Acad Emerg Med 2002;9(6):627–38. 

2. Cherpitel CJ. Drinking patterns and problems: a comparison of primary care 

with the emergency room. J Subst Abuse 1999;20:85–95. 

3. D’Onofrio G, Bernstein E, Bernstein J. The Emergency Physician and the 

Problem Drinker: Motivating Patients for Change. [videocassette] South Natick 

(MA): Marino & Company Production; 1997. 

Intervening with Alcohol Problems 111 
 4. Miller WR, Sanchez VC. Motivating young adults for treatment and lifestyle 

change. In: Howard G, editor. Issues in Alcohol Use and Misuse in Young Adults. 

Notre Dame (IN): University of Notre Dame Press; 1993. p. 55–82. 

5. Bernstein E, Bernstein J, Levenson S. Project ASSERT: an ED based intervention to increase access to primary care, preventive services, and the substance 

abuse treatment system. Ann Emerg Med 1997;30:181–9. 

6. Rhodes KV, Lauderdale DS, Stocking CB, Howes DS, Roizen MF, Levinson W. 

Better health while you wait: a controlled trial of a computer-based intervention 

for screening and health promotion in the emergency department. Ann Emerg 

Med 2001;37:284–91. 

7. Cartwright AKJ. The attitudes of helping agents towards the alcoholic client: 

The influence of experience, support, training, and self-esteem. Br J Addict 1980; 

75:413–31. 

8. Davis DA, Thamson MA, Oxman AD, Haynes RB. Changing physician 

performance: a systematic review of the effect of continuing medical education 

strategies. JAMA 1995;274:700–5. 

9. Davis D, Obrien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisy A. 

Impact of formal continuing medical education: do conferences, workshops, 

rounds, and other traditional continuing education activities change physician 

behavior or health care outcomes? JAMA 1999;282:867–74. 

10. Saitz R, Sullivan LM, Samet JH. Training community-based clinicians in 

screening and brief intervention for substance abuse problems: translating 

evidence into practice. J Subst Abuse 2000;21:21–31. 

11. O’Malley SS, Jaffe AJ, Chang G, Rode S, Schottenfeld R, Meyer RE, 

Rounsaville B. Six-month follow-up of Naltrexone and psychotherapy for alcohol 

dependence. Arch Gen Psychiatry 1996;53:217–24. 

12. Carroll K, Rounsaville BJ, Nich C, Gordon LT, Wirtz PW, Gawin F. One-year 

follow-up of psychotherapy and pharmacotherapy for cocaine dependence: 

delayed emergency of psychotherapy effects. Arch Gen Psychiatry 1994;51:989–97. 

112 Alcohol Problems Among Emergency Department Patients 
Intervening with Alcohol Problems in


Emergency Medicine:


Discussion of the DiClementi and Soderstrom Article


Kristen Lawton Barry, PhD 

Reducing death and disability related to alcohol remains a national 

health status goal.1,2 Cherpitel and others have suggested that the 

emergency department (ED) may be the ideal place to identify alcohol 

problems and to begin interventions, particularly with patients who 

enter the ED with an injury.

3–10 Several compelling reasons make the 

ED an important setting for alcohol interventions. First, a large number 

and variety of patients are seen in EDs every year. Second, many of the 

patients who use the ED do not have their hazardous drinking detected 

or treated in other primary or tertiary care settings. Third, most patients 

with alcohol problems are released from the ED rather than being 

admitted to hospitals where detection may be more likely. Finally, for 

patients seen in the ED, there can be an immediacy between the event 

bringing them to this setting (e.g., injuries) and possible identification 

of and intervention for an alcohol problem. 

Logistical challenges to brief interventions in the ED 

The ED presents unique challenges, however, for identifying and intervening with patients who drink at a hazardous level. The ED is a fastpaced environment with many competing demands that do not allow for 

concentrated periods of personnel time devoted to intervening with 

long-term problems, even if the problems are related to a particular ED 

visit. It is of great importance to develop intervention strategies that can 

be used easily and efficiently in this setting. 

Medical care challenges in the ED 

In addition to the practical problems generally associated with screening 

and intervention in this venue, pressing problems in the delivery of 

medical care will affect how we intervene in the future with ED patients 

at risk for and currently experiencing problem drinking. By 2020, there 

will be a serious shortage of nursing personnel available to work in this 

and other medical settings.

11 This shortage will come at a time when the 

Intervening with Alcohol Problems 113 
Baby Boom generation is reaching retirement age and having more 

health-related problems that lead to greater use of urgent care and 

emergency facilities. In fact, EDs are already seeing greater numbers of 

patients at a time when hospitals are closing. This critical health care 

shortage could exacerbate a vicious cycle of need for care and difficulty 

providing that care. 

