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Brief Intervention for Medical Inpatients with Unhealthy Alcohol Use: A Randomized, Controlled Trial

Richard Saitz, MD, MPH; Tibor P. Palfai, PhD; Debbie M. Cheng, ScD; Nicholas J. Horton, ScD; Naomi Freedner, MPH; Kim Dukes, PhD; Kevin L. Kraemer, MD, MSc; Mark S. Roberts, MD, MPP; Rosanne T. Guerriero, MPH; and Jeffrey H. Samet, MD, MA, MPH
[+] Article and Author Information

From Boston Medical Center and Boston University, Boston, Massachusetts; Smith College, Northampton, Massachusetts; DM-STAT, Malden, Massachusetts; and University of Pittsburgh, Pittsburgh, Pennsylvania.


ClinicalTrials.gov Identifier: NCT00183105.

Acknowledgments: The authors thank the staff and patients of the medical inpatient service and CARE Unit research associates at Boston Medical Center; the staff and house staff of the Boston University Internal Medicine Residency Training Program; and Karen Sullivan, Nicole Tibbetts, Alison Pedley, and other data management staff at DM-STAT, Malden, Massachusetts.

Grant Support: This study was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA RO1 12617) and a General Clinical Research Center grant from the National Center for Research Resources (M01 RR00533).

Potential Financial Conflicts of Interest: Honoraria: R. Saitz (Fusion Medical Education). All authors have received grant support from the National Institute on Alcohol Abuse and Alcoholism.

Requests for Single Reprints: Richard Saitz, MD, MPH, Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118; e-mail, rsaitz@bu.edu.

Current Author Addresses: Drs. Saitz, Chang, and Samet and Ms. Guerriero: Boston Medical Center, 91 East Concord Street, Suite 200, Boston, MA 02118.

Dr. Palfai: Psychology Department, Boston University, 64 Cummington Street, Boston, MA 02215.

Dr. Horton: Department of Mathematics, Smith College, 44 College Lane, Northampton, MA 01063.

Ms. Freedner: ORC Macro, 126 College Street, Burlington, VT 05401.

Dr. Dukes: DM-STAT, Inc., One Salem Street, Suite 300, Malden, MA 02148.

Dr. Kraemer, MD: University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213

Dr. Roberts: University of Pittsburgh School of Medicine, 200 Meyran Street, Suite 200, Pittsburgh, PA 15213.

Author Contributions: Conception and design: R. Saitz, T.P. Palfai, D.M. Cheng, K. Dukes, M.S. Roberts, J.H. Samet.

Analysis and interpretation of the data: R. Saitz, T.P. Palfai, D.M. Cheng, N.J. Horton, N. Freedner, K. Dukes, K.L. Kraemer, M.S. Roberts, J.H. Samet.

Drafting of the article: R. Saitz, T.P. Palfai, D.M. Cheng, N.J. Horton, N. Freedner, K.L. Kraemer, R.T. Guerriero.

Critical revision of the article for important intellectual content: R. Saitz, T.P. Palfai, D.M. Cheng, N. Freedner, K.L. Kraemer, M.S. Roberts, R.T. Guerriero, J.H. Samet.

Final approval of the article: R. Saitz, T.P. Palfai, D.M. Cheng, N. Freedner, N.J. Horton, K. Dukes, K.L. Kraemer, M.S. Roberts, R.T. Guerriero, J.H. Samet.

Provision of study materials or patients: R. Saitz.

Statistical expertise: D.M. Cheng, N.J. Horton, K. Dukes.

Obtaining of funding: R. Saitz.

Administrative, technical, or logistic support: R. Saitz, N. Freedner, R.T. Guerriero.

Collection and assembly of data: R. Saitz, N. Freedner, K. Dukes.


Ann Intern Med. 2007;146(3):167-176. doi:10.7326/0003-4819-146-3-200702060-00005
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Research associates approached 7824 persons (10 273 admissions) (Figure). Of 5813 patients who were screened, 986 (17%) reported drinking risky amounts of alcohol in the past month; 341 of these patients enrolled in the study. According to screening data, these persons were significantly more likely to be black (45% vs. 31%) and to drink greater amounts (median, 24 vs. 18 drinks/wk) than were the 183 eligible patients who declined enrollment.

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Figure.
Study flow diagram.

