Background: Between 5-30% of hospitalized patients screen positive for unhealthy alcohol use (UAU), and roughly 10-15% of patients have alcohol use disorder (AUD). Brief counseling and medications for AUD are shown to reduce alcohol consumption yet are underutilized in hospitals: over 90% of patients nationally are not screened and treated for UAU.
Purpose: To increase identification and treatment of UAU, we implemented an interprofessional team-based clinical protocol for UAU at a safety-net hospital in Austin, Texas.
Description: Our approach is based on the SBIRT (Screening, Brief Intervention, and Referral to Treatment) framework, which is shown to decrease risky drinking and its adverse health effects, increase abstinence rates, and reduce readmissions. We partnered with national leaders in SBIRT instruction and implementation to train interprofessional care team members in SBIRT delivery and motivational interviewing. The clinical protocol begins at hospital intake, when nurses screen patients with the AUDIT-PC, a shortened form of the validated AUDIT instrument used to identify UAU. Patients who score positive (≥5) on initial screening are evaluated by a substance use navigator (SUN) who performs a full AUDIT, delivers a brief intervention to reduce risky drinking using motivational interviewing principles, and, if appropriate, provides education about medications. If the patient is interested and eligible, the hospital care team starts pharmacotherapy. The SUN works with outpatient partners to arrange follow-up care, specialty referrals, and recovery resources. The SUN also contacts patients one week after discharge to provide further support and navigation as needed. Four weeks after discharge, the SUN attempts to contact the patient to readminister the AUDIT via phone to assess for changes in drinking behaviors. In 12 months (September 2022 – September 2023), 14,631 patients were admitted to the hospital and 9087 patients (62.1%) were screened with the AUDIT-PC. Of those screened, 508 patients (5.6%) screened positive, and 426 of them (83.9%) had a full AUDIT performed. Of these patients, 262 (61.5%) had a score of ≥12, signifying risk of AUD and making them eligible for pharmacotherapy.Of the 508 screen-positive patients, 79.5% were male and mean age was 51 years. About 50% of patients identified as white, 29.7% identified as Latinx/Hispanic, 9.3% identified as black or African-American, and 2% identified as American Indian, Asian, or native Hawaiian. Thirty-two percent of patients had temporary housing or were unhoused. The SUNs delivered behavioral interventions to 394 of the 508 screen-positive patients (77.6%); 170 of them (43.1%) were eligible and interested in pharmacotherapy, and 151 patients were started on medications.At 4 weeks post-discharge, 77 of 227 eligible patients (33.9%) have been successfully contacted via phone. A follow up AUDIT was completed for 56 (72.7%) patients with 48 (62.3%) attending their follow-up appointment and 44 (78.6%) reporting reduced alcohol use – 24 (42.9%) of whom stopped drinking entirely. Twenty-two patients (28.6%) had had a repeat emergency room visit or hospital readmission. The mean change in AUDIT score at reassessment was -12.2 points with a confidence interval of -14.5 to -9.9.
Conclusions: Screening, brief counseling, and medication treatment initiation for unhealthy alcohol use is feasible to implement in an inpatient setting with a multidisciplinary team, and is associated with changing patient behavior to decrease alcohol use.