VALUE OF BRIEF INTERVENTION IN THE EMERGENCY DEPARTMENT The best site for intervention is wherever the individuals who need help can be found. The first principle of intervention is that it comes to people, instead of people having to seek it out. The second is that it be timely, and the best time for early intervention is the crisis that brings the person with an alcohol or drug problem into the system for a medical, social, or criminal justice problem. An ED visit, for example, appears to be a teachable moment. Brief interventions have been shown to be effective for the at-risk user to negotiate behavior change, and for the dependent drinker and drug user to negotiate referral to treatment. The entire interaction can be accomplished in less than 10 min, and the dialogue can take place either at discharge or while suturing or casting.

INTERVENTION METHODS The BNI is a dialogue format developed in a busy urban ED for negotiating change in substance-related behaviors. In this method, the practitioner is the facilitator rather than the agent of change. The BNI may result in behavior change for the individual who is at risk and facilitates contact with the treatment system for the individual who is dependent. Through negotiation, patients' needs are tailored to solutions, and patients are matched with treatment modalities they are able to accept.

The BNI is based on the principles of brief motivational interviewing developed by Miller and Rollnick, 22 which are encapsulated in the FRAMES acronym (feedback, responsibility, advice, menu or choice, empathy, and self-efficacy). Brief cognitive motivational intervention also incorporates elements of a stages-of-change model, 23 in which five stages of change with highly predictable patterns are identified: precontemplation, contemplation, preparation, action, and maintenance, with the possibility of setbacks along the spiral pathway. Substance abusers are thought to cycle through these five stages in the course of changing their addiction behavior. Intervention techniques have been developed to suit each of these stages and explore with individuals the pros and cons of their behavior. In this process, the interventionist assists the addicted person to (1) define the problem, (2) identify his or her present stage, and (3) move through the stages of change toward recovery.

The BNI is used to assist patients to recognize and change behaviors that pose significant health risks. The goal of the interaction is to facilitate resolution of ambivalence through exploration of conflicting motivations (the pros and cons of drug use) and negotiate possible strategies for change, depending on the patient's readiness to change. The patient is seen to possess a unique store of knowledge—his or her own life history—that is essential for behavioral change to occur and just as important for achieving the goal as the interviewer's expertise. The BNI is used to increase intrinsic motivation so that change arises from within, rather than being imposed from without. The patient identifies both the problem and the solutions in order to own them. The general principles for successfully negotiating behavior change include (1) respect for the autonomy of patients and their choices; (2) negotiation based on readiness to change, and tailoring of interventions to level of readiness; (3) appreciation that ambivalence is expected, and exploitation of ambivalence is an important tool for facilitating change; (4) selection of targets for change by the patient, not the expert; (5) definition of the expert as a provider of information and support; and (6) reliance on the patient as the active decision maker.24 "A patient's motivation to change can be enhanced by using a negotiation method in which the patient, not the practitioner, articulates the benefits and costs involved."25 This theoretical understanding is the basis of the assertion that the BNI is more productive than simple advice.

The BNI protocol is based on mnemonics familiar to all emergency medical specialists, ABC and CPR:

A: Assessment B: Brief intervention C: Call back

C: Cultural competence P: Patient choice R: Readiness

The BNI consists of the following steps:

1. Establish rapport with the patient throughout the clinical encounter. Establish an atmosphere of positive regard in which the patient is not a problem but a person who has a problem.

2. Ask the patient's permission to discuss the pros and cons of drug use. Use open-ended questions and empathic and reflective listening. Explore the importance to the patient of the issues that emerge, and establish which of the pros and cons has the greatest salience in order to concentrate on those with the highest priority.

3. Summarize what the patient says to indicate that you understand what has been said (and to be sure you are correct in your interpretation). This summary technique can also elicit more information as trust develops.

4. Ask the patient to describe his or her readiness to change. A drawing of a ruler with a scale of 1 to 10 is used to elicit readiness to change use of drugs and or alcohol, as well as readiness to enter treatment. The patient points to the location on the scale that describes the current state of readiness for each score.

5. Negotiate with the patient based on his or her perception of readiness (not ready, unsure, or ready). Find out where the patient finds him or herself on the readiness ruler on a scale of 1 to 10 (a score of 1 is least ready and a score of 10 is most ready). If the patient is (a) ready (a score of 8 to 10), then the interviewer will solicit previous experience in attempting to quit, and brainstorm alternatives; (b) unsure (a score of 5 to 7), then the pros and cons of drugs or alcohol use and the pros and cons of change or treatment need to be explored, further assessment may be proposed, and the question posed, What will it take to help you take a few steps toward being more ready, say, going from 6 to 8?; (c) not ready (a score of 1 to 4), then the interviewer expresses concern, offers information about the affects of drugs and alcohol, provides a list of resources for further reference, and suggests the possibility of further contact ( T§ble...,2.,8..7.-.l).

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