Emergency department-based brief interventions for individuals with substance-related problems : a review of effectiveness.
Date: 2016-01-13
Institutions: European Monitoring Centre for Drugs and Drug Addiction
Subjects: European Monitoring Centre for Drugs and Drug Addiction, drug addiction, emergency medical treatment, health care, health risk, psychotropic substance, public health, report, social problem

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EMCDDA PAPERS
Emergency department-based brief 
interventions for individuals with substance-
related problems: a review of effectiveness

Contents: Abstract (p. 1) I Background (p. 2) I Methods (p. 7) I Results (p. 7) I Discussion (p. 14) I 
Conclusions (p. 15) I Acknowledgements (p. 20)

Abstract: This paper reviews the effectiveness of brief 
interventions in an emergency department setting. It 
presents an analysis of five systematic reviews and 16 
randomised controlled trials. Most of these studies 
focused on alcohol-related cases or on cases of 
alcohol and drug use, with four studies specifically 
targeting illicit drug use.

Brief interventions are psychosocial interventions 
designed to help recipients recognise harmful 
patterns of substance use, and to motivate and 
support them to address that use. Brief interventions 
typically use the collaborative conversation style of 
motivational interviewing and, as the name suggests, 
take only a short time, ranging from 5 to 30 minutes. 
Brief interventions are delivered by a range of 
professionals, including physicians, nurses and other 
healthcare workers; one common structure for brief 
intervention delivery employs the ‘5As’ approach: ask, 
advise, assess, assist and arrange. Many studies on 
brief interventions in an emergency department 
setting stress that this context offers an important 
‘window of opportunity’ in which to engage with 
people with substance use problems who might 
otherwise never receive any form of assessment, 
referral or intervention. Brief interventions have 
become increasingly popular because they can be 
delivered in a variety of settings, by a range of workers 

(after training) and in a short time frame; all three of 
these factors combine to keep costs relatively low.

This review found that there are potential benefits of 
brief interventions, especially in relation to behavioural 
outcomes. However, a definitive statement about 
effectiveness cannot be made, as the results of the 
studies reviewed may not be generalisable to other 
age groups, to patients with different levels of 
substance use, or, given that the focus of many of the 
studies was on alcohol, to those using illicit drugs.

However, the feasibility of brief interventions delivered 
by emergency department personnel, the absence of 
reported adverse effects and the potential cost-
effectiveness all suggest that brief interventions could 
be considered as integral to the training of emergency 
department healthcare staff.

 Keywords   brief interventions   
 emergency departments   review 

Recommended citation: European Monitoring Centre for 
Drugs and Drug Addiction (2016), Emergency department-
based brief interventions for individuals with substance-
related problems: a review of effectiveness, EMCDDA Papers, 
Publications Office of the European Union, Luxembourg.

1 / 20

 
I  Background

Psychosocial interventions are structured psychological or 
social interventions that are used to address substance-
related problems. They can be used at different stages of a 
‘treatment journey’ to identify the problem and treat it, and 
assist with social reintegration (EMCDDA, 2015).

These interventions can be used alone or in combination with 
other treatments at different points of an individual’s drug 
treatment journey or, more generally, in the context of 
universal prevention. Often, they are used at a patient’s first 
contact with health services to help them recognise and 
clarify the nature of their drug problem, and commit to 
changing their behaviour. At a later stage, these interventions 
are used to support patients with their treatment. These 
interventions are also employed, sometimes in conjunction 
with pharmacological treatment, in the treatment of opioid-
related problems. They can help patients to maintain 
behavioural goals and they support treatment retention. 
Psychosocial interventions can also involve families and 
communities during the social reintegration phase of drug 
treatment.

Brief interventions are practices typically used to help people 
recognise their substance use problems. They aim to identify a 
real or potential substance use problem and motivate an 
individual to change their behaviour. They can be administered 
opportunistically or after screening. However, there is no 
standard definition of what constitutes ‘brief’. For example, in 
2003, the World Health Organization (WHO, 2003, p. 4) 
defined face-to-face brief interventions addressing substance 
use in the context of primary care as ranging ‘from 5 minutes 
of brief advice to 15–30 minutes of brief counselling’ and, in 
2012, as ‘a maximum of two sessions’ for drug users (WHO, 
2012, p. 1); in Australia in 2004, the Department of Health (1) 
defined brief interventions as those ‘lasting as little as 30 
seconds, or extending over a few sessions lasting 5–60 
minutes’; and the National Health Service in Scotland (2) 
defined brief interventions as ‘usually less than five minutes 
but certainly no more than twenty’.

Although there is consensus with regard to the main 
characteristics and purposes of brief interventions, there is 
not an internationally agreed definition. In the absence of a 
standard definition, this report uses an operational definition 
which characterises a brief intervention as an intervention 
delivered in a short time frame which:

n 

 is delivered to individuals or small groups and aims ‘not 
solely to prevent substance use, but also to delay initiation, 

(1)  http://www.health.gov.au/internet/publications/publishing.nsf/Content/
drugtreat-pubs-front9-fa-toc~drugtreat-pubs-front9-fa-secb~drugtreat-pubs-
front9-fa-secb-6~drugtreat-pubs-front9-fa-secb-6-1
(2)  http://www.nhsggc.org.uk/content/default.asp?page=s1733

n 

n 

n 

reduce its intensification or prevent escalation into 
problematic use‘ (3);
 does not provide treatment for substance use (e.g. opioid 
substitution/maintenance treatment, detoxification or 
psychosocial counselling), although one of the aims of 
some brief interventions may be to encourage recipients to 
consider treatment;
 does not usually target those who are substance 
dependent;
 may include advice and elements of motivational 
interviewing, such as empathy, open-ended questions, a 
non-directive approach and reflective listening, in an 
attempt to reduce ambivalence about substance use and 
possible treatment.

I  How the interventions work

Brief interventions use the collaborative conversation style of 
motivational interviewing to address problematic or risky drug 
use, but are delivered in a shorter time frame, typically ranging 
from 5 to 30 minutes. Personalised feedback is provided on a 
person’s substance use. This enables them to understand 
their use in relation to other people’s use. In this approach, the 
professional delivering the brief intervention asks for 
permission to talk about possible drug or alcohol use and help 
patients to position themselves on a scale of use level. 
Questions are asked about the benefits and harms of 
substance use in an attempt to elicit a motivation to change. 
When concluding a brief intervention, a plan for change and a 
follow-up are negotiated. There are a number of brief 
intervention models, but one of the most commonly used 
consists of five phases, known as the ‘5As’: ask, advise, 
assess, assist and arrange (Babor et al., 2007).

A study carried out in the United States has shown that this 
approach is used in many different settings, including in 
emergency departments, with primary care services and with 
services for the homeless, in order to address the problems 
that people have as a result of their substance use by 
encouraging them to reflect and consider making a change 
(Saitz et al., 2014). While brief interventions are often based 
on motivational interviewing techniques, the evidence to 
support their use is still developing and there is a need for 
further research (Yuma-Guerrero et al., 2012; Taggart et al., 
2013).

