58
NIAAA Recommended Drinking Limits and SBIRT:
A Review of the Scientific Evidence
Presentation Overview
The purpose of this presentation is to inform participants about NIAAA’s drinking guidelines and to briefly illustrate the usefulness of SBIRT. This presentation consists of 7 sections:
1. The Basis for the NIAAA Guidelines
2. The Recommended Drinking Limits in NIAAA Guidelines
3. Medical Consequences of Risky Alcohol Use
4. NIAAA and SBIRT
5. SBIRT and Efficacy
6. Incorporating SBIRT into Practice
7. References
8/16/2013 3
The Basis for the NIAAA Guidelines
Evidence Behind the Numbers*
• Studies demonstrate that the 5+/4+ limits accurately reflect the amount of alcohol consumed at which psychomotor and cognitive impairment is notably increased in both men and women.
• Epidemiologic risk curve analyses reveal significant and rapid increases in the risks of:
─ Unintentional injuries
─ Deaths resulting from external causes
─ Being a target of aggression or taking part in an aggression-related event
─ Alcohol use disorders
─ Unfavorable medical, work-related, legal, and social consequences related to
drinking
• As the frequency of exceeding NIAAA’S guidelines increases, the likelihood of developing these problems increases.
*Full references provided at the end of the presentation: 4, 5, 7-10, 13, 19, 20, 21, 24, 34, 36-38, 56
8/16/2013 5
• Men and women over 65 are generally advised to have no more than 3 drinks on any day and 7 per week.
• Heavy drinking during pregnancy can cause brain damage and other serious problems in the baby. Because it is not yet known whether any amount of alcohol is safe for a developing baby, women who are pregnant or may become pregnant should not drink.
8/16/2013 6
Evidence Behind the Numbers*
*Full references provided at the end of the presentation: 32
Significance of the Numbers
Studies have consistently shown that when individuals exceed NIAAA’s daily or weekly drinking guidelines, their risk for alcohol-related problems increases significantly.
8/16/2013 7
Background on the Recommended Limits*
• The measurement of 5 or more drinks to determine alcohol risks has been used for decades, predating NIAAA.
• In the 1960s, studies conducted by Virginia Technical College and later by the University of North Carolina Highway Research Center/National Transportation Safety Board assessed the impact of alcohol use and safety.
• At blood alcohol levels (BAL) of .06 to .09 (approximately 5 drinks for a male), there is measurable impairment in reasoning, depth perception, peripheral vision, and nighttime glare recovery, as well as increased risks for accident and injury.
*Full references provided at the end of the presentation: 2, 12, 35, 56
8/16/2013 8
NIAAA Epidemiologic Studies*
• NIAAA conducted extensive, nationally representative, epidemiologic surveys including: – National Longitudinal Alcohol Epidemiologic Survey—NLAES
(1992) – National Epidemiologic Survey on Alcohol and Related
Conditions—NESARC (2001–2002) – NESARC 3-year followup (2004–2005)
• The surveys included questions regarding the frequency with which people drank more than 5 drinks in a given day.
• Findings indicated that exceeding these drinking limits can significantly increase alcohol-related health problems.
*Full references provided at the end of the presentation: 9, 15, 28, 29
8/16/2013 9
Binge Drinking Defined*
Based on consensus recommendations from a task force chaired by NIAAA Associate Director Dr. Mark Goldman in 2004, the NIAAA National Advisory Council approved the following definition for binge drinking:
*Full references provided at the end of the presentation: 30
8/16/2013 10
The Recommended Drinking Limits in NIAAA Guidelines
How Much is Too Much?*
• For healthy adults age 65 and under:
*Full references provided at the end of the presentation: 32
8/16/2013 12
• For people over 65, exceeding 3 drinks a day or 7 drinks a week is not recommended.
• Women who are pregnant or may become pregnant should not drink.
