Using Recovering Alcoholics to Help Hospitalized Patients with Alcohol Problems

The extent to which the physician intervenes with a hospitalized patient who has an alcohol use disorder correlates with the patient’s reported change in alcohol use after discharge.¹ Primary care physicians may be called on to help manage hospitalized patients with alcohol use disorders, but exactly what they should do to help these patients is not always clear.

Alcohol abuse and trauma are common and related clinical problems.² A dose-response relationship has been observed between alcohol consumption and the risk of fatal injury.³ Traumatic injury is a major public health problem and a leading cause of morbidity and mortality in the United States. It ranks first in years of life lost, first in the utilization of hospital-days, second in disability-adjusted life-years, and fourth in overall mortality.⁴ Sims and colleagues⁵ found that violent trauma had a recurrence rate of 44% and a 5-year mortality rate of 20% and that 62% of these patients abused alcohol or drugs. Rivera and coworkers⁶ found that trauma victims who were intoxicated on presentation to a trauma center were 2.5 times more likely to be readmitted for another injury than those who were not intoxicated, and those with evidence of a chronic alcohol problem were 3.5 times more likely. Others have noted similar findings.^7,8 There is a unique opportunity to initiate treatment for patients with substance abuse disorders when they are hospitalized for a traumatic injury.⁹ Often this opportunity is missed.^10,11

It is not known how to intervene with victims of alcohol-related injuries to prevent subsequent injuries. Currently there are several options that could potentially improve the outcomes of hospitalized patients who have substance use disorders, such as brief advice, brief interventions, referral to a consultation team, and referral to a treatment center. At the very least, trauma victims with substance abuse problems should be given some brief advice from the surgeon. Although most surgeons appear willing to give this advice, many feel inadequately prepared to do it.¹² Thus, the burden of performing these interventions may fall to the patient’s primary care physician or the physician who is requested by the surgeon to provide consultation services.

A technique known as “brief intervention” consists of advice in a structured format that is given to patients with a substance use disorder.¹³ These interventions have been found to be effective in a number of clinical settings, including outpatient primary care.^14-16 In particular, brief interventions performed by a trained psychologist in a trauma center have been associated with a reduction in alcohol intake and a reduced risk of trauma recidivism.¹⁷ However, these interventions require significant physician training to implement. What is needed is a simple and practical method that can be used by primary care physicians that does not require extensive physician training.

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.

The first part of the follow-up was conducted as a component of a quality improvement program and involved patients who were admitted to the hospital between August 1, 1998, and June 30, 1999. These patients were contacted between September 1999 and January 2000. One of the investigators attempted to contact the patient and/or a relative or friend identified from the medical record 6 to 12 months after the subject (n=86) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of open-ended questions was asked (eg, “Are you better?” and “In what way?”). Then some specific questions were asked. The responses were summarized according to the subject’s patterns of alcohol use since hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program. During March 2000, the responses about drinking patterns and initiation of treatment or self-help during the first 6 months following hospital discharge were categorized and coded by 2 of the authors (S.B.R. and R.L.M.).

The second part of the follow-up was conducted as a medical student summer research project and involved patients who were admitted to the hospital between June 1, 1999, and March 31, 2000. These patients were contacted during June and July of 2000. There was a 1-month overlap in admission dates with the first part of the study because of a variation in hospital length of stay. Another investigator attempted to contact the patient and/or a relative or friend identified from the medical record 4 to 12 months after the study subject (n=228) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of structured questions was asked (eg, “During the first 6 [4 or 5 months in 7 cases] months following your discharge from the hospital did you try to cut down or quit drinking?”). The responses were coded according to the patient’s patterns of alcohol use during the 6 months following hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program.

Interventions

Patients who received usual care served as the control group (n=125). There were 2 groups that received an intervention: a brief intervention group (n=119) and a peer intervention group (n=70).

Usual Physician Care. Patients in this group received care by the residents and attending surgeons of the trauma service only, because the addiction medicine consultant was not available to see them. The surgeons and the hospital’s social workers may or may not have specifically addressed the patients’ substance abuse problems before discharge. During the study period, the hospital nurses, social workers, and resident physicians were given a 1-hour educational conference (in 12 separate sessions) about alcohol detoxification, screening, and brief intervention based on a national standard.²⁵ Preprinted protocols for detoxification were available in the hospital.

Brief Intervention. Patients in this group received the services of an addiction medicine consultant as part of their overall hospital care. Before discharge, these patients were given brief (5 to 15 minutes) advice following a previously described method.²⁶

Peer Intervention. Patients in this group received the same type of brief physician advice of those in the brief intervention group, and a 30- to 60-minute visit from a peer who was active in AA. Patients had to agree to a peer visit, but refusals were rare. Volunteers were recruited through a local residential facility for individuals with substance abuse problems. There were separate facilities for men and women, but they were administered by the same organization and followed the same basic program based on the AA model. The volunteers, called assistant staff, had successfully completed the program at that facility. These volunteers attended 3 2-hour training workshops designed to increase their skills at carrying the message of AA to others. These training workshops included both didactic and role-playing sessions that were designed to help the volunteers follow a protocol based on the AA model. These peers visited with the patient in pairs before hospital discharge. They did not give advice or make treatment recommendations. Instead, they shared their personal stories and their “experience, strength, and hope” with the patient. The peers were always matched with the patients’ sex and usually with the patients’ race. There was a period of time (approximately 6 months) during the study when women volunteers were not available because the facility for women was being relocated.

Statistical Analysis

The data sets from the 2 parts of the study were combined by one of the authors who also performed the data analysis. We used the exact version of the Fisher-Freeman-Halton test²⁷ to compare the 3 treatment groups in terms of categorical baseline characteristics and follow-up rates. One-way analysis of variance was used for continuous baseline characteristics. The same analysis was performed to compare those patients for whom follow-up data could be obtained with those for whom such data could not be obtained.

We use the exact version of the Cochran-Armitage test for trend²⁸ to test the null hypothesis of no difference among the treatment groups against the alternative hypothesis that the true proportions of positive outcomes would be in the following order: control < brief intervention < peer intervention (ie, we hypothesized that the success rate for the peer intervention group would be greater than that for the brief intervention group and that the success rate for the brief intervention group would be greater than that for the control group). If a significant difference was found among the treatment groups, we used the Fisher exact test with a Bonferroni adjustment to determine which pairs of treatment groups differed from each other. Stratified analysis was used to adjust for the effect of any confounding variables.

