clinicaltrials.gov Identifier: NCT00006206.

ObjectiveAlcoholism is the leading risk factor for injury. The authors hypothesized that providing brief alcohol interventions as a routine component of trauma care would significantly reduce alcohol consumption and would decrease the rate of trauma recidivism. MethodsThis study was a randomized, prospective controlled trial in a level 1 trauma center. Patients were screened using a blood alcohol concentration, gamma glutamyl transpeptidase level, and short Michigan Alcoholism Screening Test (SMAST). Those with positive results were randomized to a brief intervention or control group. Reinjury was detected by a computerized search of emergency department and statewide hospital discharge records, and 6-and 12-month interviews were conducted to assess alcohol use. ResultsA total of 2524 patients were screened; 1153 screened positive (46%). Three hundred sixty-six were randomized to the intervention group, and 396 to controls. At 12 months, the intervention group decreased alcohol consumption by 21.8 Ϯ 3.7 drinks per week; in the control group, the decrease was 6.7 Ϯ 5.8 (p ϭ 0.03). The reduction was most apparent in patients with mild to moderate alcohol problems (SMAST score 3 to 8); they had 21.6 Ϯ 4.2 fewer drinks per week, compared to an increase of 2.3 Ϯ 8.3 drinks per week in controls (p Ͻ 0.01). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p ϭ 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up). ConclusionAlcohol interventions are associated with a reduction in alcohol intake and a reduced risk of trauma recidivism. Given the prevalence of alcohol problems in trauma centers, screening, intervention, and counseling for alcohol problems should be routine.Regional trauma centers were developed 25 years ago in response to studies showing that 40% of deaths from injuries in the United States could have been prevented if the patient had been treated in a facility with special expertise in treating injuries.1 With the advent of regional trauma systems, the preventable death rate has now been reduced to Ͻ2% to 3%; therefore, future decreases in the trauma death rate are not likely to occur as a result of improvements in the delivery of care.2 Nearly half of all trauma deaths occur at the scene; these also are not responsive to improvements in care.3,4 Future significant decreases in the death rate for injuries, therefore, depend primarily on progress in injury prevention.By far the most common underlying causes of injuries in the United States are alcohol abuse and dependence. 5,6 Studies repeatedly demonstrate that approximately 50% of patients admitted to a trauma center are under the influence of alcohol, and the mean blood alcohol concentration of such patients is 187 mg/dl, nearly twice the legal level for

The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes.

IMPORTANCE Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index–Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, –0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, –0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

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