Providing brief addictions treatment in an emergency department

Providing brief addictions treatment in an emergency department: Experiences of University of New Mexico Hospital research interventionists in the SMART-ED trial C. A. Fitz. Gerald 1, M. J. Martinez 1, D. T. Garcia 1, C. Crandall 1, A. A. Forcehimes 2 , M. P. Bogenschutz 2 1 University of New Mexico School of Medicine, Department of Emergency Medicine 2 University of New Mexico Center on Alcoholism, Substance Abuse, & Addictions INTRODUCTION Emergency departments (EDs) are receiving increased attention as venues for addiction treatment. Brief intervention in the ED may be effective and economical, and may reach those who might not seek treatment in traditional addiction treatment settings. RESULTS Three themes emerged from our discussions. We describe these themes and detail how we dealt with these challenges: Challenges inherent in the nature of the emergency department The Screening, Motivational Assessment, and Referral to Treatment in Emergency Departments (SMART-ED) study, conducted through NIDA’s National Drug Abuse Treatment Clinical Trials Network, builds on the knowledge base on brief interventions for harmful and hazardous alcohol use delivered in EDs and trauma centers, by transferring and evaluating these procedures when applied to drug use. The study contrasts substance use and substance-related outcomes among patients endorsing problematic substance use during an ED visit who are randomly assigned to one of three treatment conditions: 1) minimal screening only (MSO); 2) screening, assessment, and referral to treatment (if indicated) (SAR); and 3) screening, assessment, and referral plus a brief intervention using motivational interviewing, followed up with two telephone booster sessions (BI-B). Patients were recruited for study participation in the ED at the University of New Mexico Hospital from October 2010 through October 2011 by research assistants/brief interventionists, who screened all patients in the ED to identify potential participants. Research interventionists obtained informed consent, enrolled participants in the study, and administered MSO, SAR, or BI-B as indicated. Provision of each condition—particularly brief intervention—in the ED presented several challenges. Successful implementation of such a study or a similar intervention in this setting requires consideration of several factors. METHOD Three research interventionists working at the University of New Mexico Hospital emergency department (UNM ED) conducted a series of conversations to determine what challenges they encountered during the course of their work conducting assessment, referral, and brief intervention. Interventionists recorded, coded and categorized responses. Responses fell into one of three categories: 1) challenges inherent in the nature of the ED, 2) using Motivational Interview (MI) techniques, and 3) maintaining focus on addictions in the face of competing priorities. Patient Flow: “Flow” refers to the movement of patients through the ED clinical process. At UNM ED, patients reported wait times from 2 to more than 20 hours. • Research staff set a cut-off time and did not recruit patients who had been in the ED for more than 16 hours. Availability of Space: Adequate space to conduct confidential screening and intervention activities was often difficult to find. • Research interventionists conducted screening and intervention delivery in the ED exam rooms whenever possible, rather than in the waiting room or triage areas. Frequent Interruptions: Conducting research activities in exam rooms is challenging due to hospital staff coming in to provide services. Medical care necessarily took priority. • Interventionists needed to be flexible, and maintain the trust and rapport built with the patient in the initial stages of the intervention despite having to stop and re-start multiple times. Privacy and Confidentiality: Participants were often reluctant to discuss substance use issues with research staff as they feared that discovery by their health care provider might affect their care. • Interventionists needed to maintain strict confidentiality and professionalism by not discussing patients’ issues with medical staff. Patient Acuity: Patients who were unable to provide informed consent due to altered mental state, intoxication, or specific ailments rendering it impossible for patients to answer questions were excluded from participation in the study. • Research interventionists determined whether patients were able to participate, and consulted with a patient’s nurse or doctor if in doubt. Using Motivational Interview techniques appropriately Dual Roles: Research interventionists conducted all phases of research activities with patients in the ED, including screening, recruitment, assessment, and intervention. • Research interventionists who conducted screening and assessment with a participant did not perform intervention activities with the same patient. Another interventionist conducted BI-B when indicated. • Interventionists conducting screening and assessment took care not to use MI techniques during these phases. Maintaining focus on addictions in the face of competing priorities Medical Needs: Participants often wanted to discuss their medical condition with the interventionists. • Interventionists would remind patients to speak to their doctor, then redirect the patient to a discussion of substance use. Psychosocial/Mental Health Needs: When patients disclosed mental health/psychosocial needs, interventionists would refer the patient to hospital social workers, then redirect the patient to a discussion of substance use. • If the patient’s psychosocial /mental health needs were immediate (e. g. , threats of suicide), the interventionist ended the session and immediately informed the patient’s nurse. Other Basic Needs: There was some temptation for interventionists to focus on patients’ basic needs (e. g. , housing, employment) during the intervention. • Interventionists recommended that the patient speak to a hospital social worker for assistance with basic needs, then redirected the patient by focusing on how those needs are affected by substance use. DISCUSSION Summary There were some complexities involved in providing a brief addiction intervention in the UNM ED as part of the SMART-ED study. Themes included challenges related to: 1. The nature of the ED setting 2. The struggle of maintaining focus on addictions in the face of multiple competing patient needs 3. Using MI only during the intervention and refraining from use of this method of communication during the screening and assessment of patients. Implications for future research and program implementation Brief interventions should be designed with careful consideration of delivery in the ED environment. Providers delivering a brief intervention in an ED should be flexible, able to quickly build and maintain rapport with patients, and should maintain patients’ confidentiality at all times. Researchers and program planners should develop clear procedures for dealing with patients who present with psychosocial, mental health, or unmet basic needs, and should train interventionists accordingly. Interventionists using MI techniques would benefit from extensive training in the appropriate use of MI skills, and knowledge of when (and when not) to utilize this method of communication. ACKNOWLEDGEMENTS This research was supported by NIDA’s National Drug Abuse Treatment Clinical Trials Network