DiClemente and Soderstrom have produced a well-crafted, state-ofthe-art article and presentation about the need for, importance of, and 

challenges in conducting research on the efficacy and ultimate effectiveness of brief alcohol interventions in the ED for persons who are at-risk 

drinkers, problem drinkers, or alcohol-dependent drinkers. It is clear 

from their manuscript that a spectrum of alcohol problems presents in 

the ED and that a spectrum of solutions is necessary to meet the challenges of providing “best practices” care. 

Issues raised by DiClemente and Soderstrom 

This response to DiClemente and Soderstrom’s conference presentation 

briefly addresses issues raised by Dr. DiClementi, primarily the need for 

considering the use of technology to augment or deliver brief alcohol 

interventions in the ED. Previous research has shown that brief interventions for hazardous drinking are effective in reducing drinking levels 

across of variety of health care settings, including the ED.

12–17 However, 

the sample sizes, attrition rates, types of interventions, levels of alcohol 

use, outcomes measured, and effect sizes have varied greatly across the 

studies. In addition, the target of the intervention (at-risk drinkers, 

problem drinkers, alcohol-dependent drinkers) and the mechanism of 

intervention (physician, nursing staff, social workers, technology with 

or without provider advice) remain open questions. 

Brief alcohol interventions have generally included feedback by a 

health care professional based on patients’ responses (screening positive) 

to questions about alcohol consumption or consequences. These results 

indicate that while this approach is effective for a percentage of hazardous drinkers, it is not effective for everyone (effect sizes of ~30% to 

40%). The intervention studies based on provider feedback and advice 

to the patient have had mixed results in the ED. In addition, it remains 

difficult to engage health care professionals in conducting brief interventions in this venue because of the volume of patients and the urgency 

of other presenting problems. It is becoming clear that, to be widely 

114 Alcohol Problems Among Emergency Department Patients 
effective, an ED-based brief alcohol intervention model that requires 

providers to give advice and written materials to the screen-positive 

patients will need some modification. 

Two concepts that appear often in the literature may be useful in 

informing future research. First, the ED potentially provides an ideal 

“teachable moment” for patients who have problems with alcohol use. 

It is thought that this is particularly true if the patient’s use can be tied 

to the reason for the ED visit. However, it may also be anticipated that 

using the ED visit as a teachable moment may be effective for noninjured persons who drink at risk excessively. Second, the ED is a fastpaced environment in which providers cannot easily find time to 

conduct brief alcohol interventions, even if they have the training, 

skills, and desire to do so. The concept of the teachable moment, 

although only a conceptualization at this time, provides part of the 

seminal interest in doing alcohol interventions in the ED. On the other 

hand, the fast pace of the ED may play a role in why providers find it 

difficult to address alcohol issues at all, particularly for those patients 

who do not present in the ED with problems or conditions clearly 

linked to alcohol consumption. 

The implementation of brief alcohol intervention systems in “real 

world” emergency medical practice has not been easy. This has been 

true in primary care settings as well. Efficacy trials are the first step, 

but implementation of proven alcohol screening and brief intervention 

systems in hospital- and community-based settings has been the most 

difficult part of the process. Serious logistical challenges remain in 

developing systems that facilitate the use of these techniques on a 

regular basis. 

The combination of the potential opportunity to affect the alcohol 

consumption of at-risk drinkers and the limited time for providers to 

intervene, along with the higher volume and projected shortages of 

nursing personnel, necessitates the need to expand research on brief 

alcohol interventions specifically with the use of new technology. The 

use of technology may reduce the time needed for providers and staff 

to personally provide screening and intervention services and target 

patients who can derive benefit from the brief intervention messages. 

In addition, because of the effect sizes shown by the studies to date, 

there is also a need to target responses and elements of the brief intervention to the problems specific to each individual patient who scores 

Intervening with Alcohol Problems 115 
positive for at-risk drinking or more serious alcohol-related problems. 

The use of new technologies for individualizing brief intervention 

materials and feedback may help to fill gaps in the system of care for 

patients with at-risk and problem drinking patterns. 

This is a large challenge and a large expectation for any one system of 

intervention. Just as there is a spectrum of alcohol use problems, there 

may be a family of solutions. These solutions will need to address both 

the types of interventions that best fit each ED and medical center and 

the specific problems of the patient. “One size fits all” does not work in 

brief interventions, just as it does not work in clinical practice in general. 

Taking a public health perspective, methods are sought that are the most 

effective clinically and financially. 