I  Motivational interviewing versus brief interventions

Motivational interviewing is a collaborative conversation style 
for strengthening a person’s motivation and commitment to 
change (Miller and Rollnick, 2012). It is used to help people 

(3)  http://www.emcdda.europa.eu/topics/prevention 

2 / 20

EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenesswith different types of substance problems. Frequently, 
individuals are not fully aware of their substance problems or 
they can be ambivalent about them. Motivational interviewing 
is often referred to as a conversation about change, and it is 
used to assist drug users to identify a need for change. It 
seeks to address individuals’ ambivalence about their drug 
problems, as this is considered the main barrier to change. It 
comprises five elements: (1) expressing empathy for patients; 
(2) helping patients to identify discrepancies between their 
behaviour and their goals; (3) avoiding arguments with 
patients about their motivations and behaviours; (4) going 
along with patients’ resistance to talk about certain issues; 
and (5) supporting patients’ sense of self-efficacy.

Motivational interviewing is used to promote change in many 
different situations and settings, including outpatient services 
and primary care services. It is used in prisons (Day et al., 
2013), by social services and in the workplace. Motivational 
interviewing can be provided by therapists, counsellors or 
other specifically trained professionals. It can be used to help 
someone make a decision, to start and follow a 
pharmacological treatment plan or as a stand-alone 
psychological treatment. Generally, however, motivational 
interviewing is undertaken in multiple sessions over a period 
of weeks and at follow-up points during a course of treatment. 
The benefits of this approach are supported by evidence, with 
a recent systematic review (Smedslund et al., 2011) of 59 
studies involving 13 342 participants concluding that it can 
reduce the extent of substance abuse compared with no 
intervention. Another systematic review focused on the 
effectiveness of motivational interviewing for tackling drug 
use problems among adolescents (Barnett et al., 2012); this 
review included 39 studies, of which 67 % reported 
statistically significant improvements in substance use 
outcomes.

While motivational interviewing uses specific tools, 
intervention protocols, fidelity criteria and training plus 
supervision of the providers, brief interventions comprise 
principles from different techniques, including motivational 
interviewing, but also advice and cognitive behavioural 
therapy.

A brief intervention that includes elements of motivational 
interviewing (or cognitive behavioural therapy) can be 

delivered in a wide range of settings by a wide range of 
healthcare and social care professionals who have been 
trained in the technique, including staff at schools, outreach 
workers and staff at youth clubs, homeless services, health 
centres, general practitioners’ surgeries, emergency 
departments, and drug and alcohol services, and by police, 
probation and prison officers. Brief interventions may be 
delivered to individuals or to small groups, and may also be 
self-administered. Delivery may be face-to-face, online or by 
telephone (including by text message).

I  Brief interventions in emergency departments

Brief interventions in emergency departments emerged from 
the need to counterbalance the significant impact of the 
harmful or hazardous use of drugs and alcohol on healthcare 
costs, as well as to provide an adequate intervention to 
non-treatment-seeking individuals (Bogenschutz et al., 2011).

Many commentators have pointed out that effective 
emergency department-based brief interventions that address 
substance use have the potential to have a large impact on 
public health, as:

n 

n 

n 

n 

 they offer a ‘window of opportunity’ in which to reach 
individuals with unrecognised and unmet substance use 
treatment needs who might otherwise never receive any 
form of assessment, referral or intervention (Longabaugh 
et al., 1995; Havard et al., 2012; Newton et al., 2013; 
Sanjuan et al., 2014; Ferri et al., 2015);
 they can rapidly achieve important objectives, such as 
detecting individuals with high-risk and dependent alcohol 
and drug use, making such individuals aware of their 
condition and facilitating access to specialty treatment, 
thus improving quality of care (Bernstein et al., 2009);
 emergency departments are recognised as a setting in 
which the use of drugs, and the harms associated with the 
use of drugs, including new psychoactive substances, 
could be monitored and addressed (e.g. UNODC, 2013; 
Helander et al., 2014; Wood et al., 2014);
 the brevity of the interventions means that the training of 
staff does not require a lot of investment, thus minimising 
the impact on healthcare budgets (Barrett et al., 2006; 
Havard et al., 2012; Drummond et al., 2014).

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessEmergency departments and acute drug toxicity: results from a multisite European project

The European Drug Emergencies Network (Euro-DEN) is a 

participating countries, the majority of which were related 

European Commission-funded project that brings together 

to the use of classical recreational drugs.

16 specialist centres in 10 countries (Denmark, Estonia, 

France, Germany, Ireland, Norway, Poland, Spain, 

Most of the cases (743; 57.6 %) involved the use of one 

Switzerland and the UK) in Europe to collect data on the 

drug; 357 (27.6 %) involved two drugs; 133 (10.3 %) involved 

prevalence of use of recreational drugs and new 

three drugs; and 57 cases (4.1 %) involved the use of four or 

psychoactive substances, and the associated acute harms.  

more drugs. Alcohol was co-ingested in 532 (41.2 %) cases 

Clinical toxicologists and poisons centres frequently report 

drugs were heroin (315 cases; 24.4 %), cocaine (228 cases; 

case series of acute recreational drug and new 

17.7 %), gamma-hydroxybutyrate (GHB)/gamma-

psychoactive substance toxicity; however, systematic data 

butyrolactone (GBL) (211 cases; 16.4 %), cannabis (205 

on this issue in Europe are limited.

cases; 15.9 %), amphetamine (175 cases, 13.6 %), MDMA 

and not recorded in 450 (34.9 %) cases. The most common 

The Euro-DEN project has developed a minimum dataset on 

mephedrone (60 cases, 4.7 %), unspecified benzodiazepine 

all acute recreational drug/new psychoactive substance 

(59 cases, 4.6 %) and methadone (56 cases, 4.3 %). There 

toxicity presentations to emergency departments in these 

were 126 presentations (9.8 %) involving the use of new 

(100 cases, 7.8 %), clonazepam (85 cases, 6.6 %), 

sentinel centres. 

psychoactive substances (UK, 94 cases; Poland, 18 cases; 

Germany, 10 cases; Spain, 2 cases; Norway, 1 case; 

Data from the first 4 months  (October 2013–January 2014) 

Switzerland, 1 case). 

of the 1-year data collection period showed that there were 

1 290 presentations with acute drug toxicity to emergency 

Source: Annual Meeting of the North American Congress of 

departments in 13 (81.2 %) of the 16 centres, in 8 of the 10 

Clinical Toxicology (NACCT) (2014)

I  Why this review?

The effectiveness of brief interventions with regard to alcohol 
misuse is well documented (see box on p. 5); however, there is 
less information in relation to brief interventions that address 
drug use. Moreover, the added value of brief interventions in 
emergency department settings has been extensively 
discussed, and several commentators have stressed the need 
for more research. For example:

The emergency department (ED) appears to be a 
particularly promising setting in which to identify and 
engage problematic drug users. Relatively high rates of 
psychoactive substance use disorders have been 
found in EDs, exceeding that found in primary care 
settings. This has led clinicians and researchers to 
argue for the development of more effective methods 
of screening and case finding, brief interventions, and 

referral to appropriate specialty treatment, as well as 
linkage between substance abuse services and general 
medical care, for individuals using illicit drugs who are 
seen in EDs and trauma centers.
(Bogenschutz et al., 2011, p. 417)

Further research is needed to determine if ED-based 
[alcohol] interventions can be successful for the 
reduction or elimination of other types of drug misuse.
(Youmans et al., 2010, p. 44)

The purpose of this review is to gather and assess the existing 
evidence on the effectiveness of using brief interventions in 
the context of substance use, in an emergency department 
setting, to identify individuals with drug problems, support 
behavioural change and improve referrals to specialised 
treatment centres.

