Intervention Summary

The Brief Negotiation Interview for Harmful and Hazardous Drinkers

The Brief Negotiation Interview (BNI) for Harmful and Hazardous Drinkers is a screening and brief intervention model designed for use in hospital emergency departments (EDs) with adults who are presenting for acute care and have a history of harmful and hazardous drinking. The intervention is designed to reduce a patient's high-risk level of alcohol use and driving under the influence (defined as driving after consuming more than three drinks).

If a patient consents to screening, he or she is administered a 17-item health history screening questionnaire, which contains alcohol quantity and frequency questions recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to identify harmful and hazardous drinkers. NIAAA defines harmful and hazardous drinking as the consumption of more than 14 drinks per week (or more than 4 drinks per occasion) by men 65 years and younger or the consumption of more than 7 drinks per week (or more than 3 drinks per occasion) by women of any age or by men older than 65 years. Patients who have a positive screening result on the basis of the NIAAA definition of harmful and hazardous drinking receive the intervention, which is delivered by attending physicians, physician associates, or advanced practice registered nurses during the course of ED medical care, while the patient is waiting for the doctor, laboratory results, or medications. The BNI can be implemented in 10 minutes, and it uses motivational interviewing and cognitive behavioral strategies to capitalize on a "teachable moment," with the goal of achieving a patient-centered agreement for reducing his or her drinking. The BNI consists of the following steps:

The interventionist establishes rapport with the patient and asks permission to discuss his or her alcohol consumption.
The interventionist reviews the patient's screening responses and provides feedback, placing the screening results within the context of NIAAA's guidelines for low-risk drinking, and asks the patient if he or she sees a connection between drinking and the ED visit.
The interventionist assesses the patient's motivation to change by asking the patient how likely he or she is to change his or her drinking behavior and why, using a scale from 1 to 10, where 1 indicates that he or she is not ready to change any aspect of drinking behavior and 10 indicates that he or she is very ready to change.
The interventionist and patient negotiate a plan for changing the patient's drinking behavior by setting goals, and the patient signs an agreement to decrease drinking. The interventionist also arranges follow-up services by providing the patient with direct referrals to substance abuse treatment.

In addition, implementing staff may choose to provide patients with a 10-minute, follow-up booster session by phone at 1 month after the ED visit.

Before delivering the BNI, implementing staff must complete 2 hours of training and proficiency testing.

Descriptive Information

Areas of Interest	Substance use disorder treatment
Outcomes	1: Alcohol use 2: Driving after consuming more than three drinks
Outcome Categories	Alcohol
Ages	18-25 (Young adult) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	Urban Suburban
Implementation History	The BNI was first implemented as a part of a randomized controlled trial in the Yale-New Haven Hospital ED in New Haven, Connecticut. As part of the Academic ED SBIRT Research Collaborative, additional ED providers were trained in California, Colorado, Connecticut, Georgia, Massachusetts, Michigan, New Jersey, New Mexico, Rhode Island, Virginia, and Washington, DC. More than 1,000 ED practitioners who have received training in BNI have delivered this intervention to more than 2,000 patients.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	The BNI model has been adapted for implementation in hospital-based outpatient and/or inpatient medical settings in the areas of obstetrics and gynecology, primary care, pediatrics (for children as young as 11 years), and psychiatry, as well as in adolescent clinics. It also has been expanded to target tobacco use and unsafe sexual practices.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

D'Onofrio, G., Fiellin, D. A., Pantalon, M. V., Chawarski, M. C., Owens, P. H., Degutis, L. C., et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Annals of Emergency Medicine, 60(2), 181-192.

Supplementary Materials

D'Onofrio, G., Bernstein, E., & Rollnick, S. Motivating patients for change: A brief strategy for negotiation. In E. Bernstein & J. Bernstein (Eds.), Case studies in emergency medicine and the health of the public (pp. 295-303). Boston, MA: Jones & Bartlett Publishers.

D'Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D. A., Busch, S. H., Chawarski, M. C., et al. Brief intervention for hazardous and harmful drinkers in the emergency department. Annals of Emergency Medicine, 51(6), 742-750.

D'Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D. A., & O'Connor, P. G. Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Academic Emergency Medicine, 12(3), 249-256.

D'Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D., & O'Connor, P. G. Project ED Health II BNI training manual. New Haven, CT: Yale University School of Medicine.