A sample size of 28 per group was sufficient to achieve 80% power for detecting differences in success rates (as measured by initiation of treatment or self-help) among the groups of 5% in the control group, 10% in the brief intervention group, and 30% in the peer intervention group using a one-tailed significance level of 0.05. All computations for the study were performed using Epi Info Version 6.04c (USD Inc, Stone Mountain, Ga, 1999), StatXact 4.0.1 (CYTEL Software Corp, Cambridge, Mass, 1998), and SPSS software version 10.0 (SPSS, Inc, Chicago, Ill, 1999). Continuous variables were summarized as mean plus or minus the standard deviation.

Results

Of the 314 patients in the study 258 (82.2%) were men; 244 (77.7%) were white; and the mean age was 37.2 years plus or minus 12.5 years (range=18-80). The mean blood alcohol concentration on admission for these 314 patients was 35.8 mmol per L plus or minus 26.5 mmol per L (165 mg/dL±122 mg/dL ) with a range of 00.0 to 143.3 mmol per L (000-660 mg/dL).

Of the 314 patients in our study, 140 (44.6%) were contacted following hospital discharge through communication with the subject, the subjects’ relatives, or both. Among the members of the control group, the follow-up rate was 35.2% (44/125); among those who received a brief intervention it was 47.9% (57/119); and among those who received a peer intervention, it was 55.7% (39/70). This represents a statistically significant difference at the Bonferroni cutoff of 0.05 divided by 3 (0.0167) between the control and peer intervention groups (P=.003) but not between the control and brief intervention groups (P=.023), or the brief and peer intervention groups (P=.152) using the Fisher exact test Table 1.

Among the 140 patients in the study, follow-up data were obtained from the patient in 97 instances (69%), from a friend or family member in 38 (27%), and from other sources in 5 (4%). For the 44 members of the control group, follow-up data were obtained from the patient in 37 instances (84%), from a friend or family member in 6 (14%), and from other sources in 1 (2%). For the 57 patients who received a brief intervention, follow-up data were obtained from the patient in 35 instances (61%), from a friend or family member in 21 (37%), and from other sources in 1 (2%). For the 39 patients who received a peer intervention, follow-up data were obtained from the patient in 25 instances (64%), from a friend or family member in 11 (28%), and from other sources in 3 (8%). The Fisher-Freeman-Halton test indicates a significant difference between the control and brief intervention groups (P=.012) but no difference between the control group and the peer intervention group (P=.117) or between the brief and peer intervention groups (P=.341), using the Bonferroni criterion of 0.0167. Those patients for whom follow-up data could be obtained were compared with those for whom it could not be obtained in terms of age, race, sex, and BAC on admission. The only significant difference that was found was for race: Follow-up data were available for 49.2% of the white patients but for only 28.6% of the nonwhite patients (P=.003). In terms of sex, follow-up data were available for 42.2% of the men and 55.4% of the women (P=.051). The mean age of those for whom follow-up data were available was 38.1 years plus or minus 12.8, compared with 36.4 years plus or minus 12.3 for those lost to follow-up (P=.226). The mean BAC on admission was 38.0 mmol per L plus or minus 27.8 (175 mg/dL±128) for those we were able to follow up, compared with 34.1 mmol per L plus or minus 25.4 (157 mg/dL±117) for those lost to follow-up (P=.233).

Comparisons of the baseline characteristics of the 140 patients across the 3 treatment groups are shown in Table 2. No significant differences were found at baseline between the groups at the 0.05 level except for male sex (P=.003); however, BAC almost reached statistical significance (P=.054).

The results for the main outcome measures of the 3 groups are shown in Table 3. The data reflect the fact that 7 patients drank for several weeks following hospital discharge but then abstained from drinking. As hypothesized, the success rates were greatest in the peer intervention group, followed by the brief intervention and control groups. All 3 outcomes showed statistically significant differences across groups. In terms of pairwise comparisons, the comparison between the control group and the peer intervention group met the Bonferroni criterion of 0.0167 for both abstinence for 6 months following hospital discharge (P=.013) and abstinence during the sixth month following hospital discharge (P=.007). For initiation of treatment or self-help, the comparisons of the peer group with both the control group and the brief intervention group were significant using the Bonferroni criterion (P <.001 in both cases).

Stratifying by sex yielded results that were not materially different from those presented in the Table (P=.016 for 6 months of abstinence; P=.007 for abstinence at during the sixth month; and P <.001 for initiation of treatment or self-help). Stratifying by BAC also did not affect the P values in any material way (data not shown).

Because of inconsistencies between the data from the 2 parts of the study and because of missing or unrecorded data, we can only make qualitative statements about other outcomes. No patient who was completely abstinent for the entire 6 months following hospital discharge had began drinking again by the time of the telephone interview. Many patients in the intervention groups (approximately a third) drank after hospital discharge and continued to drink up to the time of the follow-up interview, although a few of these patients claimed to have cut down. Only a few patients initially abstained from alcohol but returned to drinking at the time of follow-up. Most of the follow-up information came from the patient, our preferred source for outcome data. No patient who claimed to be abstinent had a family member who contradicted that report. However, several patients admitted to drinking (or using drugs) who had a member of the family who reported that the patient was abstinent. In those cases in which a family member could be located but the patient could not, it was usually because the patient was still drinking, living on the streets, or had no telephone. It was rare that the family member reported a favorable outcome (ie, abstinence), and we could not confirm this directly with the patient.

Several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital and especially for the visits by the peers. Some of these patients dramatically changed their lives. At least 3 patients in the peer intervention group went from being unemployed and homeless to full-time employment and having a permanent residence after they entered a treatment program and became involved in AA. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. At the time this manuscript was being prepared, one of these individuals was serving as a volunteer making visits to hospitalized patients with drinking problems.

Discussion

Previous studies have shown that brief interventions by professionals appear to help motivate patients to reduce drinking. Our study demonstrates that peers may help motivate patients to initiate treatment or self-help as well as promote abstinence. Brief physician advice followed by a visit with a volunteer from AA shows promise as a simple, practical, inexpensive, and effective intervention that may help to prevent patients from returning to alcohol use. This could lead to reductions in recurrent injuries for patients hospitalized with alcohol-related injuries.

Primary care physicians could use this approach to intervene with any patient hospitalized with alcohol-related problems. At our institution, peer volunteers are often called to visit patients with substance use disorders who are hospitalized by the surgery, medicine, family medicine, and psychiatry services. We used trauma patients, because there is a large volume of such patients at our institution who routinely have had toxicology tests performed on admission. Also, an existing trauma registry database facilitated the collection of patient data.