New directions in brief alcohol interventions in emergency 

medicine 

One of the innovations being tested at this time is the use of automated 

computerized screening with real-time production of brief workbook 

content tailored to specific problems. The use of computerized, tailored 

messaging represents an important technique to provide targeted, 

individualized feedback to patients considered most open to change 

messages. Tailored messaging systems have been found effective in the 

areas of depression, smoking cessation, dietary intake, and use of 

mammography.

18 

Other technologies that may be useful in the future include the use of 

interactive voice recognition (IVR) technology to facilitate screening, 

delivery of educational interventions, and follow-up of patient progress 

by telephone. IVR telephone availability 24 hours/day could facilitate 

follow-up of ED patients. Interactive computer programs on laptops or 

palm computers, web-based interventions, computerized bundling of 

brief health messages for multiple health risks (e.g., smoking, alcohol 

use, seat belt use), and audio interventions tailored to specific problems 

and delivered through headsets19 are also being posited as potential 

approaches in emergency and urgent care settings. 

Some of these technologies have been raised because of system 

barriers to provider-based interventions. The use of technology 

(e.g., hand-held computerized screening, interactive headphone delivery 

of messages, tailored messaging booklets) to assist in interventions in a 

116 Alcohol Problems Among Emergency Department Patients 
crowded, busy venue may allow a level of privacy that addresses the 

shame and stigma many individuals feel about problems related to 

alcohol misuse and abuse. 

Patients in the emergency setting range from those with no alcohol 

problems to those with severe dependence. In the next few years, a 

variety of exciting intervention techniques will be tested in EDs and 

urgent care clinics. Drs. DiClemente and Soderstrom have set the stage 

for us to think about what is needed in the future to provide best practices care to patients with problems related to alcohol use. Any methods 

that are developed with researchers and clinicians working together will 

help to overcome barriers and promote best practices care for a range of 

drinkers in the emergency setting. 

References 

1. U.S. Department of Health and Human Services. Healthy People 2000. 

National promotion and disease prevention objectives. Washington (DC): U.S. 

Department of Health and Human Services; 1990. DHHS Publication No. 

(PHS) 91-50212. 

2. U.S. Department of Health and Human Services. Healthy People 2010: 

Understanding and Improving Health. 2nd ed. Washington (DC): U.S. Government Printing Office; 2000. 

3. Cherpitel CJ. Breath analysis and self-reports as measures of alcohol-related 

emergency room admission. J Stud Alcohol 1989;50:155–61. 

4. Cherpitel CJ. Alcohol, Injury, and risk-taking behavior: data from a national 

sample. Alcohol Clin Exp Res 1993;17(4):762–6. 

5. Dewey KE. Alcohol related attendances at the accident and emergency 

department. Ulster Med J 1993;62(1):58–62. 

6. Zink BJ, Maio RF. Alcohol use and trauma. Acad Emerg Med 1994;1(2):171–3. 

7. Maio RF. Alcohol and injury in the emergency department: opportunities for 

intervention. Ann Emerg Med 1995;26:221–3. 

8. Dyehouse JM, Sommers MS. Brief interventions after alcohol-related injuries. 

Substance abuse interventions in general nursing practice. Nurs Clin North Am 

1998;33(1):93–104. 

Intervening with Alcohol Problems 117 
 9. Longabough R, Minugh PA, Nirenberg TD, Clifford PR, Becker B, Woolard R. 

Injury as a motivator to reduce drinking. Acad Emerg Med 1995;2(9):817–25. 

10. Sommers MS, Dyehouse JM, Howe SR, Lemmink J, Davise K, McCarthy M, 

Russlee AC. Attribution of injury to alcohol involvement in young adults 

seriously injured in alcohol-related motor vehicle crashes. Am J Crit Care 2000; 

9:28–35. 

11. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered 

nurse workforce. JAMA 2000;283(22):2948–54. 

12. Chick J, Lloyd G, Crombie E. Counseling problem drinkers in medical wards: 

a controlled study. Br Med J 1985;290,965–7. 

13. Babor TF, Grant M. Project on Identification and Management of Alcoholrelated Problems. Report on Phase II: A Randomized Clinical Trial of Brief 

Interventions in Primary Health Care. Geneva: World Health Organization; 1992. 

14. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief


physician advice for problem alcohol drinkers: a randomized controlled


trial in community-based primary care practices. JAMA 1997;277(13):1039–45.


15. Wright S, Moran L, Meyrick M, O’Connor R, Tourquet R. Intervention by an


alcohol health worker in an accident and emergency department. Alcohol Alcohol


1998;33(6):651–6.


16. Dinh-Zarr T, Diguiseppi C, Heitman E, Roberts I. Preventing injuries


through interventions for problem drinking: a systematic review of randomized


controlled trials. Alcohol Alcohol 1999;34:609–21.


17. Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, Daranciang E, Dunn


CW, et al. Alcohol interventions in a trauma center as a means of reducing the


risk of injury recurrance. Ann Surg 1999;230:473–83.


18. Strecher VJ, Kreuter MW, DenBoer DJ, Kobrin SC, Hospers HJ, Skinner CS.


The effects of computer-tailored smoking cessation messages in family practice


settings. J Fam Pract 1994;39:262–70.


19. Blow FC, Barry KL. Older Patients with at-risk and problem drinking


patterns: new developments in brief interventions. J Geriatr Psychiatry


Neurol 2000; 13(3):115–23.


118 Alcohol Problems Among Emergency Department Patients 
General Discussion 

Richard Longabaugh commented on how much remains unknown 

about what motivates patients to change their use of alcohol. He noted 

that researchers at Brown previously had found that readiness to change 

was predicted by whether or not patients attributed their ED injury visit 

to their drinking. They expected the same result in their new study with 

hazardous drinkers who had a positive BAC at the time of their injury 

visit. However, they were surprised to find that regardless of whether 

the injury was attributed to alcohol or not, patients did equally well at 

follow-up. Consequently, the motivational mechanism is not clear. 

Another surprise was that in the new study, a single intervention session 

at the time of the emergency visit made no difference in any outcome 

measures at either 3 months or 1 year. Patients who returned 7 to 

10 days later for a second intervention session did not improve on 

outcomes at 3 months, but they did improve on alcohol-related negative 

consequences and injuries at 1 year. Two-thirds of the patients returned 

for a second session, but that proportion varied from one-third to 90% 

across the different interventionists. 

Kristen Barry noted that in primary care studies, one session seems 

to be enough to foster change. However, she found it interesting that 

booster sessions worked in this setting. Even though the intervention 

did not decrease drinking, it did decrease drinking-related consequences, which may be part of what we’re looking for in this setting. 

Carlo DiClemente said the message needs to be reinforced after discharge. In his work, they are using a feedback letter and phone calls 

at two weeks and six weeks. He noted that Longabaugh’s data indicate 

there is benefit from a post-discharge contact and that we will see if 

other studies confirm that. 

Herman Diesenhaus added that there must be some type of maintenance activity if we are dealing with a chronic, relapsing condition. 

The research questions are how to determine which patients need 

maintenance activities, what types of activities they need, and when 

or how often they are needed. 

Intervening with Alcohol Problems 119 
Christopher Dunn related that his research interventions took 30 to 

40 minutes, but his interventions outside the research arena took about 

20 minutes because the process did not have to be so complicated and 

uniform, and there was less data collection. He observed that the first 

question of the SMAST (“Do you think you’re a normal drinker?”) 

forced people to label and marginalize themselves. This had created 

many difficulties during his interventions. He noted that he prefers the 

AUDIT. An original goal of the study was to encourage post-discharge 

alcohol treatment, but only 5% to 10% of study patients went to at least 

one treatment or Alcoholics Anonymous session. Consequently, he 

questioned how important that goal should be. Very few patients refused 

to speak to him or had problems with privacy during the interview. 

Family members were present less than 10% of the time, and their 

impact on the intervention varied. He noted that even though interventions are evidence-based, organizations and interventionists in nonresearch settings will make an intervention their own. In any case, he 

observed, even in the existing randomized trials of interventions that use 

motivational interviewing, we cannot evaluate the effect of counselors’ 

skill levels. In future trials, he recommended that the fidelity of the 

intervention and variations among interventionists be more closely 

monitored. 

Barry agreed that we have not monitored closely enough what intervention is being delivered by the interventionists we train. The good news is 

that across many trials, the interventions being delivered seem to work. 

She also agreed that the first question of the SMAST is problematic. She 

noted that the short and long MAST for geriatric patients have been 

modified, eliminating the problems. 

Peter Monti agreed with Dunn that measuring treatment fidelity is 

extremely important. He cited a brief report and an upcoming chapter 

in a book about interventions with adolescents that describes how 

studies at Brown evaluate fidelity. He also noted that none of the three 

clinical trials (Gentillelo’s with trauma patients, his own with adolescents, and Longabaugh’s in the ED) used physicians or ED staff to 

conduct interventions. He recommended that future research evaluate 

whether using physicians or ED staff is more cost effective than using 

specially hired staff. He wondered if using ED physicians could increase 

treatment efficacy enough to offset the added cost of training and 

possible decreased delivery of interventions. He also noted that given 

120 Alcohol Problems Among Emergency Department Patients 
the costs and difficulties of the ED setting, the relative efficacy and 

cost of booster sessions is another important issue deserving further 

research. In his continuing trial, he should be able to address this 

question because adolescents will be randomized to booster sessions 

or a single session. Although his study of adolescents found reductions 

in risky behavior and alcohol-related harm, he was disappointed to find 

no effect on drinking. Given the harmful levels of drinking among 

adolescents in his studies, he remarked that it is irresponsible for interventions not to focus on drinking as well as harm. 