Mundt, J. C., Bohn, M. J., King, M., & Hartley, M. T. Automating standard alcohol use assessment instruments via interactive voice response technology. Alcoholism: Clinical and Experimental Research, 26(2), 207-211.

Pantalon, M. V., Martino, S., Dziura, J., Li, F.-Y., Owens, P. H., Fiellin, D. A., et al. Development of a scale to measure practitioner adherence to a brief intervention in the emergency department. Journal of Substance Abuse Treatment, 43(4), 382-388.

Sobell, L. C., & Sobell, M. B. Timeline follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten & J. Allen (Eds.), Measuring alcohol consumption: Psychosocial and biological methods (pp. 41-72). Totowa, NJ: Humana Press.

The Project ED Health BNI Adherence Scales--Training, Research, and Booster Versions

Outcomes

Outcome 1: Alcohol use
Description of Measures	Alcohol use was measured with the Timeline Followback (TLFB) interview, a calendar-based method for reconstructing days of drinking over a specified time period. Through the TLFB interview, patients reported the number of drinks they had in the past 7 days and the number of binge drinking episodes in the past 28 days. Binge drinking was defined as the consumption of more than four drinks per occasion by men age 65 and younger and more than three drinks per occasion by women of any age and by men older than 65 years. Each patient's number of drinks in the past 7 days was assessed by a phone-based interactive voice response system at baseline and at the 6- and 12-month follow-ups. The patient's number of binge drinking episodes in the past 28 days was assessed by a phone-based interactive voice response system at baseline and by a research associate through a phone-based interview at the 6- and 12-month follow-ups.
Key Findings	In a randomized clinical study, adult patients who presented to a university-based hospital's ED for acute care and had a history of harmful and hazardous drinking (as determined by a general health questionnaire that included alcohol quantity and frequency questions recommended by NIAAA) were assigned to one of four conditions: the BNI; the BNI with a booster, which was a follow-up phone call made by a trained primary care nurse 1 month after the patient's ED visit; standard care (i.e., the general health questionnaire and whatever the ED treatment team did in their practice upon learning the patient had a drinking history), which was used as the comparison condition; or standard care without baseline or 6-month assessment, which was included in the study to control for the effects of assessment on the main outcome. Findings indicated the following from baseline to the 6- and 12-month follows-ups: Patients who received the BNI with or without a booster reported consuming fewer drinks in the past 7 days than patients in the comparison condition (p = .045). Patients older than 26 years who received the BNI with or without a booster reported consuming fewer drinks in the past 7 days than 18- to 26-year-old patients who received the BNI with or without a booster and patients older than 26 years in the comparison condition (p = .002). Patients who received the BNI with or without a booster reported having fewer binge drinking episodes in the past 28 days than patients in the comparison condition (p = .03). Patients older than 26 years who received the BNI with or without a booster reported having fewer binge drinking episodes in the past 28 days than 18- to 26-year-old patients who received the BNI with or without a booster and patients older than 26 years in the comparison condition (p = .007). Neither the number of drinks in the past 7 days nor the number of binge drinking episodes in the past 28 days differed significantly between the BNI conditions.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.9 (0.0-4.0 scale)

Outcome 2: Driving after consuming more than three drinks
Description of Measures	Driving after consuming more than three drinks was measured as the number of times patients reported driving after consuming more than three drinks more than once in the past 12 months. For each patient, a research associate assessed this outcome through a face-to-face interview at baseline and a phone-based interview at the 12-month follow-up.
Key Findings	In a randomized clinical study, adult patients who presented to a university-based hospital's ED for acute care and had a history of harmful and hazardous drinking (as determined by a general health questionnaire that included alcohol quantity and frequency questions recommended by NIAAA) were assigned to one of four conditions: the BNI; the BNI with a booster, which was a follow-up phone call made by a trained primary care nurse 1 month after the patient's ED visit; standard care (i.e., the general health questionnaire and whatever the ED treatment team did in their practice upon learning the patient had a drinking history), which was used as the comparison condition; or standard care without baseline or 6-month assessment, which was included in the study to control for the effects of assessment on the main outcome. From baseline to the 12-month follow-up, the decrease in the percentage of participants who reported driving after consuming more than three drinks more than once in the past 12 months was greater for patients who received the BNI with or without a follow-up booster than for those in the comparison condition (p = .04): 39% to 31% for the BNI with a booster, 38% to 29% for the BNI, and 43% to 42% for the comparison condition.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult)	71.9% Male 28.1% Female	62.9% White 21.6% Black or African American 13.3% Hispanic or Latino 2.2% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Alcohol use	3.8	3.8	3.9	3.9	4.0	4.0	3.9
2: Driving after consuming more than three drinks	2.5	2.5	3.9	3.9	4.0	4.0	3.5