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessBrief interventions for harmful alcohol use in primary care settings

There are numerous reviews, studies and commentaries on 

general practice (24 trials) or in emergency settings (five 

brief interventions for alcohol use, especially in primary care 

trials), and the meta-analysis showed that participants in 

settings; an example of such a brief intervention is shown in 

the intervention group had lower alcohol consumption than 

Figure 1. Primary care settings are, in fact, considered to be 

those in the control group after follow-ups of 1 year or more 

an ideal setting in which to conduct these interventions 

(mean difference: –38 g/week, 95 % CI –54 to –23 g/week). 

because it is reported that between 22 and 70 % of patients 

Interestingly, the authors also found that a longer period of 

use primary care facilities after an alcohol-related injury 

counselling had little additional benefit.

(e.g. D’Onofrio and Degutis, 2002; Patton, 2012; Wojnar and 

Jakubczyk, 2014).

However, as O’Donnell et al. (2014) suggest, there is still a 

lack of understanding about the  ‘active components’ of 

Overall, the available evidence points towards a positive 

such interventions, and caution is needed when planning a 

effect of brief interventions, especially with regard to 

wider roll-out. Indeed, the effectiveness of alcohol-related 

alcohol-related behavioural outcomes.

brief interventions is not overwhelmingly supported by the 

evidence from all sample populations and settings. For 

A recent Cochrane review assessed the effectiveness of 

example, studies have typically targeted mainly males and 

brief interventions in heavy alcohol users admitted to 

are not necessarily applicable to women; in addition, many 

hospital wards (McQueen et al., 2011). The analysis of 14 

do not take a long-term perspective or the findings may not 

randomised controlled trials and controlled clinical trials 

be generalisable if the focus of the study is on substances 

involving 4 041 individuals, mainly male adults (16 years or 

other than alcohol. Relevant recent reviews and 

older), indicates the potential benefits of brief interventions. 

commentaries include those by Carney and Myers (2012), 

Patients in brief intervention groups showed a greater 

Emmen et al. (2004), Foxcroft et al. (2014), Gates et al. 

reduction in alcohol consumption than those in control 

(2009), Heather (2011), Kaner et al. (2007), O’Donnell et al. 

groups at the 6-month and 9-month follow-ups, although 

(2013), McCormick et al. (2010), Smedslund et al. (2011) 

this was not maintained at one year. In addition, effects 

and Wachtel and Staniford (2010).

were evident in terms of the reduction in death rates after 6 

months (RR (*) 0.42, 95 % confidence interval (CI) 0.19 to 

0.94) and one year (RR 0.60, 95 % CI 0.40 to 0.91).

These results confirmed the findings of an earlier systematic 

review (Kaner et al., 2007) that evaluated brief interventions 

for alcohol users in primary care settings. A total of 29 

controlled trials from various countries were identified in 

(*)  RR refers to relative risk (or risk ratio). This compares the ratio of the risk of 
disease (or death) among people who are exposed to the risk factor, to the 
risk among people who are unexposed.  Alternatively, relative risk is defined 
as the ratio of the cumulative incidence rate among those exposed to the rate 
among those not exposed.  To estimate a relative risk, you need a cohort 
study, from which incidence can be calculated. An RR of 1.0 means that the 
two incidence rates are equal, so the factor has no effect. An RR of 2 would 
indicate that the exposed people are twice as likely to get the disease; an RR 
of 0.5 means they are half as likely, so the factor has protected them from the 
disease.

5 / 20

EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessFIGURE 1
How to conduct a brief intervention for alcohol disorders

Brief Intervention Training Notes  

Orient the Patient 

Identify yourself and explain your role on the trauma team.  
Get permission, explicit or implicit, from the patient to talk together for a few minutes.  
Explain the purpose of this discussion is to  

1) give them information about health risks that may be related to their drinking,  
2) get their opinions about their drinking, and  
3) discuss what, if anything, they want to change about their drinking.  

Using Binge Question

Feedback 

0Range: The number of drinks people have on a single occasion varies a great deal, from nothing to more than 10 drinks.  
0And we know that having too many drinks at one time can alter judgment and reaction times.  
0Normal: Most drinkers in the United States have fewer than 2 (♀) or 3 (♂) drinks on a single occasion.  
0Give Binge Questions results. "You drank more than that ___ times last month, increasing your risk for health problems."  
0 Elicit the patient’s reaction. "What do you make of that?"  

Using AUDIT 

0Range: AUDIT scores can range from 0 (non-drinkers) to 40 (probably physically dependent on alcohol).  
0AUDIT has been given to thousands of patients in medical settings, so you can compare your score with theirs.  
0Normal AUDIT scores are 0–7, which represent low-risk drinking.  About half of the U.S. population doesn't drink.  
0Give patients their AUDIT score. "Your score of ___ means you are (at risk or high risk), putting you in danger of health problems."  
00 Elicit the patient’s reaction. "What do you make of that?"  

Listen for Change Talk 

Goals  a) Listen for pro-change talk—the patient’s concerns, 
problem recognition, and downsides of drinking. 

b) Summarize the patient’s feelings both for and against 

current drinking behavior. 
"On the one hand . . .  On the other hand . . ." 

Methods 

"What role do you think alcohol played in your injury?" 

Explore pros and cons of drinking. "What do you like about 
drinking? What do you like less about drinking?" 

Is this patient interested in change? 

"On a scale of 0 to 10 [with 0 indicating not important, not confident 
or not ready], rate.  . ." 

". . . how important it is for you to change your drinking behavior?" 
". . . your level of readiness to change your drinking behavior?" 

"Why did you choose ___ [the # stated] and not a lower number?" 

If the patient is interested in changing, use these questions. 

"What would it take to raise that number?"  
"How confident are you that you can change your drinking behavior?"  

Reflect and summarize throughout. 

Options 

"Where does this leave you? Do you want to quit, cut down, or 
make no change?" 

You could:  

Manage your drinking,  
Eliminate drinking from your life,  
Never drink and drive,  

Continue  Usual drinking pattern, or  

Seek help.  

If appropriate, ask about a plan.  "How will you do that? Who will 
help you? What might get in the way?"

Close on Good Terms 

0Summarize  the  patient’s  statements  in  favor  of  change.  
0Emphasize the patient’s strengths.  
What agreement was reached?  

Always thank the patient for speaking with you. 

Source: Centers for Disease Control and Prevention (2014)

If You Give Advice 

When you have significant concerns or important information to 
impart, use this approach. It reduces the possibility of patient 
resistance. 

Ask: 
Advise: 

Ask: 

Ask permission to discuss your concerns. 
If permission is granted, give information or 
share your concerns. 
Ask for the patient’s reaction to your comments. 

April 2009: C Dunn, C Field, D Hungerford, S Shellenberger, J Macleod 

6 / 20

EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessI  Methods

We included systematic reviews or randomised controlled 
trials published in English between 2000 and 2014, focusing 
on brief interventions for substance use in emergency 
settings. The definition of brief intervention used was very 
broad (see Background) and substance use included the use 
of alcohol, tobacco or illicit drugs. All participants were 
included regardless of age, sex and nationality. The inclusion 
criteria did not specify any particular outcome and all 
outcomes were considered.