Many primary care physicians already possess the skills required to give patients brief advice about harmful lifestyles and are familiar with the use of community resources that can help their patients. Most communities that are large enough to have a hospital are large enough to support several AA groups. As part of the AA program, members are expected to carry the message of AA to alcoholics who are still drinking. They consider this Twelfth Step Work an essential part of the program that leads to personal progress in AA. Most physicians can easily identify patients who could benefit from hearing the message of AA. It is often not difficult to link up these 2 groups of individuals.²⁹ The local AA office can be called from the patient’s bedside telephone. After the physician explains the situation to the person who answers the call, the telephone can then be given to the patient. If the patient agrees, a member of AA may come to the hospital for a visit. These visits typically last 30 minutes to an hour. Sometimes the AA member may visit again during the patient’s hospital stay or at the time of discharge to escort the patient to an AA meeting. This service is provided without cost to the patient, the patient’s insurance carrier, or the hospital.

Limitations

Our study has many of the limitations of initial retrospective studies: a nonrandomized design, a study sample limited to a particular type of patient, limited follow-up data, variation in the interval from the time of the intervention to the time of follow-up data collection, reliance on self-report, and treatment groups that were not masked to the follow-up interviewers. The nonrandomized design might suggest that some of the favorable outcomes could be the result of selection bias. However, as indicated in Table 2, the baseline characteristics of the 3 groups were similar, except that women were under-represented in the peer intervention group. This finding is probably because of the limited availability of women peer volunteers during a 6-month period of time during the study. The trend towards a lower BAC in the control group suggests that patients with severe alcohol problems may be over-represented in the experimental groups. If anything, this would have biased the study results against the 2 intervention groups. However, the diagnosis of an alcohol use disorder was made using a chart audit for the control group (which did not always provide enough information to differentiate abuse from dependence), while an unstructured patient interview was used for the intervention group. Limited follow-up is a frequent problem in the patient populations used for alcohol use studies. Response rates of approximately 50% are typical. It is not clear why the follow-up rates for nonwhite patients were lower than for white subjects. We did seem to experience more problems with disconnected telephones in the nonwhite population, suggesting that there may be some economic differences between the 2 groups. We observed a significantly better follow-up rate for those in the peer intervention group. This is probably because we established contacts for follow-up directly from the patient in the intervention groups and could verify telephone numbers, but we had to rely on the medical record for the telephone numbers of the members of the control group. These numbers were not always correct. Also, we had significantly fewer family contacts in the control group. We did not record the exact timing of the follow-up after hospital discharge for each individual patient, and therefore could not compare the mean follow-up intervals between groups. However, for the reasons mentioned in the qualitative part of the results section, we do not believe that this problem would have influenced our results in any material manner. Our study was performed with trauma patients who may not be representative of other patient groups. Painful injuries and court appearances related to driving while intoxicated may be important factors that influence drinking behaviors. However, we have observed some nonsurgical patients who have benefited from peer interventions. We relied on patient self-report for outcomes and found a difference between the control and the 2 intervention groups. Although patients with alcohol use disorders may not accurately report their alcohol consumption, it is unlikely that those in the intervention groups would be more likely to report abstinence or to report initiation of treatment or self-help than those in the control group. We preferentially coded the poorest outcome information we obtained from the patient or the family member. Therefore, the source of the follow-up data had a minimal favorable impact on its accuracy. Although the follow-up interviewers knew to which group an individual patient belonged, they asked the interview questions from a printed script, to reduce observer bias to a minimum. Finally, although we obtained severity of disease data for the intervention groups (ie, abuse vs dependence) this information was not available for the control group.

Conclusions

The significant findings of our study suggest that the methods we employed should be evaluated in a well-funded rigorously designed prospective randomized study with more patients who would be objectively evaluated for the severity of their alcohol use disorder and with mechanisms to confirm and quantify the subjects’ self-reports of alcohol consumption and to ensure higher follow-up rates.

In the meantime, physicians can request that members of AA visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are not difficult to arrange, involve no costs, pose little patient risk, and might be of great benefit to some patients. We have continued to observe individual patients who were able to find sobriety following these interventions. These patients have expressed opinions that it was primarily the peers who motivated them to seek help for their problem drinking.

Acknowledgments

This work was supported, in part, by the University of Louisville Summer Research Scholarship Program and the University of Louisville Hospital Trauma Institute. We are indebted to the anonymous alcoholic members of a local self-help organization and to The Healing Place for assistance with locating volunteers to visit with our patients. We thank Karen Newton and Gail Wulfman for their assistance with the training of the volunteers. We thank Phillip Boaz, Janet Wallace, and Lance Hottman for their help with the data collection and Margaret M. Steptoe and Murphy Shields for their assistance in the preparation of this manuscript.

The extent to which the physician intervenes with a hospitalized patient who has an alcohol use disorder correlates with the patient’s reported change in alcohol use after discharge.¹ Primary care physicians may be called on to help manage hospitalized patients with alcohol use disorders, but exactly what they should do to help these patients is not always clear.

Alcohol abuse and trauma are common and related clinical problems.² A dose-response relationship has been observed between alcohol consumption and the risk of fatal injury.³ Traumatic injury is a major public health problem and a leading cause of morbidity and mortality in the United States. It ranks first in years of life lost, first in the utilization of hospital-days, second in disability-adjusted life-years, and fourth in overall mortality.⁴ Sims and colleagues⁵ found that violent trauma had a recurrence rate of 44% and a 5-year mortality rate of 20% and that 62% of these patients abused alcohol or drugs. Rivera and coworkers⁶ found that trauma victims who were intoxicated on presentation to a trauma center were 2.5 times more likely to be readmitted for another injury than those who were not intoxicated, and those with evidence of a chronic alcohol problem were 3.5 times more likely. Others have noted similar findings.^7,8 There is a unique opportunity to initiate treatment for patients with substance abuse disorders when they are hospitalized for a traumatic injury.⁹ Often this opportunity is missed.^10,11

It is not known how to intervene with victims of alcohol-related injuries to prevent subsequent injuries. Currently there are several options that could potentially improve the outcomes of hospitalized patients who have substance use disorders, such as brief advice, brief interventions, referral to a consultation team, and referral to a treatment center. At the very least, trauma victims with substance abuse problems should be given some brief advice from the surgeon. Although most surgeons appear willing to give this advice, many feel inadequately prepared to do it.¹² Thus, the burden of performing these interventions may fall to the patient’s primary care physician or the physician who is requested by the surgeon to provide consultation services.

A technique known as “brief intervention” consists of advice in a structured format that is given to patients with a substance use disorder.¹³ These interventions have been found to be effective in a number of clinical settings, including outpatient primary care.^14-16 In particular, brief interventions performed by a trained psychologist in a trauma center have been associated with a reduction in alcohol intake and a reduced risk of trauma recidivism.¹⁷ However, these interventions require significant physician training to implement. What is needed is a simple and practical method that can be used by primary care physicians that does not require extensive physician training.

