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Intervention Summary

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Project ASSERT

Project ASSERT (Alcohol and Substance Abuse Services, Education, and Referral to Treatment) is a screening, brief intervention, and referral to treatment (SBIRT) model designed for use in health clinics or emergency departments (EDs). Project ASSERT targets three groups:

  1. Out-of-treatment adults who are visiting a walk-in health clinic for routine medical care and have a positive screening result for cocaine and/or opiate use. Project ASSERT aims to reduce or eliminate their cocaine and/or opiate use through interaction with peer educators (substance abuse outreach workers who are in recovery themselves for cocaine and/or opiate use and/or are licensed alcohol and drug counselors).
  2. Adolescents and young adults who are visiting a pediatric ED for acute care and have a positive screening result for marijuana use. Project ASSERT aims to reduce or eliminate their marijuana use through interaction with peer educators (adults who are under the age of 25 and, often, college educated).
  3. Adults who are visiting an ED for acute care and have a positive screening result for high-risk and/or dependent alcohol use. Project ASSERT aims to motivate patients to reduce or eliminate their unhealthy use through collaboration with ED staff members (physicians, nurses, nurse practitioners, social workers, or emergency medical technicians).

Adolescents, young adults, and adults visiting a participating health clinic or ED for medical care are screened for substance use by Project ASSERT interventionists--peer educators or ED staff members who have been trained to deliver the intervention. Patients with a positive screening result are engaged by interventionists with the Brief Negotiated Interview (BNI), a semiscripted, motivational interviewing counseling session that focuses on the negative consequences associated with drug use and unhealthy drinking. Using the BNI, the interventionist builds rapport with the patient; asks the patient for permission to discuss drug and alcohol use; explores the pros and cons of the behavior associated with drug and alcohol use; discusses the gap between the client's real and desired quality of life; assesses the client's readiness for change in the targeted behavior; and develops an action plan, which includes direct referrals and access to substance abuse treatment.

When a peer educator delivers the intervention to an adult who uses cocaine and/or opiates or to an adolescent or young adult who uses marijuana, he or she follows up with each patient by telephone 10 days after the health clinic or ED visit. This call serves as a 5- to 10-minute booster session to discuss what has transpired since the BNI and to find out whether new service referrals are needed. When ED staff members deliver the intervention to an adult with high-risk and/or dependent alcohol use, a follow-up booster session is not provided.

On average, Project ASSERT is delivered in 15 minutes, although more time may be needed, depending on the severity of the patient's substance use problem and associated treatment referral needs. The face-to-face component of the intervention is completed during the course of medical care, while the patient is waiting for the doctor, laboratory results, or medications.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: May 2011
1: Cocaine and opiate abstinence
2: Alcohol use
3: Marijuana abstinence
4: Marijuana use
Outcome Categories Alcohol
Drugs
Ages 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Inpatient
Outpatient
Geographic Locations Urban
Suburban
Rural and/or frontier
Tribal
Implementation History Project ASSERT was originally funded as a Critical Populations Demonstration Grant by SAMHSA in 1993. It was first implemented in 1994 at the Boston Medical Center Emergency Department; since 1998, Project ASSERT has been continuously funded by the Boston Medical Center. In 1999, it was adopted and implemented at Yale-New Haven Hospital, New Haven, Connecticut. More than 30 sites have implemented the intervention in Connecticut, Massachusetts, and New York. Over 500,000 individuals have been screened for at-risk and dependent alcohol and drug use, and approximately 125,000 participants have received the brief motivational intervention, with at least 25,000 individuals being referred to treatment through Project ASSERT.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
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
Review Date: May 2011

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

Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77(1), 49-59.  Pub Med icon

Study 2

Academic ED SBIRT Research Collaborative. (2007). 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.  Pub Med icon (Published simultaneously in Alcohol/drug screening and brief intervention: Advances in evidence-based practice, pp. 79-92, by R. Saitz & M. Galanter, Eds., 2007, New York, NY: Haworth Medical Press)

Academic ED SBIRT Research Collaborative. (2007). The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Annals of Emergency Medicine, 50(6), 699-710.  Pub Med icon

Study 3

Bernstein, E., Edwards, E., Dorfman, D., Heeren, T., Bliss, C., & Bernstein, J. (2009). Screening and brief intervention to reduce marijuana use among youth and young adults in a pediatric emergency department. Academic Emergency Medicine, 16(11), 1174-1185.  Pub Med icon

Supplementary Materials

Bernstein, E., & Bernstein, J. (2009). Evolution of an emergency department-based collaborative intervention for excessive and dependent drinking: From one institution to nationwide dissemination, 1991-2006. In C. J. Cherpitel, G. Borges, N. Giesbrecht, D. Hungerford, M. Peden, V. Poznyak, R. Room, & T. Stockwell (Eds.), Alcohol and injuries: Emergency department studies in an international perspective (pp. 175-180). Geneva, Switzerland: World Health Organization.