How Much is 1 Drink?*
0.6 fluid ounces or 14 grams of "pure" alcohol is the standard measurement used to define a typical drink
*Full references provided at the end of the presentation: 31
8/16/2013 13
Medical Consequences of Risky Alcohol Use
Physiological Consequences of Risky Drinking*
Excessive alcohol use is associated with many negative health and societal-related outcomes, including:
• Certain types of cancer, including breast cancer • Obesity • High blood pressure • Stroke • Injury • Type 2 diabetes • Accident and death resulting from drunk driving • Violence, including homicide and sexual assault • Suicide • Cirrhosis of the liver
*Full references provided at the end of the presentation: 14,18,22,23,27,33,41,42,45,47,50,52
8/16/2013 15
Physiological Consequences of Risky Drinking
8/16/2013 16
Progressive Effects of Alcohol Based on Blood Alcohol Concentration
Full references provided at the end of the presentation: 51 8/16/2013 17
Incidence of Alcohol Use Disorders Increases in Relationship to Exceeding NIAAA Guidelines*
Data analyzed extensively from NIAAA’s 2001 and 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)
• When daily drinking limits were exceeded:
– Prevalence of possessing either alcohol abuse or dependence rose linearly as the frequency of exceeding the limits increased.
– Exceeding weekly limits, in addition to daily limits, increased the incidence of having both disorders.
*Full references provided at the end of the presentation: 9
8/16/2013 18
Weekly Alcohol Consumption Limits: USDA and NIAAA Consistency
U.S. Department of Agriculture (USDA) definition of moderate drinking:
NIAAA definition of heavy drinking:
Full references provided at the end of the presentation: 11, 25, 45, 46
8/16/2013 19
NIAAA and SBIRT
What is SBIRT?
An intervention that includes the following:
• Screening: Universal screening for quickly assessing use and severity of alcohol, illicit drugs, and prescription drug abuse
• Brief Intervention: A brief motivational and awareness-raising intervention given to risky or problematic substance users
• Referral to Treatment: Referrals to specialty care for patients with substance use disorders
• Treatment can be brief treatment or specialty AOD treatment
8/16/2013 21
NIAAA and SBIRT
• The essential approach to alcohol screening and intervention remains unchanged.
• In the 2005 NIAAA Clinician Guidelines, new directions for alcohol screening included a simplified, single-question screening question.
• This guide recommends that this validated single-question screener be used in conjunction with the AUDIT.
Full references provided at the end of the presentation: 47
8/16/2013 22
• Men: How many times in the past year have you had 5 or more drinks in a day?
• Women: How many times in the past year have you had 4 or more drinks in a day?
(a response of ≥ 1 is considered positive)
8/16/2013 23
NIAAA Single Question Alcohol Screen
Impact of SBIRT on Public Health
• SBIRT provides an opportunity for primary care, emergency service providers, and other community health providers to take proactive measures for patients who may be engaged in risky use of substances, but are not currently seeking treatment and are not in need of specialty treatment.
• SBIRT demonstrates that a rapid and simple set of procedures has the potential for impacting the public health burden of substance abuse.
8/16/2013 24
Using Both Daily and Weekly NIAAA Limits*
The consensus is that NIAAA’s daily and weekly limits are considered the best option for balancing both sensitivity and specificity in predicting alcohol-related outcomes.
*Full references provided at the end of the presentation: 6
8/16/2013 25
SBIRT and Efficacy Over 200 Published Studies Demonstrating Effectiveness
SBIRT Benefits: Primary Care Settings*
0% 20% 40% 60%
Drinks Per Week
BingeDrinking
ER Visits
Nonfatal Injuries
Hospitalizations
Arrests
*Full references provided at the end of the presentation: 3
8/16/2013 27
SBIRT Impact on Individuals and Communities*
At the 6-month GPRA† followup, people who received SBIRT services reported:
• 41% reduction in alcohol use
• 68% reduction in illicit drug use
• Fewer arrests, more stable housing, improved employment status, fewer emotional problems, and improved overall health
† Government Performance Results Act of 1993 (GPRA) findings are based on self reported data and do not include a control group. *Full references provided at the end of the presentation: 43
8/16/2013 28
Changes in Substance Use and Other Outcomes*
State Cohorts I-IV
Count of Intakes: 1,474,659
Count of Matched Six Month Follow-up: 21,035
*Full references provided at the end of the presentation: 45
8/16/2013 29
Mental Health Related Outcomes*
State Cohorts I–IV
Count of Intakes: 1,474,659
Count of Matched Six Month Follow-up: 21,035
*Full references provided at the end of the presentation: 45
8/16/2013 30
SBIRT Benefits ED and Trauma Centers
Studies have repeatedly demonstrated SBIRT’s value, especially pertaining to alcohol problems (see reference section for full citation)
• Bernstein, E. and Bernstein, J. (2008). Effectiveness of alcohol screening and brief motivational intervention in the emergency department setting.