Participants who dropped out at 3 months were permanently lost to follow-up. Participants who could not be contacted at 3 months may have been contacted at 12 months. MMSE = Mini-Mental State Examination. *During the first 7 months of the study, 22% of the 5813 total screened participants were screened; 19% of those screened during this time were drinking risky amounts. During the remainder of the study (when we changed screening criteria and screened 78% of the 5813), 17% were drinking risky amounts. †Analyses for assistance at 3 months included only participants with alcohol dependence; at 3 months, 112 persons in the control group and 98 persons in the intervention group had alcohol dependence. All other analyses included all randomly assigned participants with available data.

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Brief Intervention Effective for Inpatients Considering Change
Posted on March 5, 2007
Lisa J. Merlo
University of Florida
Conflict of Interest: None Declared

Saitz et al. described null findings for their "Brief Intervention for Medical Inpatients with Unhealthy Alcohol Use" (February 6, 2007 issue), concluding that brief intervention "is inadequate for medical inpatients with unhealthy alcohol use" (p. 174). We would like to suggest an alternative interpretation of their results.

The authors reported that less than 35% of eligible patients agreed to participate in their study. Thus, the sample may have been biased in that it was likely comprised of individuals amenable to discussing their alcohol consumption. Given that addiction is marked by denial and that problem recognition is typically viewed as a first step to recovery, it seems unlikely that this sample is representative of the population of alcohol abusing hospital inpatients as a whole, many of whom reportedly do not view their drinking as problematic. Rather, it may be that the sample consisted primarily of individuals in the contemplation or preparation stages of change, meaning that they were already thinking about or preparing to make a change in their drinking (though this information was not reported by the authors).

Assessment and feedback, as well as offering the patient assistance (if desired) are considered key components of brief motivational interventions. Thus, as the authors discussed, it is possible that the extended assessment and feedback sessions that the control group received served as an adequate intervention. This assumption is supported by the study finding that almost half of the control sample sought treatment for their alcohol addiction in the months following their hospitalization. The surprising nature of these results is highlighted by the authors' own a priori hypothesis that only 4% of the participants in the control group would seek help. Rather than viewing the brief intervention as "inadequate," perhaps it would be more appropriate to view the inpatient assessment and feedback as the single most effective brief intervention for patients who are already considering making a change. For some, it may be a tipping point--enough to "tip the balance" toward action.

It would be worthwhile to examine the effectiveness of the brief motivational intervention among patients in trauma and emergency rooms, and addiction or psychiatric hospital inpatients who are not interested in making a change (i.e., individuals who are in the pre-contemplation stage). Brief motivational interventions are often successful in helping individuals move from pre-contemplation to contemplation or preparation, which may make these patients more receptive to offers for assistance.

Lisa J. Merlo, Ph.D. Research Assistant Professor Department of Psychiatry Divisions of Addiction Medicine and Child & Adolescent Psychiatry University of Florida

Dheeraj Kumar, M.D. Medical Director Hospitalist Section Clinical Assistant Professor Division of Internal Medicine Department of Medicine University of Florida

Mark S. Gold, M.D. Distinguished Professor & Chief McKnight Brain Institute Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health & Family Medicine Division of Addiction Medicine University of Florida

Conflict of Interest:

None declared

Old wine in new skins: brief interventions ineffective for alcohol dependent individuals
Posted on March 19, 2007
Gallus Bischof
University of Luebeck, Department of Psychiatry and Psychotherapy
Conflict of Interest: None Declared