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.

The first part of the follow-up was conducted as a component of a quality improvement program and involved patients who were admitted to the hospital between August 1, 1998, and June 30, 1999. These patients were contacted between September 1999 and January 2000. One of the investigators attempted to contact the patient and/or a relative or friend identified from the medical record 6 to 12 months after the subject (n=86) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of open-ended questions was asked (eg, “Are you better?” and “In what way?”). Then some specific questions were asked. The responses were summarized according to the subject’s patterns of alcohol use since hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program. During March 2000, the responses about drinking patterns and initiation of treatment or self-help during the first 6 months following hospital discharge were categorized and coded by 2 of the authors (S.B.R. and R.L.M.).

The second part of the follow-up was conducted as a medical student summer research project and involved patients who were admitted to the hospital between June 1, 1999, and March 31, 2000. These patients were contacted during June and July of 2000. There was a 1-month overlap in admission dates with the first part of the study because of a variation in hospital length of stay. Another investigator attempted to contact the patient and/or a relative or friend identified from the medical record 4 to 12 months after the study subject (n=228) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of structured questions was asked (eg, “During the first 6 [4 or 5 months in 7 cases] months following your discharge from the hospital did you try to cut down or quit drinking?”). The responses were coded according to the patient’s patterns of alcohol use during the 6 months following hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program.

Interventions

Patients who received usual care served as the control group (n=125). There were 2 groups that received an intervention: a brief intervention group (n=119) and a peer intervention group (n=70).

Usual Physician Care. Patients in this group received care by the residents and attending surgeons of the trauma service only, because the addiction medicine consultant was not available to see them. The surgeons and the hospital’s social workers may or may not have specifically addressed the patients’ substance abuse problems before discharge. During the study period, the hospital nurses, social workers, and resident physicians were given a 1-hour educational conference (in 12 separate sessions) about alcohol detoxification, screening, and brief intervention based on a national standard.²⁵ Preprinted protocols for detoxification were available in the hospital.

Brief Intervention. Patients in this group received the services of an addiction medicine consultant as part of their overall hospital care. Before discharge, these patients were given brief (5 to 15 minutes) advice following a previously described method.²⁶

Peer Intervention. Patients in this group received the same type of brief physician advice of those in the brief intervention group, and a 30- to 60-minute visit from a peer who was active in AA. Patients had to agree to a peer visit, but refusals were rare. Volunteers were recruited through a local residential facility for individuals with substance abuse problems. There were separate facilities for men and women, but they were administered by the same organization and followed the same basic program based on the AA model. The volunteers, called assistant staff, had successfully completed the program at that facility. These volunteers attended 3 2-hour training workshops designed to increase their skills at carrying the message of AA to others. These training workshops included both didactic and role-playing sessions that were designed to help the volunteers follow a protocol based on the AA model. These peers visited with the patient in pairs before hospital discharge. They did not give advice or make treatment recommendations. Instead, they shared their personal stories and their “experience, strength, and hope” with the patient. The peers were always matched with the patients’ sex and usually with the patients’ race. There was a period of time (approximately 6 months) during the study when women volunteers were not available because the facility for women was being relocated.

Statistical Analysis

The data sets from the 2 parts of the study were combined by one of the authors who also performed the data analysis. We used the exact version of the Fisher-Freeman-Halton test²⁷ to compare the 3 treatment groups in terms of categorical baseline characteristics and follow-up rates. One-way analysis of variance was used for continuous baseline characteristics. The same analysis was performed to compare those patients for whom follow-up data could be obtained with those for whom such data could not be obtained.

We use the exact version of the Cochran-Armitage test for trend²⁸ to test the null hypothesis of no difference among the treatment groups against the alternative hypothesis that the true proportions of positive outcomes would be in the following order: control < brief intervention < peer intervention (ie, we hypothesized that the success rate for the peer intervention group would be greater than that for the brief intervention group and that the success rate for the brief intervention group would be greater than that for the control group). If a significant difference was found among the treatment groups, we used the Fisher exact test with a Bonferroni adjustment to determine which pairs of treatment groups differed from each other. Stratified analysis was used to adjust for the effect of any confounding variables.

A sample size of 28 per group was sufficient to achieve 80% power for detecting differences in success rates (as measured by initiation of treatment or self-help) among the groups of 5% in the control group, 10% in the brief intervention group, and 30% in the peer intervention group using a one-tailed significance level of 0.05. All computations for the study were performed using Epi Info Version 6.04c (USD Inc, Stone Mountain, Ga, 1999), StatXact 4.0.1 (CYTEL Software Corp, Cambridge, Mass, 1998), and SPSS software version 10.0 (SPSS, Inc, Chicago, Ill, 1999). Continuous variables were summarized as mean plus or minus the standard deviation.

Results

Of the 314 patients in the study 258 (82.2%) were men; 244 (77.7%) were white; and the mean age was 37.2 years plus or minus 12.5 years (range=18-80). The mean blood alcohol concentration on admission for these 314 patients was 35.8 mmol per L plus or minus 26.5 mmol per L (165 mg/dL±122 mg/dL ) with a range of 00.0 to 143.3 mmol per L (000-660 mg/dL).

Of the 314 patients in our study, 140 (44.6%) were contacted following hospital discharge through communication with the subject, the subjects’ relatives, or both. Among the members of the control group, the follow-up rate was 35.2% (44/125); among those who received a brief intervention it was 47.9% (57/119); and among those who received a peer intervention, it was 55.7% (39/70). This represents a statistically significant difference at the Bonferroni cutoff of 0.05 divided by 3 (0.0167) between the control and peer intervention groups (P=.003) but not between the control and brief intervention groups (P=.023), or the brief and peer intervention groups (P=.152) using the Fisher exact test Table 1.

Among the 140 patients in the study, follow-up data were obtained from the patient in 97 instances (69%), from a friend or family member in 38 (27%), and from other sources in 5 (4%). For the 44 members of the control group, follow-up data were obtained from the patient in 37 instances (84%), from a friend or family member in 6 (14%), and from other sources in 1 (2%). For the 57 patients who received a brief intervention, follow-up data were obtained from the patient in 35 instances (61%), from a friend or family member in 21 (37%), and from other sources in 1 (2%). For the 39 patients who received a peer intervention, follow-up data were obtained from the patient in 25 instances (64%), from a friend or family member in 11 (28%), and from other sources in 3 (8%). The Fisher-Freeman-Halton test indicates a significant difference between the control and brief intervention groups (P=.012) but no difference between the control group and the peer intervention group (P=.117) or between the brief and peer intervention groups (P=.341), using the Bonferroni criterion of 0.0167. Those patients for whom follow-up data could be obtained were compared with those for whom it could not be obtained in terms of age, race, sex, and BAC on admission. The only significant difference that was found was for race: Follow-up data were available for 49.2% of the white patients but for only 28.6% of the nonwhite patients (P=.003). In terms of sex, follow-up data were available for 42.2% of the men and 55.4% of the women (P=.051). The mean age of those for whom follow-up data were available was 38.1 years plus or minus 12.8, compared with 36.4 years plus or minus 12.3 for those lost to follow-up (P=.226). The mean BAC on admission was 38.0 mmol per L plus or minus 27.8 (175 mg/dL±128) for those we were able to follow up, compared with 34.1 mmol per L plus or minus 25.4 (157 mg/dL±117) for those lost to follow-up (P=.233).