Bernstein, E., Bernstein, J., & Levenson, S. (1997). Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine, 30(2), 181-189.  Pub Med icon

Bernstein, E., Topp, D., Shaw, E., Girard, C., Pressman, K., Woolcock, E., et al. (2009). A preliminary report of knowledge translation: Lessons from taking screening and brief intervention techniques from the research setting into regional systems of care. Academic Emergency Medicine, 16(11), 1225-1233.  Pub Med icon

Levy, S., Sherritt, L., Harris, S. K., Gates, E. C., Holder, D. W., Kulig, J. W., et al. (2004). Test-retest reliability of adolescents' self-report of substance use. Alcoholism: Clinical and Experimental Research, 28(8), 1236-1241.  Pub Med icon

Perrine, M. W., Mundt, J. C., Searles, J. S., & Lester, L. S. (1995). Validation of daily self-reported alcohol consumption using interactive voice response (IVR) technology. Journal of Studies on Alcohol, 56(5), 487-490.  Pub Med icon

Outcomes

Outcome 1: Cocaine and opiate abstinence
Description of Measures Cocaine and opiate abstinence for the prior 30 days was measured by radioimmune assay of hair samples (30-day window of detection), with confirmation of positive opiate results by gas chromatography-mass spectrometry. Negative screening results indicated 30-day abstinence. Hair samples were obtained at baseline and the 6-month follow-up.
Key Findings In a randomized clinical trial, adults who presented at urban, teaching hospital-based, walk-in health clinics for routine medical care were screened for cocaine and opiate use by radioimmune assay of hair samples. Those who had a positive screening result, were out of treatment, and agreed to participate were assigned to the intervention group, which received Project ASSERT, or the comparison group, which received a handout and was read a scripted statement--"based on your screening responses, you would benefit from help with your drug use"--by the interventionist, with no discussion. The handout included a list of treatment options and harm reduction information about safe sex and needle exchange. Study results included the following:

  • At the 6-month follow-up, the percentage of participants who were abstinent from cocaine use was higher for the intervention group than the comparison group (22.3% vs. 16.9%; p = .045). This difference was associated with a small effect size (odds ratio = 1.51, adjusted for baseline group differences in health insurance and homelessness).
  • At the 6-month follow-up, the percentage of participants who were abstinent from opiate use was higher for the intervention group than the comparison group (40.2% vs. 30.6%; p = .050). This difference was associated with a small effect size (odds ratio = 1.57, adjusted for baseline group differences in health insurance and homelessness).
  • At the 6-month follow-up, the percentage of participants who were abstinent from both cocaine and opiate use was higher for the intervention group than the comparison group (17.4% vs. 12.8%); however, this group difference was not statistically significant.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.8 (0.0-4.0 scale)
Outcome 2: Alcohol use
Description of Measures Alcohol use was assessed with the 7-item, abridged version of the National Alcohol Screening Day screening form adapted for emergency medicine.

Three questions measured the quantity and frequency of alcohol use and were developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA):

  • "On average, how many days per week do you drink alcohol (beer, wine, liquor)?"
  • "On a typical day when you drink, how many drinks do you have?"
  • "What is the maximum number of drinks you had on any given occasion during the last month?"
An average number of drinks per week was calculated by multiplying the participant's number of drinking days per week by the number of drinks consumed on a typical drinking day. Participants were considered at-risk drinkers (and eligible for study enrollment) if, by self-report, they exceeded the NIAAA guidelines for low-risk drinking published in Helping Patients Who Drink Too Much: A Clinician's Guide. The NIAAA low-risk limits used were ≤4 drinks per drinking occasion and ≤14 standard drinks per week for men, ≤3 drinks per drinking occasion and ≤7 drinks per week for women, and ≤1 drink per day and ≤7 drinks per week for adults 65 years and older.