Gail D’Onofrio noted that her planned study will use physicians, 

physician assistants, and senior emergency medicine residents to deliver 

brief interventions for injured and non-injured harmful and hazardous 

drinkers. The study will allocate resources to promote adherence to the 

treatment protocol and monitor treatment fidelity. It also will control 

for ancillary treatments that might influence intervention outcome. 

Edward Bernstein noted that Project Assert adapted a readiness-tochange instrument for use in the ED. Patients were asked to place 

themselves on a readiness scale of 1 to 10. If patients rated themselves 

on the low end of the scale, researchers then asked them what would 

bring them to a higher score. 

DiClemente commented that such adjustments to instruments are often 

necessary. In assessing change, interventionists can use three markers to 

help them: importance, confidence, and readiness. 

Barry praised the use of a linear method to measure stages of change. 

She added that an in-home, brief intervention linked with primary care 

found no association between stage of change and outcome. She thought 

more research is needed on this issue. 

Daniel Hungerford noted that there are operational realities in the 

emergency department that must be considered in order to implement 

interventions. At the same time, some central questions need to be 

submitted to empirical testing. The screening and brief intervention 

trial he and colleagues conducted in West Virginia did not include a 

booster session and had a mode intervention time of about 14 minutes. 

Although outcomes for the experimental and control groups were not 

significantly different at 3 months, outcomes improved for both groups 

Intervening with Alcohol Problems 121 
compared to baseline. At 12 months, outcomes for both groups were 

still not different, but the percentage of patients who had improved had 

decreased and was no longer significantly different from baseline. He 

concluded that a brief intervention might have a short-lived effect that 

degrades over time. Consequently, a booster intervention might be 

helpful. His second point was that there is an easy assumption that a 

brief intervention is more appropriate for patients with mild-tomoderate problems than for patients with severe problems. It is thought 

they are more likely to respond successfully. The West Virginia project 

is on a college campus. Many of the college students who visit the ED 

have mild alcohol problems and are confident they could overcome 

their alcohol problems if they wanted to. However, most of them do 

not feel this issue is important enough to address. At follow-up, it is the 

non-students and students with more severe problems who are more 

likely to improve. He concluded we should not trust easy assumptions, 

but instead treat them as empirical questions. 

Barry reinforced the importance of looking at this issue by age groups, 

noting that young adult males were least affected by interventions in the 

Wisconsin early intervention study. She concurred with Hungerford’s 

observation that intervention effects seem to wear off after a period of 

time. She suggested that although booster interventions are needed, 

perhaps they are not needed very often, particularly in primary care 

settings. Maintenance of effect might be possible with yearly consultations. 

DiClemente noted that some trials have found patients with more severe 

problems being helped; others have helped patients with more moderate 

problems. Readiness to change may or may not be related to problem 

severity. Similarly, readiness to cut down may not coincide with readiness to abstain. Patients who are more ready to cut down are generally 

less ready to abstain. There is strong evidence that readiness to change 

and confidence, especially before treatment, are unrelated. Sophisticated 

research is required to tease apart the complex interactions between 

these variables. 

D’Onofrio agreed that methodological issues are extremely important. 

She noted that research studies often attempt to control so many variables and follow up with patients so frequently that control groups 

receive so much attention focused on alcohol that it may constitute an 

122 Alcohol Problems Among Emergency Department Patients 
intervention, particularly when compared with patients who receive 

standard care. Even if the assessment is embedded in a general healthneeds survey, patients know they are being asked about alcohol, and that 

could affect their answers. These methodological problems can mask 

valid intervention effects. 

Monti believed that a decision to screen only for patients with severe 

alcohol problems is premature. In his study of adolescents, he saw a 

decrease in drinking among all groups. However, the only patients who 

showed a differential effect from the brief intervention were precontemplators in the 13- to 17-year-old group. For younger children, he concluded, the emergency room visit was a powerful event. 

Robert Woolard related that many ED patients they approached to 

participate in research still had measurable blood alcohol levels. Brown’s 

IRB required a mental status exam to ensure patients could understand 

the research dimensions of the project before they could be enrolled in 

the study. Therefore, the study was able to correlate mental status exam 

scores with alcohol levels at the time of consent. Patients with BACs of 

0.10 and 0.08 g/dl had impaired mental status, mostly in short-term 

memory. He wondered at what blood alcohol level patients could 

remember an intervention. If they had had to wait until patients were 

sober, many would be discharged because in his ED, patients are discharged when staff estimate their BAC is below 0.08 g/dl. 