I  Search strategy

A literature search was conducted using a variety of search 
terms, including ‘emergency department/room/accident and 
emergency’, ‘brief intervention’, ‘drug’, ‘alcohol’, tobacco’, 
‘substance’, ‘systematic review’, ‘randomised (or ‘randomized’) 
random controlled/control trial’ and ‘randomised (or 
‘randomized’) controlled/control clinical trial’. The academic 
databases available via EBSCO (e.g. MEDLINE and PsycINFO) 
were searched. Searches were also conducted of the 
Cochrane Library, Drug and Alcohol Findings, the EMCDDA 
website and Medscape, and of reference lists from relevant 
published studies.

I  Data collection and analysis

The author screened all of the titles and abstracts identified 
through the search strategies. If an abstract suggested that a 
paper might be potentially relevant, the full text was read and 
the study was excluded if the focus was not on substance use, 
if the intervention was not a brief intervention and/or if the 
study was not conducted in an emergency setting. Studies 
that were not randomised controlled trials were also excluded.

Information was collated from systematic reviews according 
to the characteristics of the review, the substance(s) it 
focused on and the results/authors’ conclusions. Information 
from the randomised controlled trials was collated according 
to the country in which they were conducted, the 
characteristics of the trials, the substance(s) they focused on, 
the samples, and the measures used and their outcomes.

I  Results

aspects of three randomised controlled trials were reported in 
two publications each (Barrett et al., 2006, and Crawford et 
al., 2004; Daeppen et al., 2007, 2010; Magill et al., 2009; Monti 
et al., 2007), resulting in a total of 16 primary studies.

FIGURE 2
Flow-chart of included studies and subdivision by target 
substance

Included studies

Systematic reviews 
n=5

Randomised controled trials 
n=16

alcohol 
n=3

drugs 
n=0

alcohol 
and 
drugs 
n=2

alcohol 
n=10

drugs 
n=4

alcohol 
and 
drugs 
n=2

I  Systematic reviews

We included five systematic reviews, which analysed a total of 
78 studies. Three of the five systematic reviews focused solely 
on studies among young people, ‘youth’, college students and 
adolescents, while the rest included the general population.

All five were concerned with alcohol, three with alcohol alone 
and two with alcohol and drugs, although one of the latter 
group considered seven studies, of which six were concerned 
with alcohol alone.

To varying degrees, the five publications discussed the quality 
of the studies they reviewed, pointing out that the poor quality 
of some and the methodological variations among them 
meant that firm conclusions about the effectiveness of brief 
interventions in emergency departments could not be drawn.

I  Randomised controlled trials

We found publications using the search methods described in 
Methods; however, different aspects of three randomised 
controlled trials were reported in two publications each, 
resulting in a total of 16 studies and a total sample size of 
8 875 individuals.

After the results of the search were scrutinised to ensure that 
they fitted the criteria for inclusion, and those that did not 
were eliminated, five systematic reviews and 19 publications 
on randomised controlled trials and randomised controlled 
clinical trials remained (see Figure 2). However, different 

Ten of the randomised controlled trials were based in the 
United States, two in the United Kingdom, two in Australia, 
one in Poland and one in Switzerland. Thus, only 4 of the 16 
randomised controlled trials were delivered in European 

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenesscountries, of which three were in European Union Member 
States.

this lack of long term follow up. Perhaps longer follow up to 2 
years would demonstrate reductions in consequences’ 
(Woolard et al., 2013, p. 1737).

The majority of studies (n = 10) investigated alcohol-related 
cases. Ten focused on use defined as hazardous/risky/
harmful drinking, with one specifically targeting the 
combination of alcohol and peer violence, another targeting 
alcohol and risky driving, and a third examining alcohol and 
human immunodeficiency virus (HIV) risk behaviour. Four 
studies targeted only drugs-related cases, with three focusing 
on drug use (whether recent, in the last 3 months or in the last 
30 days), while one study included individuals with substance 
use disorders in general. Two studies targeted both alcohol 
and drug use. Three also looked into the cost-effectiveness of 
the brief intervention.

I  Heterogeneity

The analysis of the 16 trials revealed enormous variation in 
every aspect of the trials. The participants, study designs, 
types of interventions and outcome measures varied 
significantly among studies making comparison difficult, as 
outlined in the paragraphs below.

Samples

Individually, the size of the different studies varied from 45 to 
1 441 participants, and their ages ranged from 14 to over 66 
years. Four studies focused exclusively on young people aged 
25 years or under.

A lack of effectiveness was reported by one of the studies 
described here (Cunningham et al., 2012), but this was 
apparently because of the selection criteria used. Cunningham 
et al. (2012) reported on a brief intervention that had several 
aims, one of which was to reduce alcohol use. The intervention 
was ineffective at achieving this, but this might have been 
because of the low level of alcohol use (i.e. any alcohol use, even 
one drink) required for study inclusion and, as noted by recent 
reviews, positive effects of brief interventions are typically found 
only with higher than baseline consumption levels.

Follow-up periods and attrition rates

The follow-up periods of the trials reported here varied from 1 
to 12 months, and one brief intervention (concerned with 
changing attitudes) conducted only a single follow-up 
immediately after the intervention. Woolard et al. (2013) are 
among those who argue for longer follow-up periods as ‘One 
year follow up may be too short a time to detect small but 
important changes in negative consequences and injuries. 
One criticism of studies of BI [brief interventions] has been 

Of the 16 brief interventions analysed, seven included two 
follow-ups, five had one follow-up, one had three follow-ups 
and one had four follow-ups. Follow-ups were not part of the 
study design in two cases, and in the other case follow-up was 
ongoing at the time of publication and final results were not 
available. The brief interventions that conducted follow-ups 
used a variety of methods:

n 
n 
n 

n 
n 

n 

n 

 telephone (used by six brief interventions);
 telephone, email or mail (used by two brief interventions);
 self-administration using a computer (used by two brief 
interventions);
 face-to-face interview (used by two brief interventions);
 a combination of face-to-face interview and hair analysis 
(used by one brief intervention);
 a combination of telephone and face-to-face interview 
(used by one brief intervention);
 a combination of face-to-face questionnaire and scrutiny of 
records from hospitals, community health services and 
social services, and information from the police and courts 
(used by one brief intervention).

Attrition rates varied widely. At 12 months, the lowest rate was 
16 % and the highest was 69 %. Overall, the highest rate was 
69 % at 12 months and the lowest was 13 % at 3 months.

Attrition can bias the results of studies in which the 
effectiveness of an intervention is assessed. For example, in a 
publication that synthesised results from alcohol-related brief 
interventions delivered in emergency departments, WHO 
(2009) commented that ‘as many as 47 % of patients in the 
studies refused to participate. Refusal rates of this magnitude 
can introduce significant bias (e.g., only patients who have 
less severe problems or are motivated to change their drinking 
behaviour may agree to participate)’ (WHO, 2009, p. 166).

Interventions and comparisons

We observed that, after screening, trial participants that met 
inclusion criteria were randomised to a diverse range of 
interventions. Nine trials had three intervention arms, six trials 
had two and one trial had four. All participants were screened 
and/or their substance use was assessed, and most of the 
non-intervention groups received standard care, an 
information or referral leaflet, or feedback, which, in some 
cases, was tailored to the participant’s assessment results.