• Washington State Department of Social and Health Services, Research and Data Analysis Division. (2007). Medicaid costs declined among emergency department patients who received brief interventions for substance use disorders through WASBIRT.
• Vaca, F. and Winn, D. (2007). The basics of alcohol screening, brief intervention and referral to treatment in the emergency department.
• Schermer, C., Moyers, T., Miller, W., and Bloomfield, L. (2006). Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests.
• D'Onofrio, G. and Degutis, L. (2002). Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review.
• Gentilello, L., et al. (1999). Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence.
8/16/2013 31
SBIRT: Consensus Among Medicine and Government
Organizations recommending SBIRT: • NIAAA
• SAMHSA
• American College of Surgeons Committee on Trauma (ACS-COT)
• American Medical Association
• American Public Health Association
• American Society of Addiction Medicine (ASAM)
• Centers for Medicaid and Medicare Services (CMS)
• American Academy of Family Medicine
• Centers for Disease Control and Prevention
8/16/2013 32
American College of Surgeons Committee on Trauma (ACS-COT)*
ACS-COT mandates that Level I and II trauma centers have SBIRT capabilities and recommends the integration of SBIRT into all trauma centers.
*Full references provided at the end of the presentation: 49, 50
8/16/2013 33
A Closer Look at SBIRT’s Generation of Cost Savings*
Findings in a 2010 study of
Washington State’s SBIRT program:
The program reduced monthly Medicaid costs by approximately $366 per member (compared with those who did not receive brief interventions).
*Full references provided at the end of the presentation: 17
8/16/2013 34
Incorporating SBIRT Into Practice
Rationale for Universal Screening
• Drinking and drug use are common.
• Drinking and drug use can increase risk for health problems, safety risks, and a host of other issues.
• Drinking and drug use often go undetected.
• People are more open to change than you might expect.
8/16/2013 36
Benefits of Universal Screening
• Provides an opportunity for education, early intervention
• Alerts provider to risks for interactions with medications or other aspects of treatment
• Offers an opportunity to engage the patient further
• Has proved beneficial in reducing high-risk activities for people who are not dependent
8/16/2013 37
What is Screening?
• A range of evaluation procedures and techniques to capture indicators of risk
• A preliminary assessment that indicates probability that a specific condition is present
• A single event that informs subsequent diagnosis and treatment
8/16/2013 38
Screening Tools Currently Used in Practice*
• The National Institute on Alcohol Abuse and Alcoholism (NIAAA) validated single-question screener
• The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
• The Alcohol Use Disorder Identification Test (AUDIT and AUDIT-C)
• The Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT)
• The Comprehensive Adolescent Severity Inventory (CASI)
• The Cut down, Annoyed, Guilty, and Eye Opener (CAGE) test or the CAGE-AID, which includes questions about alcohol and illicit drugs
*Information obtained from the SBIRT Medical Residency and State Aggregate Report FY 2011
8/16/2013 39
Key Points for Screening
• Screen everyone.
• Screen for both alcohol and drug use, including Rx abuse and tobacco.
• Explore each substance; many patients use more than one.
• Follow up positives or "red flags" by assessing details and consequences of use.
• Show nonjudgmental, empathic verbal and non-verbal behaviors during screening.
8/16/2013 40
Screening Strategy
Use a brief yet valid screening question:
The NIAAA Single-Question Screener
8/16/2013 41
Prescreening
Sensitivity/Specificity: 82%/79%
*Full references provided at the end of the presentation: 42
8/16/2013 42
Drinking Limits
Recommended Low-Risk Limits
Men = 4 per day / 14 per week
Women/anyone 65+ = 3 per day / 7 per week
8/16/2013 43
A Positive Alcohol Screen = At-Risk Drinker
8/16/2013 44
*Full references provided at the end of the presentation: 55
AUDIT
Alcohol Use Disorders Identification Test
What is It?
• Ten questions, self-administered or through an interview, address recent alcohol use, alcohol dependence symptoms, and alcohol-related problems.
• Developed by the World Health Organization (WHO).
What are the strengths?
• Public domain—the test and manual are free.
• Validated in multiple settings, including primary care.
• Test is brief and flexible.
• Focuses on recent alcohol use.
• Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use.
Limitations?