The article "Brief intervention for medical inpatients with unhealthy alcohol use" by Richard Saitz and Colleagues concludes that "brief intervention (BI) is inadequate for medical inpatients with unhealthy alcohol use". We fear that their main finding is old wine in new skins: that BI is ineffective with alcohol dependent individuals. As discussed by the authors, a central issue deals with the representativity of their sample. Compared to the at-risk drinkers who declined study participation, the 35% of at-risk drinkers enrolled in the intervention study tended to report higher values on the AUDIT, and reported a significantly higher number of drinks per drinking occasion and per week. This indicates a sample bias towards individuals with more severe problems for whom BIs are not effective in outpatient settings either (1). In addition, failure to identify intervention effects in non-dependent inpatients in the present study does not necessarily mean that the intervention was ineffective. It may also reflect problems of statistical power as data was based on 80 at-risk drinkers without alcohol dependence only. Since BIs are assumed to produce small to medium effects (2), it is very unlikely to detect differences between the Control and the Intervention group in this study. Since most studies on BI in general hospital settings did not systematically diagnose and exclude alcohol dependent individuals (3), more research using larger samples of non- dependent at-risk drinkers is needed before we can draw evidence-based conclusions. There are also remarkable differences compared to findings from intervention studies in outpatient settings. The rates of utilization of formal help among alcohol dependent patients (44-49%) and the reduction in drinking in both groups were much higher than we would expect from the results of studies with outpatients, a finding that is in line with results from other studies in general hospital settings (3) and that is supported by data indicating elevated motivation to change among alcohol dependent individuals in general hospitals compared to those in the general population (4). Since remission from alcohol problems is a widespread phenomenon and health problems are an important trigger for unassisted recovery from alcohol dependence (5), data indicate that these processes are more common in inpatients than in outpatients. In addition, hospitalisation due to somatic crisis may be a "window of opportunity" for self-initiated change, especially when an extensive assessment has been conducted.

References

1. Bertholet N, Daeppen JB, Wietslisbach V, Fleming M, Burnand B. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Arch. Intern. Med. 2005;165:986 -995.

2. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97:279-292.

3. Emmen MJ, Schippers GM, Bleijenberg G, Wollersheim H. Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. BMJ. 2004;328:318.

4. Rumpf HJ, Hapke U, Meyer C, John U. Motivation to change drinking behavior: Comparison of alcohol dependent individuals in a general hospital and a general population sample. Gen. Hosp. Psychiatry. 1999;21:348-353.

5. Bischof G, Rumpf H-J, Hapke U, Meyer C, John U. Maintenance factors of recovery from alcohol dependence in treated and untreated individuals. Alcoholism: Clinical and Experimental Research. 2000;61:783-786.

Conflict of Interest:

None declared

Brief intervention was not adequate for medical inpatients identified by screening
Posted on March 26, 2007
Richard Saitz
Boston University
Conflict of Interest: None Declared

Merlo et al. and Bischof & Freyer-Adam did not correctly characterize the proportion of eligible subjects that enrolled in our study. It was 65% (341/524), remarkably high for an alcohol brief intervention (BI) trial. Readiness to change, AUDIT, and many other alcohol severity-related characteristics were similar in those enrolled vs. a) those eligible who did not, and b) those with risky use who were ineligible (1).

Our trial had fewer exclusion criteria than most (2) and readiness was not among them. Nonetheless, many of our subjects were considering change (as noted in Table 1 of our article). Furthermore, in medical patients, greater readiness is not predictive of less drinking or problems, calling into question approaches that select subjects for intervention based on stage of change (3, 4). We find lack of representativeness an unlikely explanation for our findings.

Merlo et al. write that our controls received "assessment and feedback." However, controls received no feedback. And at least 3 reasons argue against assessment effects as an explanation for our results: 1) mixed model analyses suggested lack of an effect (similar when including subjects with 1 or 2 follow-up assessments); 2) there is not yet sufficient evidence on assessment effects in this population (particularly in those not seeking treatment); and 3) BI studies in other settings have been positive despite assessments.

BI has efficacy in selected patients with nondependent unhealthy alcohol use in primary care. In other settings (e.g. emergency departments, inpatient medicine services), BI may not have efficacy, as trials are beginning to demonstrate. Moreover, evidence does not support efficacy in non-treatment-seeking adults with dependence. This is not old news in medical inpatients; and it is of relevance now because BI is currently being widely disseminated to these populations. We agree BI may have efficacy in nondependent inpatients, but this remains to be proven, and will be relevant to only a small proportion of screen-positive inpatients (~20%). Our study shows that most medical inpatients with unhealthy alcohol use are unlikely to benefit from BI alone and it is not the first negative study in this setting (5).

We do not agree that BI is "effective for inpatients considering change." Hospitalization may be a time for self-change, but evidence that BI improves on that is limited. Our study and others are the best approaches to provide evidence to direct clinical efforts, and for how to improve care where current BIs fall short.