The brief interventions were delivered by a range of methods. 
Many included more than one method because they had more 
than one intervention condition and different methods were 

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessemployed for each intervention condition. The methods used 
were as follows:

n 

n 
n 
n 
n 
n 
n 

 face-to-face delivery of the intervention by a therapist, 
health worker, nurse or doctor, which ranged from a few 
minutes of advice to one or more 30- to 60-minute sessions 
that included elements of motivational interviewing;
 delivery by a therapist assisted by a computer;
 delivery by a computer;
 an advice leaflet;
 personalised feedback on screening results;
 mail;
 text messaging.

Most of the publications examined provided details of the 
training that the brief intervention delivery staff had received, 
and many used professionals that were already experienced in 
the technique. However, Daeppen et al. (2010) highlighted 
that, despite systematic training, there were important 
differences in counsellor performances with regard to eliciting 
change. These authors noted that ‘Counsellors who had 
superior MI [motivational interviewing] skills achieved better 
outcomes overall and maintained efficacy across all levels of 
patient ability to change, whereas counsellors with inferior MI 
skills were effective mostly with patients who had higher 
levels of ability to change’ (Daeppen et al., 2010, p. 612).

Several of the brief interventions that had more than one 
intervention condition used different staff for each condition. 
The information on brief intervention delivery staff was unclear 
in three of the publications on the 16 trials, but the delivery 
staff of the remaining 13 trials comprised:

n 
n 

n 
n 
n 

n 

n 
n 
n 

n 
n 

 trained research assistants (two trials);
 a computer only and therapists assisted by a computer 
(two trials);
 alcohol health workers (one trial);
 nurses (one trial);
 emergency department doctors and nurses, and drug and 
alcohol counsellors (one trial);
 members of the research team, emergency department 
staff and alcohol health workers (one trial);
 therapists with a Bachelor’s or Master’s degree (one trial);
 trained research assistants and nurse clinicians (one trial);
 trained interveners with a Master’s degree in the social 
work field or a related field (one trial);
 professional health educators (one trial);
 trained interveners with a PhD or Master’s degree in a 
discipline related to mental health (one trial).

Outcome measures

The majority of the studies (n = 11) focused on behavioural 
outcomes and substance use, and used self-reported 

measurements. Instruments varied among studies but the 
most commonly used were the Alcohol, Smoking and 
Substance Involvement Screening Test (ASSIST), the Alcohol 
Use Disorders Identification Test (AUDIT), a shortened version 
of the Addiction Severity Index (ASI-Lite), the Quick Drinking 
Assessment Interview (form 90-AQ), the Drinker Inventory of 
Consequences, the Short Index of Problems (DrInC, SIP) and 
the Timeline Followback (TLFB) method.

In five studies, the primary outcomes were the following: 
alcohol-related consequences and peer violence 
(Cunningham et al., 2012); attitudes and intentions with 
regard to drugs and HIV (Bonar et al., 2014); uptake of HIV/
hepatitis C virus (HCV) screening, and attitudes and beliefs 
towards HIV/HCV screening (Merchant et al., 2014); risky 
driving and alcohol use (Sommers et al., 2013); and 
attendance for substance use treatment (Tait et al., 2005).

I  Effects of the interventions

A summary of the effects of the interventions analysed, in 
both systematic reviews and experimental studies, is 
presented in Table 1.

Systematic reviews

One review (D’Onofrio and Degutis, 2002) concluded that 
emergency department-based screening and brief 
interventions were effective at reducing repeated visits to the 
emergency department. Nilsen et al. (2008) also suggested a 
positive effect of brief interventions on substance-related 
outcomes, albeit improvements were also observed in control 
groups.

The remaining three reviews stressed that the overall 
effectiveness of the studied interventions was inconclusive: 
Newton et al. (2013) reported that the brief interventions did 
not reduce alcohol use significantly more than other care; 
Yuma-Guerrero et al. (2012) observed that six of the seven 
studies that they reviewed showed positive effects on alcohol 
consumption and/or its consequences for all participants 
regardless of study condition; and Taggart et al. (2013) 
concluded that the seven studies they reviewed ‘showed 
promise but had variable success’.

Implicitly or explicitly, the review authors suggested the need 
for more research, development and testing of brief 
interventions in emergency departments, to establish their 
short- and long-term effectiveness among a variety of 
populations. Two issues are particularly significant in this 
context: variations in the study protocols, which make it 
difficult to compare different studies, and the poor quality of 
some of the studies reviewed. Yuma-Guerrero et al. (2012) 

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenesstherefore call ‘for future studies to have more consistent 
methodology (eg, outcome measures, inclusion criteria) so the 
results can support decisive conclusions and policy changes’ 
(Yuma-Guerrero et al., 2012, p. 6).

Randomised controlled trials/clinical trials

Overall, the heterogeneity among the 16 trials is clear 
(see Table 1). This makes comparisons difficult and hampers 
definitive conclusions about the effectiveness of brief 
interventions.

Six of the 16 trials (Monti et al., 2007; Walton et al., 2008; 
Magill et al., 2009; Cherpital et al., 2010; Havard et al., 2012; 
Suffoletto et al., 2012; Bonar et al., 2014) reported that the 
brief intervention had been effective, although Bonar et al. 
(2014) reported on an ongoing trial and had no data on 
follow-ups at the time of publication.

In two trials (Crawford et al., 2004; Barrett et al., 2006; 
Sommers et al., 2013), the brief intervention had been 
effective initially, but the effect had diminished by the 
12-month follow-up. Partial effectiveness, that is, measures of 
different outcomes that showed different degrees of 
effectiveness (including ineffectiveness), was reported by four 
trials (Tait et al., 2005; Daeppen et al., 2007, 2010; 
Cunningham et al., 2012; Woolard et al., 2013).

The ineffectiveness of a brief intervention was reported in four 
trials (Dent et al., 2008; Drummond et al., 2014; Merchant et 
al., 2014; Woodruff et al., 2014).

TABLE 1
Synthesis of trials

Brief intervention 
effectiveness

Effective

Effective but not 
sustained at 
follow-up

Trials Reference

6

2

Monti et al., 2007; Walton et al., 2008; 
Magill et al., 2009; Cherpital et al., 
2010; Havard et al., 2012; Suffoletto et 
al., 2012; Bonar et al., 2014

Crawford et al., 2004; Barrett et al., 
2006; Sommers et al., 2013

Partial effectiveness 4

Ineffective

4

Tait et al., 2005; Daeppen et al., 2007, 
2010; Cunningham et al., 2012; 
Woolard et al., 2013

Dent et al., 2008; Drummond et al., 
2014; Merchant et al., 2014; Woodruff 
et al., 2014

Many studies of brief interventions in emergency 
departments, including those discussed here, have reported 
improvements in their control groups, at least in the short 
term. Two explanations have been given for this. First, the 
implementation of brief interventions addressing substance 
use in emergency departments necessarily involves screening 

and/or assessment before randomisation to intervention 
conditions, and establishes the nature and extent of 
participants’ substance use. This, especially if the assessment 
is lengthy, may motivate participants to change their 
behaviour without further intervention because their attention 
will be drawn to their substance use, and, in many trials, 
feedback is given on the results, or the control groups are 
given an advice leaflet. Second, participants who perceive that 
the reason for their emergency department visit is related to 
their substance use may be motivated to change their 
substance-using behaviour.