Study Strengths

The TLFB interview has strong psychometric properties and is considered a gold standard self-report measure for alcohol use recall. One of the alcohol use items--number of drinks in the past 7 days--was collected by a phone-based interactive voice response system, which increased its reliability by minimizing social desirability effects, and comparison with face-to-face interviews increased its validity. Three independent, trained raters who were blind to study hypotheses and condition assignments used a tested fidelity instrument to rate audiotapes of intervention and booster sessions, and the mean ratings indicated good adherence: 77.5% for the intervention session and 73% for the booster session. Attrition rates and missing data did not differ among study conditions, and missing data were modeled through a series of sensitivity analyses on primary outcome measures. Random assignment controlled for many potential confounding variables. A prospective power analysis to determine sample size ensured adequate power to detect intervention effects on the primary outcome of alcohol use, and an intent-to-treat approach coupled with state-of-the-art, mixed-model statistical procedures enabled the use of all available data for study participants.

Study Weaknesses

One of the outcomes--driving after consuming more than three drinks--was measured by face-to-face and phone-based interviews with research associates instead of the interactive voice response system, which most likely decreased its reliability. Additionally, only face validity was established for the outcome of driving after consuming more than three drinks; there was no independent verification of the respondent's self-report.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

BNI Testing Case

BNI Training Cases

D'Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D., & O'Connor, P. G. Project ED Health II: BNI training manual. New Haven, CT: Yale University School of Medicine.

D'Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D., & O'Connor, P. G. Project ED Health: Brief Negotiated Interview (BNI) steps [Laminated card]. New Haven, CT: Yale University School of Medicine.

Pantalon, M. V. Research BNI Adherence Scale (BAS). New Haven, CT: Yale School of Medicine.

Project ED Health Booster, BNI Adherence Scale (BAS)

Project ED Health Training, BNI Adherence Scale (BAS)

The Emergency Practitioner and the Unhealthy Drinker [DVD]

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.5	4.0	3.3	3.6

Dissemination Strengths

The program Web site provides a synopsis of considerations for implementation, including examples of settings in which the program has been implemented and how the implementation was conducted. Training materials are well developed and comprehensive, incorporating best practices through a multimedia presentation, role-plays, and rehearsals. Adherence scales that can be used to support quality assurance are provided. Some guidance is provided to assist new implementation sites in the development of a quality assurance protocol.

Dissemination Weaknesses

There is limited written detail on how new sites should use the implementation tools and concepts outlined on the program Web site. Comprehensive quality assurance protocols, including clear, standardized instructions for monitoring fidelity and intervention outcomes and using the resulting data to improve program delivery, are not provided.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
BNI Training Manual	Free	Yes
BNI Steps (laminated card)	Free	Yes
The Emergency Practitioner and the Unhealthy Drinker (DVD)	Free	Yes
BNI Testing Case	Free	Yes
BNI Training Cases (3)	Free	Yes
2-hour, on-site BNI Training	Varies depending on site needs and location	Yes
4-hour, on-site BNI Training of Trainers	Varies depending on site needs and location.	No
Technical assistance and consultation via Webinar, phone, and/or in-person meetings	Varies depending on site needs	No
BNI Adherence Scale, Training Version	Free	Yes
BNI Adherence Scale, Research Version	Free	No
BNI Adherence Scale, Booster Version	Free	No

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Academic ED SBIRT Research Collaborative. An evidence-based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance Abuse, 28(4), 79-92. (Published simultaneously in Alcohol/drug screening and brief intervention: Advances in evidence-based practice, pp. 79-92, by R. Saitz & M. Galanter, Eds., New York, NY: Haworth Medical Press)

D'Onofrio, G., & Degutis, L. C. Integrating Project ASSERT: A screening, intervention, and referral to treatment program for unhealthy alcohol and drug use into an urban emergency department. Academic Emergency Medicine, 17(8), 903-911.

* D'Onofrio, G., Fiellin, D. A., Pantalon, M. V., Chawarski, M. C., Owens, P. H., Degutis, L. C., et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Annals of Emergency Medicine, 60(2), 181-192.