Comparisons of the baseline characteristics of the 140 patients across the 3 treatment groups are shown in Table 2. No significant differences were found at baseline between the groups at the 0.05 level except for male sex (P=.003); however, BAC almost reached statistical significance (P=.054).

The results for the main outcome measures of the 3 groups are shown in Table 3. The data reflect the fact that 7 patients drank for several weeks following hospital discharge but then abstained from drinking. As hypothesized, the success rates were greatest in the peer intervention group, followed by the brief intervention and control groups. All 3 outcomes showed statistically significant differences across groups. In terms of pairwise comparisons, the comparison between the control group and the peer intervention group met the Bonferroni criterion of 0.0167 for both abstinence for 6 months following hospital discharge (P=.013) and abstinence during the sixth month following hospital discharge (P=.007). For initiation of treatment or self-help, the comparisons of the peer group with both the control group and the brief intervention group were significant using the Bonferroni criterion (P <.001 in both cases).

Stratifying by sex yielded results that were not materially different from those presented in the Table (P=.016 for 6 months of abstinence; P=.007 for abstinence at during the sixth month; and P <.001 for initiation of treatment or self-help). Stratifying by BAC also did not affect the P values in any material way (data not shown).

Because of inconsistencies between the data from the 2 parts of the study and because of missing or unrecorded data, we can only make qualitative statements about other outcomes. No patient who was completely abstinent for the entire 6 months following hospital discharge had began drinking again by the time of the telephone interview. Many patients in the intervention groups (approximately a third) drank after hospital discharge and continued to drink up to the time of the follow-up interview, although a few of these patients claimed to have cut down. Only a few patients initially abstained from alcohol but returned to drinking at the time of follow-up. Most of the follow-up information came from the patient, our preferred source for outcome data. No patient who claimed to be abstinent had a family member who contradicted that report. However, several patients admitted to drinking (or using drugs) who had a member of the family who reported that the patient was abstinent. In those cases in which a family member could be located but the patient could not, it was usually because the patient was still drinking, living on the streets, or had no telephone. It was rare that the family member reported a favorable outcome (ie, abstinence), and we could not confirm this directly with the patient.

Several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital and especially for the visits by the peers. Some of these patients dramatically changed their lives. At least 3 patients in the peer intervention group went from being unemployed and homeless to full-time employment and having a permanent residence after they entered a treatment program and became involved in AA. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. At the time this manuscript was being prepared, one of these individuals was serving as a volunteer making visits to hospitalized patients with drinking problems.

Discussion

Previous studies have shown that brief interventions by professionals appear to help motivate patients to reduce drinking. Our study demonstrates that peers may help motivate patients to initiate treatment or self-help as well as promote abstinence. Brief physician advice followed by a visit with a volunteer from AA shows promise as a simple, practical, inexpensive, and effective intervention that may help to prevent patients from returning to alcohol use. This could lead to reductions in recurrent injuries for patients hospitalized with alcohol-related injuries.

Primary care physicians could use this approach to intervene with any patient hospitalized with alcohol-related problems. At our institution, peer volunteers are often called to visit patients with substance use disorders who are hospitalized by the surgery, medicine, family medicine, and psychiatry services. We used trauma patients, because there is a large volume of such patients at our institution who routinely have had toxicology tests performed on admission. Also, an existing trauma registry database facilitated the collection of patient data.

Many primary care physicians already possess the skills required to give patients brief advice about harmful lifestyles and are familiar with the use of community resources that can help their patients. Most communities that are large enough to have a hospital are large enough to support several AA groups. As part of the AA program, members are expected to carry the message of AA to alcoholics who are still drinking. They consider this Twelfth Step Work an essential part of the program that leads to personal progress in AA. Most physicians can easily identify patients who could benefit from hearing the message of AA. It is often not difficult to link up these 2 groups of individuals.²⁹ The local AA office can be called from the patient’s bedside telephone. After the physician explains the situation to the person who answers the call, the telephone can then be given to the patient. If the patient agrees, a member of AA may come to the hospital for a visit. These visits typically last 30 minutes to an hour. Sometimes the AA member may visit again during the patient’s hospital stay or at the time of discharge to escort the patient to an AA meeting. This service is provided without cost to the patient, the patient’s insurance carrier, or the hospital.

Limitations

Our study has many of the limitations of initial retrospective studies: a nonrandomized design, a study sample limited to a particular type of patient, limited follow-up data, variation in the interval from the time of the intervention to the time of follow-up data collection, reliance on self-report, and treatment groups that were not masked to the follow-up interviewers. The nonrandomized design might suggest that some of the favorable outcomes could be the result of selection bias. However, as indicated in Table 2, the baseline characteristics of the 3 groups were similar, except that women were under-represented in the peer intervention group. This finding is probably because of the limited availability of women peer volunteers during a 6-month period of time during the study. The trend towards a lower BAC in the control group suggests that patients with severe alcohol problems may be over-represented in the experimental groups. If anything, this would have biased the study results against the 2 intervention groups. However, the diagnosis of an alcohol use disorder was made using a chart audit for the control group (which did not always provide enough information to differentiate abuse from dependence), while an unstructured patient interview was used for the intervention group. Limited follow-up is a frequent problem in the patient populations used for alcohol use studies. Response rates of approximately 50% are typical. It is not clear why the follow-up rates for nonwhite patients were lower than for white subjects. We did seem to experience more problems with disconnected telephones in the nonwhite population, suggesting that there may be some economic differences between the 2 groups. We observed a significantly better follow-up rate for those in the peer intervention group. This is probably because we established contacts for follow-up directly from the patient in the intervention groups and could verify telephone numbers, but we had to rely on the medical record for the telephone numbers of the members of the control group. These numbers were not always correct. Also, we had significantly fewer family contacts in the control group. We did not record the exact timing of the follow-up after hospital discharge for each individual patient, and therefore could not compare the mean follow-up intervals between groups. However, for the reasons mentioned in the qualitative part of the results section, we do not believe that this problem would have influenced our results in any material manner. Our study was performed with trauma patients who may not be representative of other patient groups. Painful injuries and court appearances related to driving while intoxicated may be important factors that influence drinking behaviors. However, we have observed some nonsurgical patients who have benefited from peer interventions. We relied on patient self-report for outcomes and found a difference between the control and the 2 intervention groups. Although patients with alcohol use disorders may not accurately report their alcohol consumption, it is unlikely that those in the intervention groups would be more likely to report abstinence or to report initiation of treatment or self-help than those in the control group. We preferentially coded the poorest outcome information we obtained from the patient or the family member. Therefore, the source of the follow-up data had a minimal favorable impact on its accuracy. Although the follow-up interviewers knew to which group an individual patient belonged, they asked the interview questions from a printed script, to reduce observer bias to a minimum. Finally, although we obtained severity of disease data for the intervention groups (ie, abuse vs dependence) this information was not available for the control group.