Overall, the evidence suggests a positive trend with regard to 
the use of brief interventions in emergency settings to reduce 
substance use. There is also some tentative evidence pointing 
to the effectiveness of brief interventions at reducing 
substance-related harms and consequences, such as peer 
violence and return visits to the emergency department, as 
well as facilitating access to treatment. However, because the 
studies are very heterogeneous, it would be premature to 
make definitive statements about the effectiveness of brief 
interventions in emergency department settings.

I  Cost-effectiveness

Three of the randomised controlled trials reported here include 
data on the cost-effectiveness of brief interventions in 
emergency departments. Barrett et al. (2006), who reported an 
effective brief intervention, concluded that a face-to-face 
intervention with an alcohol health worker was cost-effective. 
Specifically, the randomised controlled trial did not show 
significant differences in costs or effectiveness at 12-month 
follow-up; however, a cost-effectiveness acceptability analysis 
revealed that there is at least a 65 % probability that a referral 
to an alcohol health worker is more cost-effective than the 
control treatment for all values that a decision-maker would be 
willing to pay for a unit of reduction in alcohol consumption. In 
addition, the brevity of the treatment, its low cost and its 
short-term effectiveness add to its case for selection. Similarly, 
Havard et al. (2012), in a study of a brief intervention that was 
reported to be effective, concluded that mailing personalised 
feedback represents a good economic investment, especially 
relative to face-to-face emergency department-based brief 
alcohol interventions: ‘the direct cost of providing mailed 
feedback was AUD 5.83 per patient, a fraction of the 
equivalent per-patient cost of USD 135.35 associated with the 
face-to-face intervention evaluated in the only comparable 
study conducted’ (Havard et al., 2012, p. 328).

However, Drummond et al. (2014), who reported that the brief 
intervention that they studied was ineffective, recommended, 
without providing detailed results of a cost-effectiveness analysis, 
that screening and feedback ‘is likely to be easier and less 
expensive to implement than more complex interventions’ (p. 9).

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessTABLE 2
Summary of the effects of the brief interventions

Authors and date

Effectiveness 
quick guide

Outcome(s)

Interventions

Results

Systematic reviews

D’Onofrio and 
Degutis (2002); 
n = 41

Nilsen et al. (2008); 
n = 14

+

+

ED visits

Alcohol use, risky 
drinking practices, 
harms/consequences 
and injury frequency

Screening and BI for 
alcohol problems in the 
EDs

Emergency care BAIs 
for injury patients

Newton et al. (2013); 
n = 9

–

Alcohol use, drug use 
and substance 
use-associated 
injuries

Brief ED interventions 
for youth who use 
alcohol and other drugs

Taggart et al. (2013); 
n = 7

?

Yuma-Guerrero et 
al. (2012); n = 7

?

Alcohol use and 
alcohol-related 
harms/consequences

ED interventions for 
college drinkers

Alcohol use and 
alcohol-related 
harms/consequences

Screening, BI and 
referral for alcohol use 
in adolescents

Randomised controlled trials/clinical trials

1.* Barrett et al. 
(2006); United 
Kingdom

* Crawford et al. 
(2004); United 
Kingdom

(+)

(+)

Alcohol use

Information leaflet and 
referral to an AHW who 
delivered a BI (lasting 
30–50 minutes); or an 
information leaflet only

2. Bonar et al. 
(2014); USA

+

Attitudes and 
intentions towards 
drugs and HIV

Intervener-delivered BI 
assisted by computer 
(30 minutes); 
30-minute 
computerised BI; or 
enhanced usual care, 
including a 3-minute 
oral review of health 
resource brochures

3. Cherpitel et al. 
(2010); Poland

+

Alcohol use and 
alcohol-related 
harms/consequences

SBIRT (Screening, Brief 
Intervention and 
Referral to Treatment)

In the six ED-based studies, the intervention led to fewer 
ED visits

Of the 12 studies that compared pre- and post-BI results, 
11 observed a significant effect of the BI on at least some 
of the outcomes: alcohol intake, risky drinking practices, 
alcohol-related negative consequences and injury 
frequency. BI patients achieved greater reductions than 
control group patients, although there was a tendency for 
the control group(s) to also show improvements. Moreover, 
five studies failed to show significant differences between 
the compared treatment conditions

Universal and targeted BIs did not significantly reduce 
alcohol use more than other care.
Clear benefits of using ED-based BIs to reduce alcohol and 
other drug use and associated injuries or high-risk 
behaviours remain inconclusive because of variation in the 
methods used to assess outcomes and poor study quality

Each study found reductions in alcohol intake patterns or 
reductions in alcohol-related harm in the intervention 
group, although some between-group differences were not 
statistically significant

Four of the seven studies demonstrated a significant 
intervention effect, but no single intervention reduced both 
alcohol consumption and alcohol-related consequences. 
Moreover, six of the seven studies reviewed showed 
positive alcohol consumption and/or consequence effects 
for all participants regardless of intervention condition

Six-month follow-up: statistically significantly lower levels 
of drinking in those referred to an AHW
Twelve-month follow-up: observably lower drinking levels in 
those referred to an AHW

Six-month follow-up: those referred to an AHW were 
consuming a mean of 59.7 units of alcohol per week 
compared with 83.1 units in the information leaflet only 
group. This difference is statistically significant
Twelve-month follow-up: those referred to an AHW were 
drinking 57.2 units per week compared with 70.8 units in 
the information-only group (not statistically significant) and 
had a mean of 0.5 fewer visits to the ED over the following 
12 months. Differences in quality of life were not found

Differences between baseline and immediately post-
intervention were measured:
n 

 compared with enhanced usual care, participants 
receiving the intervener-delivered BI showed significant 
improvements in confidence and intentions;
 computerised BI (delivered by computer alone) patients 
showed increased importance, readiness, confidence 
and help-seeking;
 both intervener-delivered BI (assisted by a computer) 
and computerised BI groups showed an 
increased likelihood of condom use with regular 
partners relative to the enhanced usual care group

n 

n 

Three-month follow-up: all three conditions showed a 
significant reduction in at-risk drinking and number of 
drinks per drinking day (Cherpitel et al., 2009)
Twelve-month follow-up: significant declines between 
baseline and 12 months in secondary outcomes of the 
RAPS4 test (four questions to test for alcohol dependence), 
in the number of drinking days per week and the maximum 
number of drinks on an occasion (only for the intervention 
condition) and in negative consequences for both the 
assessment and intervention conditions

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessAuthors and date

Effectiveness 
quick guide

4. Cunningham et al. 
(2012); USA

(+)

Outcome(s)

Interventions

Results

Alcohol-related 
harms/consequences 
and peer violence

A BI delivered by a 
computer alone or a BI 
delivered by a therapist 
assisted by a computer

–

Alcohol use

n 

n 

Six-month follow-up: significant reductions in alcohol-
related consequences reported for both BI conditions
Twelve-month follow-up:
n 

 the significant reductions in alcohol-related 
consequences reported in both BI groups at 6 months 
were not maintained;
 the BIs did not affect alcohol consumption: the BI 
delivered by computer alone group, the BI delivered by 
a therapist assisted by a computer group and the 
control group did not differ in alcohol-related variables;
 in comparison with the control group, the therapist-
delivered BI group showed significant reductions in 
peer violence