Four items, from the CAGE instrument, measured the severity of alcohol use by participants who, per the NIAAA low-risk limits, were identified as being at risk:

  • C--"Have you ever felt you should cut down on your drinking?"
  • A--"Have people annoyed you by criticizing your drinking?"
  • G--"Have you ever felt bad or guilty about your drinking?"
  • E--"Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?"
Participants responded to each question with "yes" (1 point) or "no" (0 points), and points were summed to determine a baseline score. Participants with baseline CAGE scores of >2 were defined as possibly dependent drinkers (high level), and participants with baseline CAGE scores of <2 were considered at risk but unlikely to be dependent drinkers (low level).

The National Alcohol Screening Day screening form was administered in person in the ED (baseline) and by telephone at 3 months after the ED visit (follow-up), using an automated interactive voice response system.
Key Findings In a multisite clinical trial, adults who presented to 1 of 14 university-based EDs were screened for at-risk drinking (i.e., being over the low-risk limits established by NIAAA). Those who had a positive screening result at baseline and agreed to participate were assigned sequentially to the intervention group, which received Project ASSERT, or the comparison group, which received a written list of local referral resources. Study results included the following:

  • From baseline to the 3-month follow-up, intervention group participants reported a greater decrease in drinks per week than comparison group participants (22.5 to 14.1 vs. 22.9 to 17.4; p < .05) and a greater decrease in maximum drinks per drinking occasion (8.6 to 6.5 vs. 8.4 to 7.2; p < .05).
  • At the 3-month follow-up, the percentage of participants no longer exceeding the NIAAA low-risk drinking limits was higher for the intervention group than the comparison group (27.8% vs. 18.4%; p < .05).
  • At the 3-month follow-up, the percentage of participants with baseline CAGE scores of <2 who no longer exceeded the NIAAA low-risk limits was higher for the intervention group than the comparison group (37.2% vs. 18.6%; p < .05).
  • At the 3-month follow-up, for participants with baseline CAGE scores of <2, those in the intervention group reported 1.2 fewer drinks per maximum drinking occasion in the prior 30 days (p = .05) and 2.8 fewer drinks per week in the prior 30 days (p = .05) than those in the comparison group.
Studies Measuring Outcome Study 2
Study Designs Quasi-experimental
Quality of Research Rating 3.2 (0.0-4.0 scale)
Outcome 3: Marijuana abstinence
Description of Measures Marijuana abstinence was assessed with the Timeline Followback method, which uses a calendar format with holidays and special events to trigger retrospective recall of daily substance use across a specified time period. Participants used this tool to self-report marijuana consumption in the prior 30-day period at enrollment (baseline) and at the 3- and 12-month follow-ups. Marijuana consumption was defined as smoke in any form, including passive smoke or a toke (i.e., a puff on a marijuana cigarette or pipe), and consumables (e.g., baked goods containing cannabis). Marijuana abstinence was defined as zero marijuana consumption reported in the prior 30 days.
Key Findings In a randomized clinical study, youth and young adults (aged 14-21 years) who presented to an urban, university-based pediatric ED for acute care were screened for marijuana and alcohol use. Those who had a positive screening result for marijuana use (smoked marijuana ≥3 days in the prior 30 days) but a negative result for alcohol use and agreed to participate in the study were assigned to one of three groups: the intervention group, which received Project ASSERT; an assessed comparison group; or a nonassessed comparison group. The assessed comparison group (like the intervention group) received a battery of assessment instruments, a handout with information on the risks of marijuana use and a listing of adolescent treatment and community resources, and 3- and 12-month follow-up appointments. The nonassessed comparison group received the handout and a 12-month follow-up appointment.