Conclusions

The significant findings of our study suggest that the methods we employed should be evaluated in a well-funded rigorously designed prospective randomized study with more patients who would be objectively evaluated for the severity of their alcohol use disorder and with mechanisms to confirm and quantify the subjects’ self-reports of alcohol consumption and to ensure higher follow-up rates.

In the meantime, physicians can request that members of AA visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are not difficult to arrange, involve no costs, pose little patient risk, and might be of great benefit to some patients. We have continued to observe individual patients who were able to find sobriety following these interventions. These patients have expressed opinions that it was primarily the peers who motivated them to seek help for their problem drinking.

Acknowledgments

This work was supported, in part, by the University of Louisville Summer Research Scholarship Program and the University of Louisville Hospital Trauma Institute. We are indebted to the anonymous alcoholic members of a local self-help organization and to The Healing Place for assistance with locating volunteers to visit with our patients. We thank Karen Newton and Gail Wulfman for their assistance with the training of the volunteers. We thank Phillip Boaz, Janet Wallace, and Lance Hottman for their help with the data collection and Margaret M. Steptoe and Murphy Shields for their assistance in the preparation of this manuscript.

The extent to which the physician intervenes with a hospitalized patient who has an alcohol use disorder correlates with the patient’s reported change in alcohol use after discharge.¹ Primary care physicians may be called on to help manage hospitalized patients with alcohol use disorders, but exactly what they should do to help these patients is not always clear.

Alcohol abuse and trauma are common and related clinical problems.² A dose-response relationship has been observed between alcohol consumption and the risk of fatal injury.³ Traumatic injury is a major public health problem and a leading cause of morbidity and mortality in the United States. It ranks first in years of life lost, first in the utilization of hospital-days, second in disability-adjusted life-years, and fourth in overall mortality.⁴ Sims and colleagues⁵ found that violent trauma had a recurrence rate of 44% and a 5-year mortality rate of 20% and that 62% of these patients abused alcohol or drugs. Rivera and coworkers⁶ found that trauma victims who were intoxicated on presentation to a trauma center were 2.5 times more likely to be readmitted for another injury than those who were not intoxicated, and those with evidence of a chronic alcohol problem were 3.5 times more likely. Others have noted similar findings.^7,8 There is a unique opportunity to initiate treatment for patients with substance abuse disorders when they are hospitalized for a traumatic injury.⁹ Often this opportunity is missed.^10,11

It is not known how to intervene with victims of alcohol-related injuries to prevent subsequent injuries. Currently there are several options that could potentially improve the outcomes of hospitalized patients who have substance use disorders, such as brief advice, brief interventions, referral to a consultation team, and referral to a treatment center. At the very least, trauma victims with substance abuse problems should be given some brief advice from the surgeon. Although most surgeons appear willing to give this advice, many feel inadequately prepared to do it.¹² Thus, the burden of performing these interventions may fall to the patient’s primary care physician or the physician who is requested by the surgeon to provide consultation services.

A technique known as “brief intervention” consists of advice in a structured format that is given to patients with a substance use disorder.¹³ These interventions have been found to be effective in a number of clinical settings, including outpatient primary care.^14-16 In particular, brief interventions performed by a trained psychologist in a trauma center have been associated with a reduction in alcohol intake and a reduced risk of trauma recidivism.¹⁷ However, these interventions require significant physician training to implement. What is needed is a simple and practical method that can be used by primary care physicians that does not require extensive physician training.

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.

The first part of the follow-up was conducted as a component of a quality improvement program and involved patients who were admitted to the hospital between August 1, 1998, and June 30, 1999. These patients were contacted between September 1999 and January 2000. One of the investigators attempted to contact the patient and/or a relative or friend identified from the medical record 6 to 12 months after the subject (n=86) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of open-ended questions was asked (eg, “Are you better?” and “In what way?”). Then some specific questions were asked. The responses were summarized according to the subject’s patterns of alcohol use since hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program. During March 2000, the responses about drinking patterns and initiation of treatment or self-help during the first 6 months following hospital discharge were categorized and coded by 2 of the authors (S.B.R. and R.L.M.).

The second part of the follow-up was conducted as a medical student summer research project and involved patients who were admitted to the hospital between June 1, 1999, and March 31, 2000. These patients were contacted during June and July of 2000. There was a 1-month overlap in admission dates with the first part of the study because of a variation in hospital length of stay. Another investigator attempted to contact the patient and/or a relative or friend identified from the medical record 4 to 12 months after the study subject (n=228) was discharged from the hospital. A standard introduction was read to the respondent, and verbal consent was obtained. Following this, a series of structured questions was asked (eg, “During the first 6 [4 or 5 months in 7 cases] months following your discharge from the hospital did you try to cut down or quit drinking?”). The responses were coded according to the patient’s patterns of alcohol use during the 6 months following hospital discharge and whether the subject had initiated substance abuse treatment or a self-help program.

Interventions

Patients who received usual care served as the control group (n=125). There were 2 groups that received an intervention: a brief intervention group (n=119) and a peer intervention group (n=70).

Usual Physician Care. Patients in this group received care by the residents and attending surgeons of the trauma service only, because the addiction medicine consultant was not available to see them. The surgeons and the hospital’s social workers may or may not have specifically addressed the patients’ substance abuse problems before discharge. During the study period, the hospital nurses, social workers, and resident physicians were given a 1-hour educational conference (in 12 separate sessions) about alcohol detoxification, screening, and brief intervention based on a national standard.²⁵ Preprinted protocols for detoxification were available in the hospital.