5.* Daeppen et al. 
(2010); Switzerland

+

Alcohol-related 
predictors of change

A BAI delivered by a 
trained research 
assistant; control group 
with screening and 
assessment; or control 
group with screening 
only

Twelve-month follow-up: the BAI had no influence on the 
main alcohol use outcome. Across all three groups (BAI, 
control group with screening and assessment, control 
group with screening only), there were similar proportions 
of low-risk drinkers; there were similar reductions in drinking 
frequency, quantity, binge drinking frequency and scores; 
and there were similar numbers of days hospitalised and 
numbers of medical consults

* Daeppen et al. 
(2007); Switzerland

–

Alcohol use

6. Dent et al. (2008); 
Australia

–

Alcohol use

7. Drummond et al. 
(2014); United 
Kingdom

–

AUDIT status

8. Havard et al. 
(2012); Australia

+

Alcohol use

Twelve-month follow-up: data show an impact resulting 
from the ‘progression of change’ talk during the course of 
the intervention. Communication characteristics of 
counsellors (i.e. MI-consistent behaviours) and patients 
(e.g. an expression of an ability to change) during the 
intervention predicted changes in alcohol consumption 12 
months later
Despite systematic training, important differences in 
counsellor performance were highlighted as counsellors 
with superior MI skills achieved better outcomes overall 
and maintained efficacy across all levels of patients’ ability 
to change, whereas counsellors with inferior MI skills were 
effective mostly only with patients who had higher levels of 
ability to change

Three-month follow-up: overall, maximum daily alcohol 
consumption decreased from a median of 13.5 standard 
drinks at enrolment to 9.25 drinks at 3 months, and 
participants that received standard care reported fewer 
drinks than those randomised to MI

Six- and 12-month follow-ups: there was no difference 
between intervention conditions for AUDIT status or any 
other outcome measures. At month 6, the odds ratio of 
being AUDIT negative for the brief advice (5 minutes of 
advice) group compared with the patient information leaflet 
group was 1:103. The odds ratio for the brief lifestyle 
counselling group (20 minutes of lifestyle counselling by an 
AHW) compared with the patient information leaflet group 
was 1:247

Mailed personalised feedback achieved a statistically 
significant reduction in the quantity/frequency of alcohol 
consumption relative to screening alone.
However, the effect was limited to patients who reported 
alcohol consumption in the 6 hours prior to the onset of the 
condition that led to the ED visit or who perceived that 
alcohol was a contributing factor in the condition for which 
they presented

No counselling 
(standard care); 
same-day BI by an 
emergency nurse or 
doctor; or motivational 
intervention within 1 
week by off-site drug 
and alcohol counsellors 
(by MI)

A patient information 
leaflet; 5 minutes of 
brief advice; or referral 
to an AHW who 
provided 20 minutes of 
brief lifestyle 
counselling

The intervention group 
received personalised 
feedback via mail 
regarding their alcohol 
consumption; the 
control group received 
no feedback

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessAuthors and date

9.* Magill et al. 
(2009); USA

Effectiveness 
quick guide

Outcome(s)

Interventions

Results

+

Herbal cannabis use

A one-session 
motivational 
intervention that 
included personalised 
feedback; or a 
personalised feedback 
report only

Six-month follow-up: herbal cannabis use declined from 
baseline for both groups (a one-session motivational 
intervention or only a personalised feedback report)
Twelve-month follow-up: only motivational intervention 
participants continued to reduce their use of herbal 
cannabis. Reductions in the number of days of use of 
herbal cannabis with alcohol appeared to be primarily a 
function of decreased alcohol use

* Monti et al. (2007); 
USA

+

Alcohol use

10. Merchant et al. 
(2014); USA

–

Uptake of HIV/HCV 
test screening and 
attitudes and beliefs 
towards HIV/HCV 
screening

11. Sommers et al. 
(2013); USA

(+)

Risky driving and 
alcohol use

12. Suffoletto et al. 
(2012); USA

+

Alcohol use

13. Walton et al. 
(2008); USA

+

Alcohol use and 
alcohol-related 
predictors of change

A self-administered 
HIV/HCV risk 
assessment alone 
(control arm), followed 
by a post-assessment 
questionnaire; or the 
assessment plus a BI 
about drug misuse and 
screening for HIV/HCV 
(intervention arm), 
followed by a post-
intervention 
questionnaire

BI group (assessed at 
baseline and received 
the BI); contact control 
group (assessed at 
baseline but received 
no intervention); or 
no-contact control 
group (not assessed at 
baseline, received no 
intervention)

Weekly text-messaging 
feedback with goal 
setting (intervention); 
weekly text-messaging 
drinking assessments 
without feedback 
(assessment); or 
control (no intervention)

Advice and tailored 
booklet; advice and 
generic booklet; no 
advice and tailored 
booklet; or no advice 
and generic booklet

Six-month follow-up: motivational intervention participants 
consumed alcohol on fewer days, had fewer heavy drinking 
days and consumed fewer drinks per week in the month 
prior to follow-up than feedback-only patients
Twelve-month follow-up: the effects at the 6-month 
follow-up were maintained. Twice as many motivational 
intervention participants as feedback-only participants had 
reliably reduced their volume of alcohol consumption

Uptake of combined rapid HIV/HCV screening was nearly 
identical for each study arm.
There were no differences between the BI and control study 
arms with regard to changes in beliefs about the value of 
combined HIV/HCV screening, self-perception of HIV/HCV 
risk and opinions about HIV/HCV screening, post- vs. 
pre-HIV/HCV risk assessment (with or without the BI)

Six-, 9- and 12-month follow-ups: risky driving and 
hazardous drinking were significantly lower in the BI group 
than in the contact control group with no intervention, at 6 
and at 9 months, but not at 12 months

Three-month follow-up: the intervention group (weekly 
feedback with goal setting) were reported to have fewer 
heavy drinking days and fewer drinks per drinking day than 
the other groups.
The assessment group increased their drinking over the 
course of the study

The attribution of injury to alcohol-related factors was 
found to be an important moderator of change, and 
highlighting the alcohol–injury connection in brief 
ED-based alcohol interventions may augment their 
effectiveness.
Twelve-month follow-up: overall, average weekly 
consumption, frequency of heavy drinking and negative 
consequences decreased over time. Compared with those 
who attributed their injury to alcohol but did not receive 
advice, those who attributed their injury to alcohol and did 
receive advice had significantly lower levels of average 
weekly alcohol consumption and less frequent heavy 
drinking sessions, while this was not significantly 
associated with a reduction in negative consequences
Participants who reported higher levels of self-efficacy (i.e. 
those who were confident that they could control their 
drinking) had lower weekly consumption levels and fewer 
negative consequences, whereas those with higher 
readiness to change had greater weekly consumption 
levels and more negative consequences

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EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessAuthors and date

Effectiveness 
quick guide

Outcome(s)

Interventions

Results

14. Woodruff et al. 
(2014); USA

–

Drug use

The Life Shift BI group; 
or an attention placebo 
control group focusing 
on driving and traffic 
safety (Shift Gears 
group)