DiClemente reported that most of the people who got the longer intervention in his study remembered the interventionist at the two-week 

follow-up, so there was some recall. 

Richard Brown commented on high up-front costs required to develop 

technological means of delivering these services, such as computer-based 

screening. He said funding mechanisms such as small business grants 

were not always appropriate for researchers and wondered whether there 

were other funding mechanisms that might be more appropriate. 

Barry replied that her group had used the R-01 grant programs to help 

develop or adapt technology, but she admitted that R-01 grants can be 

difficult and time-consuming to obtain. 

Intervening with Alcohol Problems 123 
Brown replied that only a certain proportion of the funding can be 

applied toward development in R-01 grants, and some of the technology, 

for example interactive videos, can be quite expensive to develop. 

Elinor Walker reminded the group that the Agency for Healthcare 

Research and Quality has an R-03 program with a $100,000 cap, 

including both direct and indirect costs. She noted that these projects 

are reviewed by a study section, but one that may be more forgiving 

than R-01 study sections. However, the program is still quite competitive, and the project would probably have to involve testing as well as 

development. 

Longabaugh noted that R-21 grants, which are available for development of treatments, could be used to develop technologies. 

Mary Dufour observed that there are few applicants who are skilled at 

both the research and the business aspects of a project, so small business 

grants seldom go to people in the scientific community. If applicants 

want to go that route, she recommended they get help from someone 

well-versed in business. 

Marilyn Sommers related her experience from two clinical trials among 

hospitalized patients. In both, nurse clinicians, all female, implemented 

the study. Because the trauma population is mostly young, male, and not 

always easy to work with, the gender of the interventionist could be 

important. Perhaps physicians, especially male physicians, have more 

authority in that population, which may affect whether patients take 

advice. She observed that the gender of both interventionists and 

patients has not been well documented in studies. This can make it 

difficult to standardize interventions. She hypothesized that understanding the patient’s perception of the interventionist’s capabilities 

might be as important as having detailed measurements of intervention 

fidelity across interventionists. She noted that many researchers feel 

rushed to move these interventions into clinical settings because they 

know we need to be addressing alcohol problems. She asked the panel 

how to balance this need with the many important scientific questions 

that still need to be answered. 

124 Alcohol Problems Among Emergency Department Patients 
DiClemente observed that Project MATCH had examined associations 

between gender and treatment outcome and found that females did 

better in 12-step programs. However, to examine the effect of matching 

interventionists and patients would require randomizing large numbers 

of patients to a large number of interventionists. He agreed that the 

authority issue is important, but he suggested smaller, targeted research 

studies could address that question. He cautioned that not every study 

has to be a clinical trial focused on outcomes. To examine the issue of 

gender, patients could be randomized to interventionists and both could 

be asked to evaluate their perceptions of the interaction. He noted that 

the balance between research and clinical practice is always a challenge. 

He posed the following questions: Do we wait until we know exactly 

how the intervention works before we move interventions into practice? 

Or, do we start in a practice setting and keep refining as we go along? 

His sense was that the field would benefit from starting in the practice 

setting to learn how interventions work in real-world clinical settings. 

As research evidence accumulates, it can inform best practices. 

Barry described two intervention trials among older adults in primary 

care. Interventions performed by physicians in one trial had results as 

good as interventions performed by social workers and psychologists in 

the other. Although she thought age of the interventionist could be an 

influential factor, she was unsure because there are so many interactions 

and factors that we have not looked at very carefully. 

D’Onofrio, in response to Sommer’s concerns, suggested that a patient 

might be more receptive to nurses than physicians because they are less 

authoritative and more nurturing, and they listen better. So the reverse 

hypothesis could be just as valid. 

Sommers suggested that some of these questions could be addressed by 

pooling data sets from existing clinical trials and hoped this conference 

would be a step in that direction. 

Longabaugh noted one matching effect that persisted throughout the 

post-treatment period in Project MATCH. Clients with high trait anger, 

who were therefore likely to resist directive interventions, were more 

successful with a motivational enhancement intervention. Other clients 

Intervening with Alcohol Problems 125 
were more successful with directive treatment interventions such as a 

12-step approach or cognitive behavioral therapy. He remarked that it 

would be possible to evaluate this association by matching patients’ 

likelihood to accept directive interventions to either brief, directive 

physician-implemented interventions or specialist-based motivational 

interventions. He added that the literature shows client outcomes and 

cost-benefits are improved by either research follow-up or a brief 

monitoring phone call. Finally, he suggested that the patient’s level of 

distress could influence motivational level as much as the severity of a 

patient’s alcohol problems. 