• Does not screen for drug use or abuse, only alcohol.
8/16/2013 45
AUDIT Questionnaire
Full references provided at the end of the presentation: 46 8/16/2013 46
AUDIT Domain
Full references provided at the end of the presentation: 46
8/16/2013 47
Scoring the AUDIT
8/16/2013 48
Conclusion
In Conclusion
• NIAAA Guidelines were informed by years of research.
• Exceeding the recommended drinking limits can increase the likelihood of negative health consequences.
• SBIRT can assist with identifying drinking behaviors that may be risky or harmful to patients.
• Screening questions have proven valid for identifying persons at risk.
• Multiple screening tools are available that have been tested for sensitivity and specificity.
8/16/2013 50
References
Recommended Web-sites
NIAAAA: Professional Education Materials http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/default.aspx NIAAA: Rethinking Your Drinking. Low Risk Drinking http://rethinkingdrinking.niaaa.nih.gov/IsYourDrinkingPatternRisky/WhatsLowRiskDrinking.asp NIAAA: Surveillance Reports and Epidemiologic Manuals http://www.niaaa.nih.gov/Publications/EpidemiologicManuals/Pages/default.aspx SBIRT Colorado http://www.improvinghealthcolorado.org/ SBIRT Effectiveness Data (from SAMHSA’s newsletter) http://www.samhsa.gov/samhsanewsletter/Volume_17_Number_6/SBIRT.aspx SBIRT Research (from Boston University) http://www.bu.edu/bniart/sbirt-resources/sbirt-evidence-research/
8/16/2013 52
References
1. Bernstein, E., & Bernstein, J. (2008). Effectiveness of alcohol screening and brief motivational intervention in the emergency department setting. Annals of Emergency Medicine, 51(6), 751–754.
2. Cahalan, D., Cisin, I.H., & Crossley, H.M.(1969). American drinking practices: A national study of drinking behavior and attitudes. New Brunswick, NJ: Rutgers Center of Alcohol Studies, Monograph No. 6.
3. Campbell K.P. , et al. (Eds). (2006). A purchaser's guide to clinical preventative services: Moving science into coverage. Washington, D.C. National Business Group on Health. Alcohol misuse (screening and counseling) evidence statement.
4. Cherpitel, C., Bond, J., & Ye, Y. (2006). Alcohol and injury: A risk function analysis from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP). European Addiction Research, 12(1), 42–52.
5. Cherpitel, C., Tam, T., Midanik, L., Caetano, R., & Greenfield, T. (1995). Alcohol and non-fatal injury in the U.S. general population: A risk function analysis. Accident; Analysis and Prevention, 27(5), 651–661.
6. Dawson, D. (2000). U.S. low-risk drinking guidelines: An examination of four alternatives. Alcoholism: Clinical and Experimental Research, 24(12), 1820–1829.
7. Dawson, D. (2001). Alcohol and mortality from external causes. Journal of Studies on Alcohol, 62(6), 790–797.
8. Dawson, D. A. (1997). Alcohol, drugs, fighting and suicide attempt/ideation. Addiction Research, 5(6), 451.
9. Dawson, D. A., Grant, B. F., & Li, T. (2005). Quantifying the risks associated with exceeding recommended drinking limits. Alcoholism: Clinical and Experimental Research, 29(5), 902–908.
10. Dawson, D. A., Grant, B. F., Stinson, F. S., & Zhou, Y. (2005). Effectiveness of the Derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the U.S. general population. Alcoholism: Clinical and Experimental Research, 29(5), 844–854.
8/16/2013 53
References
11. Dawson, D., & Grant, B. (2011). The "gray area" of consumption between moderate and risk drinking. Journal of Studies on Alcohol and Drugs, 72(3), 453–458.
12. Dawson, D., & Archer, L. (1993). Relative frequency of heavy drinking and the risk of alcohol dependence. Addiction (Abingdon, England), 88(11), 1509–1518.
13. Dawson, D., Archer, L., & Grant, B. (1996). Reducing alcohol-use disorders via decreased consumption: A comparison of population and high-risk strategies. Drug and Alcohol Dependence, 42(1), 39–47.
14. Deaths and hospitalizations from chronic liver disease and cirrhosis—United States, 1980–1989. (1993). MMWR. Morbidity and Mortality Weekly Report, 41(52-53), 969–973.
15. Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism. (2000). Tenth Special Report to the U.S. Congress on Alcohol and Health from the Secretary of Health and Human Services. Rockville, MD: U.S. Department of Health and Human Services.
16. D'Onofrio, G., & Degutis, L. (2002). Preventive care in the emergency department: Screening and brief intervention for alcohol problems in the emergency department: A systematic review. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 9(6), 627–638.
17. Estee, S., Wickizer, T., He, L., Shah, M., & Mancuso, D. (2010). Evaluation of the Washington State screening, brief intervention, and referral to treatment project: Cost outcomes for Medicaid patients screened in hospital emergency departments. Medical Care, 48(1), 18–24.
18. Gentilello, L. et al.(1999). Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery, 230(4), 473–480.
19. Graham, K., & West, P. (2001). Alcohol and crime. In Heather N., Peters, T.J., & Stockwell, T. (Eds.). International handbook of alcohol dependence and problems (pp. 439–470). Chichester, England: John Wiley and Sons.
20. Greenfield, T.K. (2001). Individual risk of alcohol-related diseases and problems. In Heather, N., Peters, T.J., & Stockwell, T. (Eds.). International handbook of alcohol dependence and problems (pp. 413–437). Chichester, England: John Wiley and Sons.
8/16/2013 54
References
21. Hindmarch, I., Kerr, J., & Sherwood, N. (1991). The effects of alcohol and other drugs on psychomotor performance and cognitive function. Alcohol and Alcoholism (Oxford, Oxfordshire), 26(1), 71–79.
22. Iso, H., Baba, S., Mannami, T., Sasaki, S., Okada, K., Konishi, M., & Tsugane, S. (2004). Alcohol consumption and risk of stroke among middle-aged men: The JPHC Study Cohort I. Stroke: A Journal of Cerebral Circulation, 35(5), 1124–1129.
23. McClelland, G., & Teplin, L. (2001). Alcohol intoxication and violent crime: Implications for public health policy. The American Journal on Addictions/American Academy Of Psychiatrists In Alcoholism And Addictions, 10 Suppl, 70–85.
24. Midanik, L. T., & Tam, T. W. (1996). Risk functions for alcohol-related problems in a 1988 U.S. national sample. Addiction, 91(10), 1427.
25. Naimi, T. (2011). "Gray area" alcohol consumption and the U.S. dietary guidelines: A comment on Dawson and Grant (2011). Journal of Studies on Alcohol and Drugs, 72(4), 687.
26. National Health Service. (2011). Risks of Alcohol Misuse. Retrieved March 5, 2012, from http://www.nhs.uk/Conditions/Alcohol-misuse/Pages/Risks.aspx
27. National Highway Traffic Safety Administration (n.d.) Alcohol-Impaired Driving. Retrieved February 23, 2012, from http://www-nrd.nhtsa.dot.gov/Pubs/811385.PDF
28. National Institute on Alcohol Abuse and Alcoholism. (1997). Ninth Special Report to the U.S. Congress on Alcohol and Health from the Secretary of Health and Human Services. Rockville, MD: U.S. Department of Health and Human Services.
29. National Institute on Alcohol Abuse and Alcoholism. (1999). Alcohol and coronary heart disease. (NIAAA Alcohol Alert No. 45). Rockville, MD: U.S. Department of Health and Human Services.
30. National Institute on Alcohol and Alcoholism. (2004). NIAAA Newsletter. Retrieved February 23, 2012, from http://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.htm#council
8/16/2013 55
References
31. National Institute on Alcohol and Alcoholism (n.d.) What’s a Standard Drink? Retrieved February 17, 2012, from http://rethinkingdrinking.niaaa.nih.gov/WhatCountsDrink/WhatsAstandardDrink.asp
32. National Institute on Alcohol and Alcoholism (n.d.) What's “Low-Risk" Drinking? Retrieved February 17, 2012, from http://rethinkingdrinking.niaaa.nih.gov/IsYourDrinkingPatternRisky/WhatsLowRiskDrinking.asp
33. Pöschl, G. G., & Seitz, H. K. (2004). Alcohol and cancer. Alcohol and Alcoholism, 39(3), 155–165.
34. Rehm, J., Monga, N., Adlaf, E., Taylor, B., Bondy, S., & Fallu, J. (2005). School matters: Drinking dimensions and their effects on alcohol-related problems among Ontario secondary school students. Alcohol and Alcoholism (Oxford, Oxfordshire), 40(6), 569–574.