15. Woolard et al. 
(2013); USA

16. Tait et al. (2005); 
Australia

+

–

+

–

+

Alcohol and herbal 
cannabis use

Two sessions of BI; or 
standard care

Alcohol and herbal 
cannabis harms/
consequences

Attendance for 
substance use 
treatment

Alcohol and drug use

BI enhanced by a 
consistent support 
person; or standard 
care

ED visits

Six-month follow-up: there were no significant differences 
in self-reported abstinence for the Life Shift (12.5 %) or the 
Shift Gears group (12 %). However, hair analyses showed 
that the abstinence rate was only 7 % for the Life Shift 
group and 2 % for the Shift Gears group.
There was no significant difference between the two 
groups in the short Addiction Severity Index (ASI-Lite) drug 
use composite scores

Twelve-month follow-up: measures of binge drinking and 
combined herbal cannabis and alcohol use significantly 
decreased for the BI group compared with the standard 
care group. There were no differences in negative 
consequences or injuries between the two groups.
The BI appears to offer a mechanism to reduce risky 
alcohol and herbal cannabis use among ED patients, but 
the expected reductions in the negative consequences of 
use (such as injury) were not found at 12 months

Twelve-month follow-up: significantly more of the 
intervention group participants had attended a treatment 
agency than the usual care group participants, despite the 
fact that the actual attendance of the intervention group 
was poor (25 %). The intervention group also had a lower 
proportion of substance-related ED presentations. 
Irrespective of group, lower levels of substance use were 
reported, with both the usual care and the intervention 
groups showing improvements in psychological wellbeing

Notes:
Studies indicated with an asterisk report data on different aspects of the same trials.
Effectiveness quick guide legend:

+  Significant effect on primary outcome.
(+)  Significant initial effect on primary outcome but not sustained at follow-up.
–  No significant effect on primary outcome.
? 

Inconclusive results.

AHW, alcohol health worker; AUDIT, Alcohol Use Disorders Identification Test; BAI, brief alcohol intervention; BI, brief intervention; ED, emergency department; MI, 
motivational interviewing; RAPS4, Remorse, Amnesia, Performance and Starter drinking behaviour questionnaire.

I  Discussion

This review aimed to explore whether or not brief interventions 
in emergency departments are helpful for identifying 
individuals with drug problems, for supporting behavioural 
change and for increasing referrals to specialised treatment 
centres.

The literature research did not identify a sufficient number of 
studies that had included people with drug-related problems, 
as only two reviews included patients with drug problems, only 
four studies were on drug users, and only two studies were on 
alcohol and drug users. Nevertheless, studies conducted in 
emergency departments show that drugs and alcohol are often 
used in combination, and it is possible to assume that people 
with drug-related problems can benefit from brief interventions 
that target, at least, their alcohol intake.

Behavioural changes resulting from brief interventions, in 
terms of a reduction in substance use, seem to be supported 
by the studies, at least in the short term, particularly for 
people with alcohol problems. However, increases in referrals 
to treatment centres and in the uptake of treatments were 
measured and reported by only two studies.

Cost-effectiveness analysis was conducted in only three trials, 
with positive outcomes in two of these.

The potential benefits of brief interventions for drug users 
need to be further studied, yet the feasibility of such 
interventions delivered by emergency department personnel, 
the absence of reported adverse effects and the potential 
cost-effectiveness suggest that brief interventions could be 
considered as part of the training for emergency department 
healthcare professionals.

Several commentators (e.g. D’Onofrio and Degutis, 
2004/2005; Parkes et al., 2011) and many of the reviews and 
trials cited in this report highlight that there are a number of 
challenges with regard to implementing brief interventions in 
emergency departments. In summary, these include:

n 

n 

n 

 constraints on staff time and the perceived need to focus 
on the acute episode and the more immediate needs of the 
patient;
 ethical issues, especially in the case of young people for 
whom permission may be required from a parent or carer in 
order for them to participate in a brief intervention;
 potential trial participants’ refusal to participate for a 
variety of reasons, including not being able to participate 

14 / 20

EMCDDA PAPERS I Emergency department-based brief interventions for individuals with substance-related problems: a review of effectivenessbecause they are in pain or are too ill or, especially in the 
case of young people, because they do not want to reveal 
their substance use to their parents or others;
 concerns about insurance, because some insurance 
companies do not cover an injury caused by being under 
the influence of drugs or alcohol;
 lack of confidence in emergency department staff with 
regard to assisting in the implementation of brief 
interventions, possibly as a result of inadequate training.

n 

n 

I  Conclusions

Suggestions for future directions, in terms of the effectiveness 
of brief interventions in emergency departments, were made 
by the majority of the authors of the systematic reviews and 
reports examined in this report.

The difficulty in reaching an overall conclusion on the 
effectiveness of brief interventions in emergency 
departments, because of the heterogeneity of the studies, 
was discussed earlier, and this issue was commented upon by 
the systematic review authors and by the majority of authors 
who reported on the trials. Moreover, the majority of the trials 
focused on alcohol: only four of the 16 were concerned with 
drugs only, and two were concerned with drugs and alcohol. 
The relative lack of brief interventions in emergency 
departments specifically targeting drug use means that the 
effectiveness of such interventions cannot be conclusively 
established (e.g. Bogenschutz et al., 2011).

The authors of the systematic reviews discussed here 
recommended more research, development and testing of 
brief interventions in emergency departments, to establish 
their effectiveness among a variety of populations. This is 
echoed by the authors of the trial publications, although their 

recommendations for future development tend to concentrate 
on only the specific issues and brief interventions that they 
have studied. Further high-quality studies examining the 
relative effectiveness of brief interventions for substance use 
and other problem behaviours need to be conducted across 
varying populations. In addition, future studies should 
investigate the mediators of treatment outcomes, such as 
setting, context, method of delivery and level of staff training.

Many publications on emergency department-based brief 
interventions stress that the context offers an important 
‘window of opportunity’ to provide services to those with 
substance use problems who might otherwise never receive 
any form of assessment, referral or intervention. Moreover, 
such interventions can rapidly achieve important objectives, 
such as detecting individuals with high-risk and dependent 
alcohol and drug use, making such individuals aware of their 
condition and facilitating access to specialty treatment, thus 
improving quality of care. Finally, because of the brevity of this 
type of intervention, staff training does not require a lot of 
investment and, thus, any impacts on healthcare budgets will 
be minimised.

The results of this review show that there are potential 
benefits of brief interventions, especially in relation to 
behavioural outcomes, but a definitive statement about ‘what 
works’ cannot be made, as the results of the trials reported 
here may not be generalisable to other age groups, to samples 
with different levels of substance use or, given the focus of 
most of the studies on alcohol, to those using illicit drugs.

However, by taking a decision-making approach to the 
analysis, the feasibility of brief interventions delivered by 
emergency department personnel, the absence of reported 
adverse effects and the potential cost-effectiveness suggest 
that brief interventions could be considered as part of the 
training for emergency department healthcare professionals.

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I  Acknowledgements

The report was written by Jane Fountain.

EMCDDA project team: Marica Ferri and Alessandra Bo.

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction is the hub of drug-related information in 
Europe. Its mission is to provide the European Union and its Member States with ‘factual, objective, 
reliable and comparable information’ on drugs and drug addiction and their consequences. Established in 
1993, it opened its doors in Lisbon in 1995, and is one of the European Union’s decentralised agencies. 
The Centre offers policymakers the evidence base they need for drawing up drug laws and strategies. It 
also helps professionals and researchers pinpoint best practice and new areas for analysis.

Related publications

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Luxembourg: Publications Office of the European Union
doi:10.2810/80446 I ISBN 978-92-9168-836-4

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