Brief Intervention. Patients in this group received the services of an addiction medicine consultant as part of their overall hospital care. Before discharge, these patients were given brief (5 to 15 minutes) advice following a previously described method.²⁶

Peer Intervention. Patients in this group received the same type of brief physician advice of those in the brief intervention group, and a 30- to 60-minute visit from a peer who was active in AA. Patients had to agree to a peer visit, but refusals were rare. Volunteers were recruited through a local residential facility for individuals with substance abuse problems. There were separate facilities for men and women, but they were administered by the same organization and followed the same basic program based on the AA model. The volunteers, called assistant staff, had successfully completed the program at that facility. These volunteers attended 3 2-hour training workshops designed to increase their skills at carrying the message of AA to others. These training workshops included both didactic and role-playing sessions that were designed to help the volunteers follow a protocol based on the AA model. These peers visited with the patient in pairs before hospital discharge. They did not give advice or make treatment recommendations. Instead, they shared their personal stories and their “experience, strength, and hope” with the patient. The peers were always matched with the patients’ sex and usually with the patients’ race. There was a period of time (approximately 6 months) during the study when women volunteers were not available because the facility for women was being relocated.

Statistical Analysis

The data sets from the 2 parts of the study were combined by one of the authors who also performed the data analysis. We used the exact version of the Fisher-Freeman-Halton test²⁷ to compare the 3 treatment groups in terms of categorical baseline characteristics and follow-up rates. One-way analysis of variance was used for continuous baseline characteristics. The same analysis was performed to compare those patients for whom follow-up data could be obtained with those for whom such data could not be obtained.

We use the exact version of the Cochran-Armitage test for trend²⁸ to test the null hypothesis of no difference among the treatment groups against the alternative hypothesis that the true proportions of positive outcomes would be in the following order: control < brief intervention < peer intervention (ie, we hypothesized that the success rate for the peer intervention group would be greater than that for the brief intervention group and that the success rate for the brief intervention group would be greater than that for the control group). If a significant difference was found among the treatment groups, we used the Fisher exact test with a Bonferroni adjustment to determine which pairs of treatment groups differed from each other. Stratified analysis was used to adjust for the effect of any confounding variables.

A sample size of 28 per group was sufficient to achieve 80% power for detecting differences in success rates (as measured by initiation of treatment or self-help) among the groups of 5% in the control group, 10% in the brief intervention group, and 30% in the peer intervention group using a one-tailed significance level of 0.05. All computations for the study were performed using Epi Info Version 6.04c (USD Inc, Stone Mountain, Ga, 1999), StatXact 4.0.1 (CYTEL Software Corp, Cambridge, Mass, 1998), and SPSS software version 10.0 (SPSS, Inc, Chicago, Ill, 1999). Continuous variables were summarized as mean plus or minus the standard deviation.

Results

Of the 314 patients in the study 258 (82.2%) were men; 244 (77.7%) were white; and the mean age was 37.2 years plus or minus 12.5 years (range=18-80). The mean blood alcohol concentration on admission for these 314 patients was 35.8 mmol per L plus or minus 26.5 mmol per L (165 mg/dL±122 mg/dL ) with a range of 00.0 to 143.3 mmol per L (000-660 mg/dL).

Of the 314 patients in our study, 140 (44.6%) were contacted following hospital discharge through communication with the subject, the subjects’ relatives, or both. Among the members of the control group, the follow-up rate was 35.2% (44/125); among those who received a brief intervention it was 47.9% (57/119); and among those who received a peer intervention, it was 55.7% (39/70). This represents a statistically significant difference at the Bonferroni cutoff of 0.05 divided by 3 (0.0167) between the control and peer intervention groups (P=.003) but not between the control and brief intervention groups (P=.023), or the brief and peer intervention groups (P=.152) using the Fisher exact test Table 1.

Among the 140 patients in the study, follow-up data were obtained from the patient in 97 instances (69%), from a friend or family member in 38 (27%), and from other sources in 5 (4%). For the 44 members of the control group, follow-up data were obtained from the patient in 37 instances (84%), from a friend or family member in 6 (14%), and from other sources in 1 (2%). For the 57 patients who received a brief intervention, follow-up data were obtained from the patient in 35 instances (61%), from a friend or family member in 21 (37%), and from other sources in 1 (2%). For the 39 patients who received a peer intervention, follow-up data were obtained from the patient in 25 instances (64%), from a friend or family member in 11 (28%), and from other sources in 3 (8%). The Fisher-Freeman-Halton test indicates a significant difference between the control and brief intervention groups (P=.012) but no difference between the control group and the peer intervention group (P=.117) or between the brief and peer intervention groups (P=.341), using the Bonferroni criterion of 0.0167. Those patients for whom follow-up data could be obtained were compared with those for whom it could not be obtained in terms of age, race, sex, and BAC on admission. The only significant difference that was found was for race: Follow-up data were available for 49.2% of the white patients but for only 28.6% of the nonwhite patients (P=.003). In terms of sex, follow-up data were available for 42.2% of the men and 55.4% of the women (P=.051). The mean age of those for whom follow-up data were available was 38.1 years plus or minus 12.8, compared with 36.4 years plus or minus 12.3 for those lost to follow-up (P=.226). The mean BAC on admission was 38.0 mmol per L plus or minus 27.8 (175 mg/dL±128) for those we were able to follow up, compared with 34.1 mmol per L plus or minus 25.4 (157 mg/dL±117) for those lost to follow-up (P=.233).

Comparisons of the baseline characteristics of the 140 patients across the 3 treatment groups are shown in Table 2. No significant differences were found at baseline between the groups at the 0.05 level except for male sex (P=.003); however, BAC almost reached statistical significance (P=.054).

The results for the main outcome measures of the 3 groups are shown in Table 3. The data reflect the fact that 7 patients drank for several weeks following hospital discharge but then abstained from drinking. As hypothesized, the success rates were greatest in the peer intervention group, followed by the brief intervention and control groups. All 3 outcomes showed statistically significant differences across groups. In terms of pairwise comparisons, the comparison between the control group and the peer intervention group met the Bonferroni criterion of 0.0167 for both abstinence for 6 months following hospital discharge (P=.013) and abstinence during the sixth month following hospital discharge (P=.007). For initiation of treatment or self-help, the comparisons of the peer group with both the control group and the brief intervention group were significant using the Bonferroni criterion (P <.001 in both cases).

Stratifying by sex yielded results that were not materially different from those presented in the Table (P=.016 for 6 months of abstinence; P=.007 for abstinence at during the sixth month; and P <.001 for initiation of treatment or self-help). Stratifying by BAC also did not affect the P values in any material way (data not shown).

