Program stresses early intervention to break problem-drinking cycle

A man in inner-city Milwaukee confronted his binge beer habit after developing early signs of liver disease. A father in rural Polk County wanted to cut down on his drinking to set a good example for his children. A woman in Wisconsin’s North Woods decided to quit after driving her car off the road while intoxicated.

Although these stories come from very different places in Wisconsin, the patients involved had something in common besides the bottle-namely, someone to turn to. All of them were seeing a health educator provided through the Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL), a screening and assistance program for alcohol and drug abuse coordinated by the Department of Family Medicine at the University of Wisconsin School of Medicine and Public Health.

The program, which opened at 21 primary care clinics around the state this year, is simple and effective in early detection of at-risk or harmful drinking or drug use, numerous studies show. Four key questions that are included in any routine health care visit indicate which patients are at risk. Those patients then meet with an on-site WIPHL health educator to discuss their substance use and agree upon options for change.

For many patients, this early and brief intervention-which includes one to three follow-up consultations-is enough to help them significantly decrease or stop their alcohol and drug use. Patients who need more intensive help-only about 6 percent of those who screen positive-are referred to treatment programs with costs covered by WIPHL if they cannot pay and do not qualify for other means of assistance. Studies have proven the effectiveness of the screening, brief intervention, referral, and treatment process.

It’s a service Wisconsinites clearly need. Wisconsin regularly lands at or near the top of national rankings for high-risk and heavy drinking, according to the Centers for Disease Control. One out of four Wisconsin residents engage in illicit drug use or alcohol use to a degree defined as "at risk" by the National Institute on Alcohol Abuse and Alcoholism. Diseases and injuries related to alcohol and drug abuse make it the fourth leading cause of death in Wisconsin and the fourth leading cause of hospitalization.

"Everyone in Wisconsin is touched by alcohol and drug problems, either through their own substance use or through problems in their families and communities," says program director Richard Brown, an associate professor of family medicine at the University of Wisconsin School of Medicine and Public Health. "That tragic toll could be greatly reduced if potential alcohol or drug problems were caught at an early stage, but until now we have not had a system in place to do that."

Software engineers at Symphony Corporation, working with WIPHL, developed a program that allows for an efficient, thorough assessment of the patient’s health during the course of a simple interview. It combines questions developed by WIPHL with those developed by the World Health Organization in its Alcohol, Smoking and Substance Involvement Screening Test program (ASSIST) and other questions required by the U.S. government.

If a patient’s brief screen results indicate that he or she may have a health problem, the health educator meets with the patient and conducts an interview guided by this software. Responses are entered directly into a computer tablet to form a confidential health record for each patient to support and enhance health education as well as help WIPHL track overall progress of the program.

Not only are people’s lives improved through the kind of assistance WIPHL provides; a Wisconsin study showed that the state saves nearly $1,000 in health care and criminal justice costs for every patient receiving screening and brief intervention services.

Brown holds the lack of early intervention responsible for much of the pessimistic outlook that health professionals have toward alcohol and drug problems. "If we always waited to treat cancer until it reached advanced stages, we’d find a high failure rate with that disease also," Brown notes.

The good news is that early intervention often works. For many patients, one or two sessions with a health educator provide the wake-up call they need. That was the case with the father in Polk County.

"This man was not dependent, but he was drinking more than he wanted to," says WIPHL health educator Terry Murphy, who is stationed at the Polk County Health Department in Balsam Lake. "More than anything, he didn’t want his kids to think that drinking every night because you had a rough day at work was the right thing to do."

The patient, working with Murphy, created a plan for change with the goal of reducing his drinking to one or two nights a week. The patient was able to stick to the plan in large part because he was in charge of creating it. WIPHL health educators use the technique of motivational interviewing, in which they help patients identify and strengthen their own motivations for change as well as set their own goals. Numerous studies have shown that this method leads to excellent and lasting results in decreasing and eliminating problem drinking and drug use.

With the help of WIPHL, the Milwaukee man with the liver problem cut his drinking down from four 16-ounce beers a day to one or two a week-a significant reduction that is greatly benefiting his health. To health educator Robert Cherry, who conducted a few brief interventions with the patient at Aurora Sinai Family Care Center, allowing him to formulate his reduction plan-and not pressuring him to become abstinent-was instrumental to his success.

"He is a proud man who needed to be in charge," notes Cherry. "It was important for him to hear from me and from his physician that he had a problem, but he didn’t see himself as an alcoholic and he didn’t want people telling him what to do."

Over the next five years, the WIPHL clinics will provide an initial screening to some 100,000 patients ages 18 and older; of these initial screenings, some 25,000 people will be in need of further assistance. More clinics will be added in coming years, and the effort includes a focus on changing public policy and standards of care so that services continue to be delivered on a permanent basis.

The time to provide such assistance is long overdue, notes Brown. "For 12 years, government agencies and professional organizations have recommended that health care settings routinely provide alcohol and drug screening, intervention, and referral services to all patients," says Brown. "So far, few settings in the U.S. are doing so. This project is providing the training and resources that health care settings need to start delivering these services in urban, suburban, and rural settings around Wisconsin."

The project is funded by a $12.6 million grant from the federal Substance Abuse and Mental Health Services Administration and administered by the Wisconsin Department of Health and Family Services.