At the 12-month follow-up, the percentage of participants who abstained from marijuana was higher for the intervention group than the assessed comparison group (45% vs. 22%; p < .014). This group difference was associated with a medium effect size (odds ratio = 2.89); participants in the intervention group were almost three times as likely as those in the assessed comparison group to be abstinent at the 12-month follow-up (p < .014).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)
Outcome 4: Marijuana use
Description of Measures Marijuana use was assessed with the Timeline Followback method, which uses a calendar format with holidays and special events to trigger retrospective recall of daily substance use across a specified time period. Participants used this tool to self-report the number of marijuana use days and the number of days "getting high" in the prior 30-day period at enrollment (baseline) and at the 3- and 12-month follow-ups.
Key Findings In a randomized clinical study, youth and young adults (aged 14-21 years) who presented to an urban, university-based pediatric ED for acute care were screened for marijuana and alcohol use. Those who had a positive screening result for marijuana use (smoked marijuana ≥3 days in the prior 30 days) but a negative result for alcohol use and agreed to participate in the study were assigned to one of three groups: the intervention group, which received Project ASSERT; an assessed comparison group; or a nonassessed comparison group. The assessed comparison group (like the intervention group) received a battery of assessment instruments, a handout with information on the risks of marijuana use and a listing of adolescent treatment and community resources, and 3- and 12-month follow-up appointments. The nonassessed comparison group received the handout and a 12-month follow-up appointment. Study results included the following:

  • At the 3-month follow-up, the number of reported marijuana use days in the prior 30 days was 4.2 days fewer for participants in the intervention group compared with those in the assessed comparison group (p = .039), after controlling for baseline marijuana use.
  • At the 12-month follow-up, the number of reported marijuana use days in the prior 30 days was 5.3 days fewer for participants in the intervention group compared with those in the assessed comparison group (p = .024), after controlling for baseline marijuana use.
  • At the 12-month follow-up, among participants who reported smoking marijuana at least once in the prior 30 days, those in the intervention group were less likely to report "getting high" in the prior 30-day period compared with those in the assessed comparison group (adjusted odds ratio = 0.39; p < .027), after controlling for baseline marijuana use. This group difference was associated with a very small effect size.
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.3 (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 26-55 (Adult) 71% Male
29% Female
62% Black or African American
23% Hispanic or Latino
14% White
1% Race/ethnicity unspecified
Study 2 26-55 (Adult) 68% Male
32% Female
39% White
37% Black or African American
20% Hispanic or Latino
4% Race/ethnicity unspecified
Study 3 13-17 (Adolescent)
18-25 (Young adult)
62.4% Female
37.6% Male
79% Black or African American
15.7% Hispanic or Latino
4.8% White
0.5% Asian

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:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. 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: Cocaine and opiate abstinence 4.0 4.0 3.5 4.0 3.5 4.0 3.8
2: Alcohol use 3.0 3.0 3.5 2.8 3.5 3.5 3.2
3: Marijuana abstinence 3.5 3.5 3.5 3.5 2.5 3.5 3.3
4: Marijuana use 3.5 3.5 3.5 3.5 2.5 3.5 3.3

Study Strengths

Hair radioimmune assay, which has a 30-day window of detection, is a reliable and well-validated biochemical marker for cocaine and opiate use, and the Timeline Followback method for retrospective recall of marijuana use in the prior 30-day period has strong psychometric properties in adolescent samples. Intervention fidelity was very strong in two studies in which the intervention was delivered by peer educators who had intensive, manual-driven training that included role-plays and supervised interviews with participants; the same two studies also included a strict role designation of the peer educators as interventionists or evaluators to prevent crossover contamination. In one study, sessions with peer educators as interventionists were audiotaped and reviewed weekly by the project coordinator and investigators using a standardized instrument to assess intervention fidelity. In a third study, which used ED staff as the interventionists, intervention experts provided a 2-hour, structured training curriculum at each of the 14 participating sites, as well as an online version of the training curriculum for use by ED staff who could not attend the on-site training. Attrition was low at follow-up in one study (18%), with very little missing data. Two of the three studies used random assignment to control for many potential confounds, and one randomized study used a sophisticated blinding procedure and included a nonassessed comparison group in the study design to evaluate assessment reactivity and regression to the mean effects on outcomes at the 12-month follow-up. The statistical modeling of the outcome data in the quasi-experimental study appropriately accounted for the clustered sampling design (i.e., participants nested within sites) and for potential confounding effects of the sequential group assignment. All three studies used sophisticated modeling of the outcome data; the two studies with sizable attrition and missing data either imputed missing values on demographic control variables by participant site, that is, race, work status, education, and health status (one study), or used multiple analyses to examine the impact of attrition and missing data on the outcomes (the other study). These same two studies approximated an intent-to-treat approach. All three studies incorporated outcome mediator analyses where the subgroup sample size was adequate for statistical power.

