The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) has funded the Pennsylvania Department of Health (PA SBIRT) at $9.8 million for 5 years to provide services in general medical and other community settings. The grantees provided SBIRT services to adolescents and adult patients with substance abuse and dependence disorders.
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at-risk of developing them.Primary care, trauma centers, emergency departments, and other settings provide opportunities BEFORE more severe consequences occur.
There are three goals that SBIRT has set out to accomplish: The First is to encourage healthcare providers to screen and provide advice or counseling to their patients who misuse alcohol or other drugs.The Second is to influence risky behavior patterns and reduce exposure to the negative consequences of misuse.And finally to improve the linkages between the general community health care and specialized substance abuse providers to facilitate access to care when needed.
Additional outcomes as shown here can be found at www.insightforhealth.com. This report indicates the outcomes for patients that participated in the Texas insight for health project.
There are multiple barriers to screening and brief intervention in the medical community. Some of those include not having enough time to carry out interventions or not being reimbursed for Screening and Brief Intervention. Others include discomfort with initiating the discussion of substance use/misuse or physicians lack of training or education about the nature of substance use, misuse, or dependence. Unfortunately many physicians are uncertain about referral resources within their communities.
Traditional Substance Abuse Treatment Programs focus on patients with Alcohol or other Drug abuse or dependent diagnosis. As noted on the slide, there are differences between abuse or dependence which include withdrawal and tolerance. It is important to note that in order for the diagnosis to be made, patients must experience these symptoms for at least one year.
Screening instruments vary in their ability to detect different patterns and levels of drinking and in the degree of which they apply to specific subpopulations and settings.Some examples include:The BAC - Blood Alcohol Content- Blood test for level of ETOH in blood or other medical tests such Liver FunctionThe (AUDIT) - Alcohol Use Disorders Identification Test whichincorporates questions about quantity and frequency of alcohol use. ASSIST - Alcohol, Smoking and Substance Involvement Screening Test.. Which was developed by the World Health Organization (WHO) and covers:• tobacco,• alcohol,• cannabis,• cocaine,• amphetamine type stimulants,• sedatives,• hallucinogens,• inhalants,• opioids, and• other drugs.DAST-Drug Abuse Screening Test which consists of 28 questionsor is modified to 10 questions. This self-administered or interview tool is used to detect drug problems and also, assists with “staging” the patients level of possible dependence. The CRAFFT is intended specifically for adolescents. It draws upon adult screening instruments and covers alcohol or other drugs, in situations that are suited to adolescents. The questions are:1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?3. Do you ever use alcohol or drugs while you are by yourself Alone?4. Do you ever Forget things you did while using alcohol or drugs?5. Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?6. Have you ever gotten into Trouble while you were using alcohol or drugs?Scoring: 2 or more positive items indicate the need for further assessment.Tools such as the T-ACE/TWEAKAre use to Screen pregnant women for alcohol use has become increasingly important in light of new research showing that even low levels of prenatal alcohol exposure can harm the fetus. 4 or 5 P’sAre based on the work of Hope Ewing and Ira Chasnoff, and are screening insturments that can be used to screen women of childbearing age or those that are pregnant. Much like the CRAFFT for adolescents, the 4 or 5 P’s detects the risk the woman may be exposed to AOD use and thus at-risk of use. The cage is not listed here however the questionnaire has been evaluated in several studies, showing sensitivities ranging from 43 to 94 percent for detecting alcohol abuse and alcoholism . CAGE is well suited to busy primary care settings because it poses four straightforward yes/no questions that the clinician can easily remember and requires less than a minute to complete. However, the test may fail to detect low but risky levels of drinking . In addition, CAGE often performs less well among women and minority populations.
SBIRT uses the following guidelines developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for the definition of a “standard drink”. These guidelines are also depicted on the screening tool. Because the screening requests patients to report their level of alcohol use, it is important that each respondent has a clear understanding of what constitutes a “standard drink”. Some patients may mistakenly believe that a 16-oz beer or a martini, for example, is a single standard drink. This illustration provides a clear description of the equivalents of a standard drink.