Robert Lowe speculated that the current situation represents both a 

unique opportunity for an intervention in the emergency department 

and a failure of the primary care system. The ED seems like an appropriate venue for alcohol interventions because many ED patients have 

alcohol problems and the ED visit may represent a teachable moment. 

However, primary care is responsible for the first contact as well as 

comprehensive, continuous care. If many patients have no primary care 

or primary care providers do not screen for alcohol-related problems, 

then primary care has failed. When the ED is essentially making up for 

the failures of primary care, perhaps focusing on the ED for interventions is not the most strategic approach. He then asked how EDs should 

use their limited resources. Should they be screening for patients with 

the worst problems? Or, are these patients the least likely to respond to 

interventions available in the ED? If milder cases are more likely to 

respond, perhaps they should be a higher priority. 

D’Onofrio noted that many young, healthy patients do not go to their 

primary care provider, even if they have one. Even with managed care 

efforts to decrease expensive ED visits, the number of ED patients has 

increased, so primary care and EDs have to work together. Since brief 

intervention does not work with severely dependent patients, ED-based 

interventions should refer patients to treatment. She added that when 

she has not been able to reach everyone, she responds to patients who 

request help. However, patients who have not considered asking for 

help may make progress toward getting help because of a connection 

made by an ED intervention. 

126 Alcohol Problems Among Emergency Department Patients 
Barry agreed that difficult cases do take most of the time and resources 

currently spent on alcohol problems in the ED. She noted that we have 

to help patients who have severe alcohol problems. However, she 

believed that it is also important to use resources to reach as many 

people as possible and that systems currently exist that, once refined, 

can be fairly easy to implement. 

DiClemente pointed out that in an ideal world, primary care would 

provide consistent contact, and interventions could happen over time. 

However, until that happens, other systems will have to pick up what 

falls through the cracks. Providing resources in the emergency setting 

has implications for the primary care setting. We need to be figuring 

out how to connect primary care and emergency care settings rather 

than splitting them apart. 

Gordon Smith described difficulties he had had with his IRB in a study 

on drinking and boating injuries. He suggested that the final report 

from the conference include a section that addresses the difficult 

human subjects issues involved in working with intoxicated patients, 

such as protocols and procedures that IRBs found unacceptable. 

Barry noted that because of human subjects violations and the way 

human subjects committees have handled their paperwork, whole 

programs have been shut down. As a result, human subjects committees 

have been under intense scrutiny. She pointed out that even ongoing 

programs have been re-scrutinized and required to make protocol 

changes. However, standards seem to vary across committees. 

Smith noted that this variation is the problem and why he wants these 

concerns to be addressed by the conference in written form. 

Charles Bombardier noted that the rate of spontaneous remission could 

minimize the differences between experimental and control groups. This 

problem makes it difficult to determine the appropriate time to schedule 

outcome assessments and booster interventions. He suggested a number 

of factors that might influence spontaneous remission such as an injury, 

type and severity of injury, degree of alcohol dependence, readiness to 

change, and marital or employment status. He thought natural history 

Intervening with Alcohol Problems 127 
studies or pooling of control group data might better identify predictors. 

More data on this issue could help us plan better controlled trials—who 

to target, when to follow up, and when to give boosters. 

Ronald Maio reported that other investigators shared their protocols 

with him and this helped his IRB clearance process go more smoothly. 

He noted that most brief intervention studies in EDs have focused on 

injured patients, but that 70% to 80% of ED patients do not present 

with an injury. He wondered how much of what we learn from the 

injury patients can be applied to patients who are not injured. 

D’Onofrio replied that her study was looking at both injured and noninjured patients. She noted that primary care studies and Ed Bernstein’s 

ED project do give us experience with non-injured patients. 

DiClemente added that his study was also for both groups and most 

primary care studies involve non-injured patients. He thought their 

findings help support work with non-injured patients in the emergency 

department setting as well. 

Patricia Perry reported that one alcohol intervention project in New 

York State was implemented in 18 hospitals, but in a different way in 

each one. She observed that after interventions have been shown to be 

effective, they will have to be adapted to new settings. She suggested we 

must identify the essential elements of interventions that are required in 

any new setting. Another lesson from the New York project was that each 

site must have a champion. She observed that it would be useful to know 

in advance how to identify whom that champion might be. She added 

that physician buy-in is critical to overcoming professional resistance, 

and that it is important to identify additional partners who can move 

intervention services forward in a particular setting or institution. 

