Wednesday, February 21, 2007

To: "Academic and Scholarly Discussion of Addiction Related Topics." <>
From: SteveMDFP -at- gmail -dot- com
Subject: Re: Brief Intervention Insufficient for Medical Inpatients With Unhealthy Alcohol Use

To Fred and the List:

In my mind, the most interesting question about Brief Intervention (BI) is why it works. From a perspective borne of counseling work, it doesn't make any sense to expect significant behavior change from something that lasts only a few minutes. Where's the quality of relationship that's been proven to facilitate such change? How could there possibly be the development of therapeutic rapport, empathy, or even the conveyance of an understanding of what the problematic behavior is, exactly? Doesn't make sense.

Then I went to see a doctor myself for a minor chronic condition I'd been neglecting. I got appropriately scolded and given very directive, but appropriate, instructions. It had a significant psychological impact, somehow, and I found myself doing better at what I'd already known I should have been doing all along.

Did this behavior change depend on empathy? Nope. A deep understanding of the problematic behavior? No. It derived from being the explicit instructions of a trusted authority figure.

Our species is a social animal. That doesn't mean only that we like being around other people, to a variable degree. It also means, I think, that our brains are "hard-wired" to carry out specific social functions. One of those functions is to "follow the herd." We tend to adjust our behavior to fit in with the behavior of those around us whom we identify with.. This can be in dress, speech, mannerisms, and it happens with almost no conscious thought or deliberation.. Look at any gang or cult to see the power of this effect. I suspect group therapy, and maybe even individual therapy, work in part from this "drive to conformity."

I think BI taps into a different facet of being a social species. I think we're "hard-wired" also to dutifully follow the orders of recognized authority. History and social psychiatry provide an abundance of examples of people blindly following authority, despite knowing the orders are wrong or stupid. We do it anyway.

I wonder if BI works less well for inpatients because the trappings of the interaction undermine the perceived authority of the clinician. In a medical office visit, the experience has some similarity to having an audience with the King. You're kept waiting, attended to by a sequence of underlings, and then brought into his chamber. In contrast, in a hospital, the clinician is just another of a string of more or less anonymous visits. Also, the clinician is lowering himself to come to the client, not the other way around. Who would follow the orders of a king like that?

Food for thought.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

On 2/21/07, Fred Rotgers, Psy.D., ABPP <> wrote:

The problem here is that the target of the intervention was wrong! I ran
such a program for a number of years at Rutgers, where our goal was to
stimulate thinking about change, not actual change itself. These
interventions are opportunistic ones done with people who have little
thought of changing their drinking until the clinician approaches them.
It is grossly unrealistic to expect that a motivational intervention
(the content of which, I suspect, did NOT include formal feedback about
medical condition and its association with drinking, although this press
article does not specify that). In addition, this was very sloppy
research, and its conclusions are certainly open to question, on that
basis alone!


Frederick Rotgers, Psy.D.,ABPP, Associate Professor of Psychology
Department of Psychology
Philadelphia College of Osteopathic Medicine
4190 City Avenue
Philadelphia, PA 19131-1693
Phone: 215-871-6457
Fax: 215-871-6458

"Harm reduction is keeping them alive until the miracle happens" Sarz
Maxwell, MD, 5/7/06

To view the article with Web enhancements, go to:

This activity is supported by funding from WebMD.

Medscape Medical News
Brief Intervention Insufficient for Medical Inpatients With Unhealthy Alcohol Use CME

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: February 12, 2007; Valid for credit through February 12, 2008
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
Physicians should only claim credit commensurate with the extent of their participation in the activity.

February 12, 2007 — In a group of medical inpatients defined as risky alcohol drinkers, a 30-minute intervention was not effective, according to the results of a randomized controlled trial reported in the February 6 issue of the Annals of Internal Medicine.

"The efficacy of brief intervention in reducing alcohol consumption is well established for selected outpatients but not for medical inpatients," write Richard Saitz, MD, MPH, of the Boston Medical Center and Boston University in Boston, Massachusetts, and colleagues. "The unmet need for alcohol screening and intervention and opportunities for implementation underscore the importance of determining the efficacy of brief intervention in medical inpatients with unhealthy alcohol use. In addition, evaluating its effectiveness and practicality in real-world settings is critical to help clinicians make informed decisions when treating their patients."

On the medical service of an urban hospital, 341 medical inpatients who were drinking risky amounts of alcohol were randomized to receive a 30-minute session of motivational counseling given by trained counselors during hospitalization (n = 172) or to usual care (n = 169). Risky amounts of alcohol drinking were defined as more than 14 drinks per week or 5 or more drinks per occasion for men and more than 11 drinks per week or 4 or more drinks per occasion for women and persons 66 years or older. Of the 341 patients, 77% had alcohol dependence as defined by the Composite International Diagnostic Interview Alcohol Module.

Self-reported primary outcomes were receipt of assistance with alcohol misuse, such as specialty treatment of alcohol disorders, by 3 months in dependent drinkers and change in the mean number of drinks per day from enrollment to 12 months in all patients.

In alcohol-dependent patients, the intervention was not significantly associated with receipt of alcohol assistance by 3 months (adjusted proportions receiving assistance, 49% for the intervention group and 44% for the control group; intervention-control difference, 5%; 95% confidence interval [CI], -8% to 19%). Furthermore, the intervention was not significantly associated with drinks per day at 12 months among all patients (adjusted mean decreases, 1.5 for patients who received the intervention and 3.1 for patients who received usual care; adjusted mean group difference, -1.5; 95% CI, -3.7 to 0.6). Statistical models predicting drinks per day revealed no significant interaction between the intervention and alcohol dependence (P = .24).

Study limitations include baseline imbalances between randomized groups, 10% of patients lost to follow-up, lack of blinding of research associates and patients, primary outcomes were self-reported, change in screening criteria early in the study, and patients who received usual care were assessed and advised that they could discuss their drinking with their clinicians.

"The high prevalence of unhealthy alcohol use among medical inpatients has important implications for acute and long-term patient care," the authors conclude. "As a matter of policy, efforts focused on screening and brief intervention in hospitals should be directed elsewhere, possibly toward more intensive interventions, follow-up care, or on subgroups of patients who are more likely to benefit. Additional research must identify the most effective interventions to address unhealthy alcohol use, particularly dependence, among hospitalized patients."

The National Institute on Alcohol Abuse and Alcoholism and the National Center for Research supported this study. The authors have disclosed various financial relationships with Fusion Medical Education and/or the National Institute on Alcohol Abuse and Alcoholism.

In an accompanying editorial, Patrick G. O'Connor, MD, MPH, of the Yale University School of Medicine in New Haven, Connecticut, discusses current recommendations from the National Institute on Alcohol Abuse and Alcoholism for identifying patients with problem drinking and treating them individually according to their pattern of alcohol use.

"What should clinicians do when one of their inpatients is a problem drinker?" Dr. O'Connor writes. "The key principle is to link inpatient treatment in a continuous manner to ongoing outpatient treatment — either brief interventions for nondependent drinkers or more specialized treatment for patients with alcohol dependence. Medical hospitalization can be a hook with which to engage the problem drinker."

Dr. O'Connor has disclosed no relevant financial relationships.

Ann Intern Med. 2007;146:167-176, 223-225.

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