The purpose of screening in SBIRT is to assist individuals in recognizing preventable risks. These screenings are intended to be a simple and unobtrusive part of the office visit that may be included with other routines such as blood pressure checks, weight, vitals etc. By incorporating the initial screening questions listed here, into the other triage routines of the practice, the questions are normalized into the day to day operations of the providers.These six short questions can be self administered via questionnaire or asked by the staff.
This diagram provides an illustration of how to match between the level of risk and the type of intervention. However, clinical judgment should always be used and can override these recommended protocols.
For women and those over the age of 65 consuming more than 2 drinks per occasion or 7 or more per week is considered risky drinking.For men consuming more than 4 drinks per occasion or 14 or more drinks per week is considered risky drinking.Any use is risky when your patient is: Pregnant Driving Taking certain medications Has certain medical conditions Or is in recovery from addiction/can not control drinkingIt is important to note that there is no safe level of alcohol consumption during pregnancy. So it is advisable that no patient should drink any level of alcohol during pregnancy.
This exercise will give you the opportunity to experience which screening method will be most effective for you.For exercise 1, you can grab a partner or just complete the screen yourself. Record your answers while completing the front and back side of the Behavioral Health Assessment. Do you have enough information to respond? What questions would you ask to get more information?You will need a partner for exercise 2:This time complete the Behavioral Health Assessment Screen and AUDIT as an interview. How is this experience different or similar? Were you able to get more information by engaging your partner in conversation? Which method do you think works best for you?
SBIRT is a unique approach. It is a true paradigm shift that expands the continuum of care to include not only those that are abusing or dependent on a substance, but to those who are misusing or considered to be at-risk for substance use disorders and delivering early intervention to prevent the progression to a dependence. Much like other medical conditions that have adopted a public health perspective, SBIRT within the medical setting employs a simple universal screen to identify those at-risk as well as those who are dependent, and to intervene to avoid expensive hospitalizations for long term treatment. .
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at-risk of developing them.<br />Primary care, trauma centers, emergency departments, and other settings provide opportunities BEFORE more severe consequences occur. <br />What is SBIRT?<br />
To encourage healthcare providers to screen and provide advice or counseling to their patients who misuse alcohol or other drugs.<br />To influence risky behavior patterns and reduce exposure to the negative consequences of misuse.<br />To improve linkages between general community <br /> health care and specialized substance abuse providers to facilitate access to care when needed<br />www.ireta.org<br />Goals of SBIRT<br />
“The most common contributory factor to injury occurrence is alcohol abuse”. <br />“Alcohol is responsible for approximately half of all trauma deaths and nonfatal injuries in the United States…” <br />15-25% of injured patients in the ED are BAC positive, where 50% are male trauma patients and 40% are female trauma patients.<br />About half the time, illicit drugs are also used with alcohol. <br />American College of Surgeons Committee On Trauma, “Alcohol and Injury”, presented by the Subcommittee on Injury Prevention and Control.<br />The Problem<br />
Risks of Use…<br /> “Even though, on average, the problems of individual risky or problem drinkers are less severe than the problems of harmful and dependent drinkers, the number of risky and problem drinkers is vastly larger and creates enormous social, legal, medical, and economic problems. Of all the alcohol-related problems seen in EDs and trauma centers, the majority of these problems are experienced by risky and problem drinkers – not addicted patients.”<br />Hungerford DW. Interventions in Trauma Centers for Substance Use Disorders: New Insights on an Old Malady. Journal of Trauma. 2005;59:S10-S17.<br />
Research Outcomes for SBI<br />Brief interventions may reduce mortality rates among problem drinkers by 23% to 26% (Cuijpers, Riper, & Lemmers, 2004).<br />Compared to a control group, an intervention group had significantly fewer accidents, hospital visits, and other events related to drinking; BI provided a 5.6:1 benefit to cost ratio (Fleming et al, 2000).<br />
More Outcomes…<br /> Out of 8500 patients who received a BI:<br />71%of drinkers reduced the number of days they drank alcohol. <br />85%of binge drinkers reduced number of heavy drinking days, and 68% reported no heavy drinking days in the past 30 days. <br />89%of drug users reduced the number of days they used drugs; 80% reported no usage in the past 30 days.<br />76%of patients assessed as needing more specialized services saw an improvement in their general health after receiving SBI services. <br />(www.insightforhealth.com)<br />
More Outcomes…<br />In a trauma center analysis1:<br />Every dollar spent on SBI saved $3.81 in direct injury-related costs<br />Potential net savings of offering interventions to eligible injured adult patients would approach $1.82 billion per year<br />In community clinic analysis2:<br />Of 800 heavy drinking patients, those who received intervention had significantly fewer accidents, hospital visits, and adverse events related to drinking <br />Generated nearly $56,300 in savings for every $10,000 invested <br />In medical costs alone, the benefit-to-cost ratio of brief intervention was 3.2 to 1 over a 12-month period.<br />1Gentilello et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg. 2005; 241:541-440. 2 Dr. Michael Fleming, Jan. 2000, Project Treat. <br />
Barriers to Screening & Intervention <br />Discomfort with initiating discussion about substance- use/misuse.<br />Lack of education and training about the nature of substance use, misuse and/or dependence or treatment.<br />Uncertainty about referral resources.<br />Sense of not having enough time to carry the out interventions.<br />No insurance company reimbursement for the screening.<br />Fear of losing or alienating patients.<br />
Abuse vs. Dependence<br />Abuse<br /><ul><li>Persons use of substance causes problems in life
Lapses in performance at school, work, parenting, home etc (DUI or possession charge).