Study Weaknesses

There was no independent validation of self-reported drinking behavior, and although self-report is recognized in the field as having strong psychometric properties, the reliability and validity of drinking behavior reports are not based on studies using a motivational interviewing counseling intervention where demand characteristics in the form of social desirability may be an issue. The attrition rate at the follow-up assessments was high by group in the two ED-based studies (38% and 39% for the intervention and comparison groups, respectively, at 3 months in one study and 31%, 22%, and 34% for the intervention, assessed comparison, and nonassessed comparison groups, respectively, at 12 months in the second study), despite being incorporated into the statistical modeling of the outcome data. Two of the three studies did not use a validated fidelity instrument. In one of the two studies using peer educators as interventionists, the booster follow-up telephone contact reached only 31% of the participants in the intervention group, which may have introduced a differential effect on the outcomes. The marijuana abstinence and marijuana use outcomes are not orthogonal; participants who were abstinent at the 12-month follow-up also reported fewer days of marijuana use, and it does not appear that the investigators removed the abstinent participants from the analysis of marijuana use.

Readiness for Dissemination
Review Date: May 2011

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.

Bernstein, E., Topp, D., Shaw, E., Girard, C., Pressman, K., Woolcock, E., et al. (2009). A preliminary report of knowledge translation: Lessons from taking screening and brief intervention techniques from the research setting into regional systems of care. Academic Emergency Medicine, 16(11), 1225-1233.  Pub Med icon

BNI-ART (Brief Negotiated Interview and Active Referral to Treatment) Institute. (2011). Health promotion advocate: SBIRT training. Boston, MA: Author.

BNI-ART Institute. (2011). Training of trainers: Sample binder. Boston, MA: Author.

BNI-ART Institute. (n.d.). Interactive cases: SBIRT in action [DVD]. Boston, MA: Author.

Program Web site, http://www.bu.edu/bniart/

Other implementation and training materials:

  • Boston Medical Center job description and posting: Health promotion advocate
  • Grant application
  • Medical Record Template/Checklist
  • SBIRT Program Implementation Guide
  • Training Narrative
  • Training offerings
  • Training of Trainers Narrative

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

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

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. 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
4.0 4.0 4.0 4.0

Dissemination Strengths

A comprehensive manual and accompanying handouts for health promotion advocates (i.e., peer educators) provide information on the SBIRT program rationale, program components, staffing requirements, screening instruments, scoring sheets, and case studies. A video with case vignettes demonstrates the program principles in practice. The program Web site has many implementation tools available for download. Implementers receive intensive training through the BNI-ART Institute, which includes practice in both SBIRT and motivational interviewing skills through role-plays, videotaped review sessions, and interactions with real patients in the Boston Medical Center Emergency Department. Introductory lectures, booster sessions, and a training of trainers are additional training options available to implementers. Consultation and technical assistance are available for implementation support, skill development, and program evaluation. Multiple quality assurance tools, as well as guidance for their use, help ensure implementation fidelity and outcome measurement.

Dissemination Weaknesses

No weaknesses were identified by reviewers.

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
3-day, off-site Health Promotion Advocate Training (includes program implementation guide, training manual, and DVD) $750 per participant for up to six participants Yes (one training option is required)
3-day, on-site Health Promotion Advocate Training (includes program implementation guide, training manual, and DVD) $750 per participant for up to six participants, plus trainer travel expenses Yes (one training option is required)
3-day, on- or off-site Training of Trainers (includes training manual) $1,300 per participant for three to six participants, plus trainer travel expenses if necessary No
Monthly group consultation call Free No
On-site implementation readiness consultation $50 per hour, plus travel expenses No
Introductory SBIRT/Project ASSERT lecture $300 per site No
Technical assistance and quality assurance consultation (on-site, telephone, or email) $100 per hour, plus travel expenses if necessary No
On- or off-site skills booster training Cost varies depending on site needs, location and length of training, and number of trainers (starting at $1,500) No
Contact Information

To learn more about implementation, contact:
Caitlin K. Barthelmes, M.P.H.
(617) 414-1349
ckbart@bu.edu

To learn more about research, contact:
Edward Bernstein, M.D.
(617) 414-3453
ebernste@bu.edu

To learn more about implementation or research, contact:
Judith Bernstein, RNC, M.S.N., Ph.D.
(617) 414-1415
jbernste@bu.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):