References

1. Saitz R, Freedner N, Palfai TP, Horton NJ, Samet JH. The severity of unhealthy alcohol use in hospitalized medical patients. The spectrum is narrow. J Gen Intern Med. 2006;21:381-5. [PMID: 16686818]

2. Beich A, Thorsen T, Rollnick S. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. BMJ. 2003;327:536-42. [PMID: 12958114]

3. Williams EC, Horton NJ, Samet JH, Saitz R. Do brief measures of readiness to change predict alcohol consumption and consequences in primary care patients with unhealthy alcohol use? Alcohol Clin Exp Res. 2007 Mar;31(3):428-35. [PMID: 17295727]

4. Riemsma RP, Pattenden J, Bridle C, Sowden AJ, Mather L, Watt IS, et al. A systematic review of the effectiveness of interventions based on a stages-of-change approach to promote individual behavior change. Health Technology Assessment. York, UK:York Publishing Services; 2002;6(24). Available at http://www.hta.nhsweb.nhs.uk/fullmono/mon624.pdf accessed March 24, 2007.

5. Emmen MJ, Schippers GM, Bleijenberg G, Wollersheim H. Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. BMJ. 2004;328:318. [PMID: 14729657]

Conflict of Interest:

None declared

Thiamine, oxythiamin & alcoholism
Posted on March 25, 2008
Joseph W Arabasz MD
Joseph W Arabasz MD PC
Conflict of Interest: None Declared

Dear Dr Richard Saitz MD MPH et al, and Editors of the AIM,

I hope this note finds you well. Congratulations on such an excellent Article, "Brief Intervention for Medical Inpatients with Unhealthy Alcohol Use" which took place at the Boston University Medical Center.

I would like to interject the view that talk therapy doesn't really replace Vitamine or Nutritional deficiencies, and that a Study once noted that lab animals prefer alcohol over water, when Thiamine deficient. When the Thiamine deficiency was properly treated, then the animals then preferred to drink water over alcohol.

Recent recommendations are that Thiamine be administered to a Patient who is thought to be experiencing excessive alcohol use, or more precisely, experiencing a Wernicke's Encephalopathy dementia, at the rate of 100 mg BID on the first day of admission, and then QD afterward until further improvement in sensorium ceases.

At one time, administration of Thiamine was only recommended at the rate of 100 mg on the first day of admission for the inpatient alcoholic. The present sequence seems more reasonable.

I was impressed with a comment by Adelle Davis PHD, and Dietician in her text "Let's Get Well", that, paraphrasing, "Once an increased MDR (Minimum Daily Requirement) is established for a particular Nutrient (such as Thiamine) then it doesn't ever return to its previous reduced level" for some reason or another. Perhaps relapsing alcoholics reflect that experience. If that is the case, possibly someday a Physician or Researcher will tell us why that occurs. The unknown is always a most interesting subject.

Possibly the addition of increased Thiamine administration, with your brief intervention technique, would benefit recurrent alcoholics, and decrease their thirst for alcohol. What is considered to be a "normal" level of Thiamine (if serum levels were obtained) isn't necessarily an optimum level for a particular Patient. Clinical response to the empirical administration of Thiamine might be more important than serum Lab values. The lessons of oxythiamin and pyrithiamine, Thiamine antimetabolites, have taught us that well.

Redoing of your motivational brief intervention Study would be most interesting, with daily Thiamine dosing as the independent variable, without Vitamine B1 antimetabolites present, and with some measure of useful Thiamine serum levels.

Best wishes always. Keep up the good work.

Cordially,

Joseph W Arabasz MD PC

Past Division Chairman, Anesthesiology, Cook County Hospital, Chicago, Illinois

Past Chairman, Respiratory Therapy, Cook County Hospital, Chicago, Illinois

Diplomate ABA

Mensa

Sigma Xi, The Professional International Science Research Society

SigmaXi.org

PO Box 6939

Denver, CO 80206

303-316-1740

http://www.topica.com/lists/josepharabasz@topica.com

Conflict of Interest:

None declared

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Summary for Patients

A Brief Intervention for Hospitalized Patients with Unhealthy Alcohol Use

The summary below is from the full report titledBrief Intervention for Medical Inpatients with Unhealthy Alcohol Use. A Randomized, Controlled Trial.” It is in the 6 February 2007 issue of Annals of InternalMedicine (volume 146, pages 167-176). The authors are R. Saitz, T.P. Palfai, D.M. Cheng, N.J. Horton, N. Freedner, K. Dukes, K.L. Kraemer, M.S. Roberts, R.T. Guerriero, and J.H. Samet.

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