Repeated use of alcohol even when it’s physically dangerous to do so.
Continued alcohol use despite knowing that it has caused or worsened social or interpersonal problems.</li></ul>Dependence<br /><ul><li>Withdrawal
Experiences repeated problems at work, school, home (ex/multiple DUI’s).</li></ul>Amount/duration of use greater than intended.<br />Unsuccessful efforts to control or reduce use.<br />Spending much time using, recovering from its effects, or trying to obtain it.<br />
Who are targets for SBI?<br />Note: represents the general adult population in the US. The % of high-risk drinkers is likely to be much higher in certain settings such as emergency or trauma departments.<br />
Additional Benefits<br />Does not require drug and alcohol specialist<br />Views alcohol and drug use as a continuum – not simply “addicted” or “not addicted”<br />Provides an active systematic way to screen and provide BI or a referral for more services<br />Provides approach and language to address drug and alcohol issues and reduce resistance<br />Approach is non-confrontational and puts the responsibility for change on the patient <br />
<ul><li>It is beneficial to use a consistent tool that has been found to be reliable and valid.
Multiple options – various tools that can be administered by self-report or interview, paper and pencil or computerized.</li></ul>Screening<br />
BAC (or other medical tests such as liver function)<br />AUDIT<br />ASSIST<br />DAST<br />CRAFFT<br />T-ACE/TWEAK<br />4 or 5 P’s<br />www.projectcork.org<br />Screening Tool Examples<br />
Basic Steps in Screening<br />Step #1: Introduce the screen.<br />Step #2: Be specific in your questions.<br />Step #3: Make sure you are speaking the same<br /> language as the patient: probe and use reflective listening to make sure you understand. <br />Step #4: Convey non-judgmental attitude throughout screen no matter what the answers are. <br />
How often do you drink anything containing alcohol?<br />How many drinks do you have on a typical day when you are drinking?<br />How often do you have four or more drinks on one occasion?<br />In the last year, have you used drugs other than those required for medical reasons?<br />In the last year, have you used prescription or other drugs more than you meant to?<br />Which drug do you use most frequently? <br />Initial Screening Questions<br />
Women: > 2 drinks per occasion; > 7/week<br />Over 65: > 2 drink per occasion; > 7/week<br />Men: > 4 drinks per occasion; > 14/week<br />Any use is risky when: <br />Pregnant <br />Driving<br />Taking certain medications<br />Having certain medical conditions<br />In recovery from addiction/cannot control drinking<br />Hazardous: Pattern that increases risk for adverse consequences<br />Harmful: Negative consequences have already occurred<br />What is Risky Drinking?<br />
Paper vs. Interview <br />Exercise 1: <br />Complete screen and AUDIT as Self-Report. <br />Do you have enough information to respond? What would you ask to get more if needed? <br />Exercise 2: <br />Complete screen and AUDIT as interview. <br />How is the experience different or similar? <br />
Substance use disorders range from no use to dependence<br />Looking for opportunity for intervention<br />Changing our perception about those at-risk or dependent<br />“Meeting patients where they are”<br />Paradigm Shift<br />