35. Room, R. (1991). Measuring alcohol consumption in the US: Methods and rationales, in Hilton M.E., & Clark, W.B. (Eds.) Alcohol in America: Drinking practices and problems (pp. 26–50). Albany, NY: State University of New York Press.
36. Room, R., Bondy, S. J., & Ferris, J. (1995). The risk of harm to oneself from drinking, Canada 1989. Addiction, 90(4), 499–513.
37. Rossow, I. (1996). Alcohol-related violence: The impact of drinking pattern and drinking context. Addiction (Abingdon, England), 91(11), 1651–1661.
38. Russel, M. (2004). Alcohol consumption and problems: The relevance of drinking patterns. Alcoholism: Clinical and Experimental Research, 28(6), 921–930.
39. SBIRT Medical Residency and State Aggregate Report, FY 2011.
40. Schermer, C., Moyers, T., Miller, W., & Bloomfield, L. (2006). Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. The Journal of Trauma, 60(1), 29–34.
8/16/2013 56
References
41. Sher, L. (2006). Alcoholism and suicidal behavior: A clinical overview. Acta Psychiatrica Scandinavica, 113(1), 13–22.
42. Smith P.C., Schmid,t S.M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine 24(7), 783–788.
43. Soardo, G., Donnini, D., Varutti, R., Milocco, C., Basan, L., Esposito, W., & Sechi, L. (2006). Effects of alcohol withdrawal on blood pressure in hypertensive heavy drinkers. Journal of Hypertension, 24(8), 1493–1498.
44. Substance Abuse and Mental Health Services Administration. (2009). Screening, Brief Intervention, and Referral to Treatment: New Populations, New Effectiveness Data. Retrieved February 17, 2012, from http://www.samhsa.gov/samhsanewsletter/Volume_17_Number_6/SBIRT.aspx
45. Substance Abuse and Mental Health Services Administration, SAIS, data collected through January 20, 2012. Preliminary data from SBIRT State grantee cohorts.
46. U. S. Department of Agriculture. Center for Nutrition Policy and Promotion(2010). Section 7: Alcohol. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. Retrieved March 2, 2012 from http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/D-7-Alcohol.pdf
47. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
48. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Service Administration, Center for Substance Abuse Treatment. (2007). Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: Committee on Trauma Quick Guide. Washington, DC. (SMA) 07–4266. Retrieved March 13, 2012, from http://www.samhsa.gov/csatdisasterrecovery/featuredReports/01-alcohol%20SBI%20for%20Trauma%20Patients.pdf
49. U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. (2005). Helping patients who drink too much: A clinician’s guide. Updated 2005 Edition, NIH Publication No. 07-3769, Reprinted June 2007.
50. Vaca, F., & Winn, D. (2007). The basics of alcohol screening, brief intervention and referral to treatment in the emergency department. The Western Journal of Emergency Medicine, 8(3), 88–92.
8/16/2013 57
References
51. Virginia Tech Alcohol Abuse Prevention. Progressive Effects of Alcohol. http://www.alcohol.vt.edu/students/alcoholeffects/index.htm
52. Vong, S., & Bell, B.P. (2004). Chronic liver disease mortality in the United States 1990–1998. Hepatology 39(2), 476–483.
53. Wannamethee, S., & Shaper, A. (2003). Alcohol, body weight, and weight gain in middle-aged men. American Journal of Clinical Nutrition, 77(5), 1312–1317.
54. Washington State Department of Social and Health Services, Research and Data Analysis Division. Estee, S., He, L., Mancuso, D., & Felver, B. (2007). Medicaid costs declined among emergency department patients who received brief interventions for substance use disorders through WASBIRT.
55. Wechsler, H., & Austin, S. (1998). Binge drinking: The five/four measure. Journal of Studies on Alcohol 59(1), 122–124.
56. Wechsler, H., & Nelson, T. F. (n.d). Relationship between level of consumption and harms in assessing drink cut-points for alcohol research: Commentary on “Many college freshmen drink at levels far beyond the binge threshold” by White, et al. Alcoholism: Clinical and Experimental Research, 30(6), 922–927.
57. World Health Organization. Brief Intervention for Substance Use: A Manual for Use in Primary Care. http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf
8/16/2013 58
