Using Recovering Alcoholics to Help Hospitalized Patients with Alcohol Problems
Peer interventions have been used successfully in education.18,19 This success is based in some part on what is known as the “attraction paradigm”. The attraction process purports that the more similar the members of a relationship are in experiences, the more likely they will respond to one another positively.20 Peers have been used in some settings to augment treatment in primary care. In one study, trained peers who were recovered from depression were found to provide no additional improvement in clinical outcomes.21 In that study, one group of patients with depression who were treated with antidepressant drugs and emotional support provided by a nurse during 10 6-minute telephone calls over a 4-month period were compared with another group who also received peer support. The finding is not surprising, because peers cannot be expected to add much benefit to patients who are already receiving optimal treatment. Volunteers from Alcoholics Anonymous (AA) have been used to talk with alcoholic patients in a general hospital.22 Although impressions are that these peers are helpful, the outcomes of this procedure have not been well studied. This process can also be performed by a professional and has been called Twelve Step Facilitation.23
At our institution, volunteers from the community who were active in AA were used to speak with patients who were admitted to the hospital with alcohol-related injuries following a brief intervention from a primary care physician. These peers appeared to produce favorable outcomes with our patients. The purpose of our study was to evaluate the effectiveness of this approach and to test the alternative hypothesis that those in a peer intervention group would demonstrate more favorable outcomes than those in a brief intervention group who, in turn, would demonstrate more favorable outcomes than those in a control group.
Methods
Setting
We conducted this study in a Level I trauma center located in the primary university teaching hospital that serves a metropolitan area of more than 1 million people in a 2-state area of the Midwest. The trauma service is staffed by 2 teams of attending and resident surgeons who alternate 24-hour shifts. An addiction medicine physician provides consultative services to these patients.
Study Population
A total of 2530 patients were admitted to the hospital trauma service for injuries between August 1, 1998, and March 31, 2000, and 957 (37.8%) of these had positive toxicology tests (351 alcohol only, 352 drugs only, and 254 alcohol and drugs) on admission to the hospital. Positive toxicology tests were defined as a blood alcohol concentration (BAC) of 4.34 mmol per L or greater (Ž20 mg/dL) and/or the detection of psychoactive drugs. Toxicology screening was not performed in approximately 20% of the patients. Also, 95 patients with negative toxicology screens were known to have an active alcohol use disorder on admission to the hospital. Thus, 1052 patients served as potential study subjects.
The flow of patients through the study is shown in Table 1. A total of 738 patients were excluded as potential subjects, 632 by block randomization and 106 for other reasons. Since patients with positive toxicology tests who did not have either alcohol abuse or alcohol dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition24 were excluded from the study, all of those who were ultimately eligible for follow-up had an alcohol use disorder.
Before the patients were contacted for follow-up, they were categorized into 1 of 3 groups: a usual care group (n=125), a brief intervention group (n=119), or a peer intervention group (n=70), according to the study methods. Volunteer availability often determined which patients received a peer intervention or a brief intervention. One patient had been originally assigned to the brief intervention group, but we learned at the time of the telephone follow-up interview that a family member had arranged for the patient’s AA sponsor to visit the patient on several occasions before and after hospital discharge. This patient was subsequently excluded from our study and is not included in the numeric values of Table 1.
Procedures
This was a retrospective nonrandomized intervention study evaluating the effectiveness of interventions used to encourage trauma patients to abstain from alcohol and to initiate substance abuse treatment or self-help. We obtained initial data retrospectively from the patient’s medical record, including the patient’s demographic characteristics (age, sex, race), the patient’s telephone numbers, and the telephone numbers of relatives or friends.
The follow-up telephone interviews were conducted at 2 different times. The university’s institutional review board approved both parts of our study. The main outcome measures were: (1) complete abstinence from alcohol during the first 6 months following discharge from the hospital, (2) abstinence from alcohol during the sixth month following hospital discharge (ie, those who drank initially after discharge but subsequently became abstinent), and (3) initiation of professional alcohol treatment or self-help. The patients were considered to have initiated treatment or self-help if within the first 6 months following hospital discharge they had either: (1) attended at least one AA meeting, (2) visited a mental health or substance abuse professional at least once, (3) attended at least 1 session at an outpatient alcohol treatment center, or (4) spent at least 1 day at an inpatient or residential alcohol treatment program.