Because of inconsistencies between the data from the 2 parts of the study and because of missing or unrecorded data, we can only make qualitative statements about other outcomes. No patient who was completely abstinent for the entire 6 months following hospital discharge had began drinking again by the time of the telephone interview. Many patients in the intervention groups (approximately a third) drank after hospital discharge and continued to drink up to the time of the follow-up interview, although a few of these patients claimed to have cut down. Only a few patients initially abstained from alcohol but returned to drinking at the time of follow-up. Most of the follow-up information came from the patient, our preferred source for outcome data. No patient who claimed to be abstinent had a family member who contradicted that report. However, several patients admitted to drinking (or using drugs) who had a member of the family who reported that the patient was abstinent. In those cases in which a family member could be located but the patient could not, it was usually because the patient was still drinking, living on the streets, or had no telephone. It was rare that the family member reported a favorable outcome (ie, abstinence), and we could not confirm this directly with the patient.

Several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital and especially for the visits by the peers. Some of these patients dramatically changed their lives. At least 3 patients in the peer intervention group went from being unemployed and homeless to full-time employment and having a permanent residence after they entered a treatment program and became involved in AA. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. At the time this manuscript was being prepared, one of these individuals was serving as a volunteer making visits to hospitalized patients with drinking problems.

Discussion

Previous studies have shown that brief interventions by professionals appear to help motivate patients to reduce drinking. Our study demonstrates that peers may help motivate patients to initiate treatment or self-help as well as promote abstinence. Brief physician advice followed by a visit with a volunteer from AA shows promise as a simple, practical, inexpensive, and effective intervention that may help to prevent patients from returning to alcohol use. This could lead to reductions in recurrent injuries for patients hospitalized with alcohol-related injuries.

Primary care physicians could use this approach to intervene with any patient hospitalized with alcohol-related problems. At our institution, peer volunteers are often called to visit patients with substance use disorders who are hospitalized by the surgery, medicine, family medicine, and psychiatry services. We used trauma patients, because there is a large volume of such patients at our institution who routinely have had toxicology tests performed on admission. Also, an existing trauma registry database facilitated the collection of patient data.

Many primary care physicians already possess the skills required to give patients brief advice about harmful lifestyles and are familiar with the use of community resources that can help their patients. Most communities that are large enough to have a hospital are large enough to support several AA groups. As part of the AA program, members are expected to carry the message of AA to alcoholics who are still drinking. They consider this Twelfth Step Work an essential part of the program that leads to personal progress in AA. Most physicians can easily identify patients who could benefit from hearing the message of AA. It is often not difficult to link up these 2 groups of individuals.²⁹ The local AA office can be called from the patient’s bedside telephone. After the physician explains the situation to the person who answers the call, the telephone can then be given to the patient. If the patient agrees, a member of AA may come to the hospital for a visit. These visits typically last 30 minutes to an hour. Sometimes the AA member may visit again during the patient’s hospital stay or at the time of discharge to escort the patient to an AA meeting. This service is provided without cost to the patient, the patient’s insurance carrier, or the hospital.

Limitations

Our study has many of the limitations of initial retrospective studies: a nonrandomized design, a study sample limited to a particular type of patient, limited follow-up data, variation in the interval from the time of the intervention to the time of follow-up data collection, reliance on self-report, and treatment groups that were not masked to the follow-up interviewers. The nonrandomized design might suggest that some of the favorable outcomes could be the result of selection bias. However, as indicated in Table 2, the baseline characteristics of the 3 groups were similar, except that women were under-represented in the peer intervention group. This finding is probably because of the limited availability of women peer volunteers during a 6-month period of time during the study. The trend towards a lower BAC in the control group suggests that patients with severe alcohol problems may be over-represented in the experimental groups. If anything, this would have biased the study results against the 2 intervention groups. However, the diagnosis of an alcohol use disorder was made using a chart audit for the control group (which did not always provide enough information to differentiate abuse from dependence), while an unstructured patient interview was used for the intervention group. Limited follow-up is a frequent problem in the patient populations used for alcohol use studies. Response rates of approximately 50% are typical. It is not clear why the follow-up rates for nonwhite patients were lower than for white subjects. We did seem to experience more problems with disconnected telephones in the nonwhite population, suggesting that there may be some economic differences between the 2 groups. We observed a significantly better follow-up rate for those in the peer intervention group. This is probably because we established contacts for follow-up directly from the patient in the intervention groups and could verify telephone numbers, but we had to rely on the medical record for the telephone numbers of the members of the control group. These numbers were not always correct. Also, we had significantly fewer family contacts in the control group. We did not record the exact timing of the follow-up after hospital discharge for each individual patient, and therefore could not compare the mean follow-up intervals between groups. However, for the reasons mentioned in the qualitative part of the results section, we do not believe that this problem would have influenced our results in any material manner. Our study was performed with trauma patients who may not be representative of other patient groups. Painful injuries and court appearances related to driving while intoxicated may be important factors that influence drinking behaviors. However, we have observed some nonsurgical patients who have benefited from peer interventions. We relied on patient self-report for outcomes and found a difference between the control and the 2 intervention groups. Although patients with alcohol use disorders may not accurately report their alcohol consumption, it is unlikely that those in the intervention groups would be more likely to report abstinence or to report initiation of treatment or self-help than those in the control group. We preferentially coded the poorest outcome information we obtained from the patient or the family member. Therefore, the source of the follow-up data had a minimal favorable impact on its accuracy. Although the follow-up interviewers knew to which group an individual patient belonged, they asked the interview questions from a printed script, to reduce observer bias to a minimum. Finally, although we obtained severity of disease data for the intervention groups (ie, abuse vs dependence) this information was not available for the control group.

Conclusions

The significant findings of our study suggest that the methods we employed should be evaluated in a well-funded rigorously designed prospective randomized study with more patients who would be objectively evaluated for the severity of their alcohol use disorder and with mechanisms to confirm and quantify the subjects’ self-reports of alcohol consumption and to ensure higher follow-up rates.

In the meantime, physicians can request that members of AA visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are not difficult to arrange, involve no costs, pose little patient risk, and might be of great benefit to some patients. We have continued to observe individual patients who were able to find sobriety following these interventions. These patients have expressed opinions that it was primarily the peers who motivated them to seek help for their problem drinking.

Acknowledgments

This work was supported, in part, by the University of Louisville Summer Research Scholarship Program and the University of Louisville Hospital Trauma Institute. We are indebted to the anonymous alcoholic members of a local self-help organization and to The Healing Place for assistance with locating volunteers to visit with our patients. We thank Karen Newton and Gail Wulfman for their assistance with the training of the volunteers. We thank Phillip Boaz, Janet Wallace, and Lance Hottman for their help with the data collection and Margaret M. Steptoe and Murphy Shields for their assistance in the preparation of this manuscript.