D’Onofrio remarked that when it comes to brief interventions, many 

physicians are pre-contemplators. She suggested that changing physician 

behavior can incorporate the same concepts that are applied to changing 

patient behavior. 

128 Alcohol Problems Among Emergency Department Patients 
Jean Shope expressed her belief that addressing alcohol problems in the 

emergency department is the failure not just of primary care, but of 

many systems. Her work has been in substance abuse prevention in 

schools, where she encountered many social and legal beliefs that ran 

counter to her prevention education efforts. She believed that the ED 

setting is just one of many where alcohol problems should be addressed. 

Thomas Babor wondered whether a couple of unquestioned assumptions had arisen during discussions at the conference. The first was that 

because time and resources are limited in the emergency department, 

interventions should be simplified and limited in scope. The second was 

that we may have difficulty selling alcohol interventions because they are 

in competition with other types of interventions such as helmet use, seat 

belt use, or smoking prevention. He suggested that making interventions 

more ambitious and partnering with other programs that also are 

looking at behavioral risk factors might get us a more prominent place 

on the agenda. He suggested that the scientific question is whether we 

can intervene effectively and simultaneously for the top two or three risk 

factors that often overlap in these populations. If the science showed we 

could, the policy question would be whether we could get a bigger place 

on the agenda if we partner with other programs. 

DiClemente recalled that we used to think a patient could not quit 

smoking and drinking at the same time. Recent data have shown that not 

to be true. He also observed that patients who screen positive for one 

risk factor often have multiple risk factors. The patient could decide how 

many risk factors could be addressed at one time. A problem arises when 

the factors the patient wants to work on are not the same ones the provider thinks are most important or is most prepared to deal with. There 

are few “pure” alcoholics anymore. Most use other substances as well, so 

it is important to be able to intervene for a variety of problems. This is a 

real challenge for policy, institutional systems, and professionals. We will 

have to change our thinking and consider the many conditions for which 

we could intervene. 

Barry surmised that grant proposals to look at more than one health 

behavior at a time had already been submitted, but she did not know if 

they had been funded. 

Intervening with Alcohol Problems 129 
In response, Dunn described a 15-minute ED-based intervention funded 

to change six behaviors among youth: not wearing bike helmets, failing 

to use seat belts, carrying a weapon, binge drinking, riding with a drinking driver, and drinking and driving. However, the protocol did not ask 

patients which behaviors they were motivated to change. The intervention led to a small change in bike helmet use and a slightly larger change 

in seat belt use, but it did not lead to changes in alcohol variables or 

weapon carrying. 

D’Onofrio observed that both Project Assert and her project funded by 

the Robert Wood Johnson Foundation provided intervention for multiple behaviors, and that brief interventions for all behaviors were based 

on the same principles. She reasoned that there were so many risk factors 

that should be addressed that some sort of bundling would be necessary. 

She said that the prevalence of alcohol problems was higher than other 

risk factors. Physicians frequently ask about tetanus immunizations even 

though almost none have ever seen a case of tetanus. They readily ask 

about seat belts and distribute handouts about various behaviors. She 

believed that time is not the issue as much as redirecting the focus of the 

interaction during their time with the patient. 

Barry suggested that funding sources may have to become partners 

before support for the bundling of interventions could become a reality. 

David Lewis commented that during the last five years, patients have 

been bringing a great deal of information to medical encounters. People 

actually bring printouts of questions to ask their primary care physicians. Due to the amount of information now available, power has 

shifted from the physician to the patient. He would like to see more 

thinking about how these changes should be incorporated into research 

and more strategies that piggy-back on this information revolution and 

shift in power. 

Guohua Li disagreed with DiClemente that the efficacy of brief intervention in emergency settings had been established. He believed studies 

from England and New Zealand should be viewed very critically because 

access to health care is easier than in the United States. He believed that 

130 Alcohol Problems Among Emergency Department Patients 
studies in American emergency settings have provided inconclusive 

evidence that brief intervention works. He cautioned that literature 

reviews generally do not include all relevant studies because studies 

with negative results are seldom published. 

DiClemente agreed that efficacy in the ED setting had not been totally 

established. He noted that many practices that do not have efficacy or 

effectiveness studies behind them are adopted and become guidelines for 

standard practice. Once that happens, it is very difficult to get support to 

re-evaluate them, so it is true we must be careful when evaluating social 

science and psycho-social interventions. However, we are so sophisticated psychometrically and methodologically that virtually every piece 

of research can be dissected, revealing flaws and problems. If we continue to do that, we will never make any changes in services. He recommended a balance between the rigor of research and the application 

process that needs to happen. 

Intervening with Alcohol Problems 131