impact of addiction on diseases and services

Impact of Addiction on Impact of Addiction on Diseases and ServicesDiseases and Services

Jack B. Stein, MSW, Ph.D.Director

Division of Services ImprovementCenter for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

4 TC Collaboration MeetingNew Orleans, LA

May 28, 2008

Today’s AgendaToday’s Agenda

• Addiction as a Public Health Problem

• National Trends in Substance Use

• Science of Addiction

• Principles of Addiction Treatment

• Toward a Recovery Paradigm

• Cross-System Collaborations

3

Addiction as a Public Health Problem

Economic Impact of Alcohol and Drugs

• The economic cost to society from alcohol and drug abuse was an estimated $246 billion in 1995.

• Alcohol abuse and alcoholism cost = $166.5 billion.

• Drug abuse and dependence cost = $109.8 billion.

• Costs incurred on:

- Health Care

- Premature Death

- Impaired Productivity

- Motor Vehicle Crashes

- Crime

- Social Welfare

Greater Burden on Public SectorGreater Burden on Public Sector

50%

50%

Source: Health Affairs, July-August 2007

77%

23%

1986 All SA = $9.3BPublic = $4.6 BPrivate = $4.6 B

2003 All SA = $20.7 BPublic = $16.0 BPrivate = $4.7 B

PrivatePrivate

Public Public

Greater Burden on General Medical Care System Greater Burden on General Medical Care System

• Medical conditions were found to be more common among substance abuse patients compared to non-substance abuse patients (Mertens et al., 2003).

• Substance dependent persons without primary medical care have a substantial burden of medical illness compared to age/gender matched US population controls (De Alba et al., 2004).

Health Consequences of Substance Use

HIV/AIDS

Cardiovascular

Respiratory

Kidney

Gastro-IntestinalPrenatal

Musculoskeletal

Liver

HIV CV Resp GI Musc Kidney Liver Cancer Prenatal

Alcohol X X X X X X

Nicotine X X X X X

MJ X X

Heroin X X

Cocaine X X X X X

Steroids X X X X X

Meth X X X X

Inhalants X X X X X

MDMA X X X X X

Rx Drugs X X X X

Health Consequences of Substance AbuseHealth Consequences of Substance Abuse

Drugs and HIV:Drugs and HIV:Dangerous LiaisonsDangerous Liaisons

• Approximately 13% of the reported new AIDS cases were related to injection drug use (2006).

• 19% of males and 32% of females living with AIDS were exposed through injection drug use.

• Cocaine may foster development of HIV-associated dementia by increasing viral expression in the brain (Gekker, et al., 2004).

• Methamphetamine and HIV infection in combination are associated with deleterious cognitive effects (Rippeth, et al., 2004).

Substance Use and Prenatal EffectsSubstance Use and Prenatal Effects

• Prenatal marijuana exposure is associated with lower academic achievement at age 10 (Goldschmidt et al., 2004).

• 4 year old children exposed to cocaine in utero scored significantly lower on intelligence tests, although childrearing environments may be able to counter these deficits (Singer et al., 2004).

• Maternal cocaine use during pregnancy is associated with decreased birth weight and head size (Shankaran et al., 2004).

11

National Trends in Substance Use

Past Month Alcohol Use - 2006Past Month Alcohol Use - 2006

• Any Use: 51% (125 million)

• Binge Use: 23% (57 million)

• Heavy Use: 7% (17 million)

(Current, Binge, and Heavy Use estimates are similar to those in 2002, 2003, 2004, and 2005)

Source: NSDUH 2006

Percentages of Persons

8.78-10.81

8.15-8.77

7.52-8.14

6.81-7.51

6.30-6.80

Alcohol Dependence or Abuse in Past Year Alcohol Dependence or Abuse in Past Year Among Persons Aged 12 or OlderAmong Persons Aged 12 or Older

Source: Annual Averages Based on 2005-2006 NSDUHs

0

10

20

30

40

50

60

7015

-25

26-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65+

Age Category

Per

cent

Usi

ng

Lifetime

Past Year

Past Month

Drug Use Among the General Population Drug Use Among the General Population by Age (2006) by Age (2006)

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use & Health, 2005 & 2006


3.11-4.25

2.92-3.10

2.82-2.91

2.57-2.81

2.10-2.56

Illicit Drug Dependence or Abuse in Past Year Illicit Drug Dependence or Abuse in Past Year Among Persons Aged 12 or Older Among Persons Aged 12 or Older

Source: Annual Averages Based on 2005-2006 NSDUH


5.66-6.72

5.31-5.65

4.83-5.30

4.40-4.82

3.85-4.39

Non-Medical use of Pain Relievers in Past Year Non-Medical use of Pain Relievers in Past Year Among Persons aged 12 or OlderAmong Persons aged 12 or Older

Source: Annual Averages Based on 2005-2006 NSDUH

17

The Science of Addiction

The Brain on DrugsThe Brain on Drugs

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

YELLOW shows places in brain where cocaine goes (Striatum)

Front of brain

Back of brain

We Know That Despite Their Many Differences,Virtually All Abused Substances

Enhance the Dopamine PleasurePathway

For Example…

00

5050

100100

150150

200200

00 6060 120120 180180

Time (min)Time (min)

% o

f B

asal

DA

Ou

tpu

t%

of

Bas

al D

A O

utp

ut

NAc shellNAc shell

EmptyEmpty

BoxBox FeedingFeeding

Source: Di Chiara et al.Source: Di Chiara et al.

FOODFOOD

100100

150150

200200

DA

Con

cen

tra

tion

(%

Bas

elin

e)D

A C

once

ntr

atio

n (

% B

asel

ine)

MountsMountsIntromissionsIntromissionsEjaculationsEjaculations

1515

00

55

1010

Co

pu

latio

n F

req

ue

ncy

Co

pu

latio

n F

req

ue

ncy

SampleNumberSampleNumber

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717

ScrScrScrScrBasBasFemale 1 PresentFemale 1 Present

ScrScrFemale 2 PresentFemale 2 Present

ScrScr

Source: Fiorino and PhillipsSource: Fiorino and Phillips

SEXSEX

Natural Rewards Elevate Dopamine LevelsNatural Rewards Elevate Dopamine LevelsNatural Rewards Elevate Dopamine LevelsNatural Rewards Elevate Dopamine Levels

00100100200200300300400400500500600600700700800800900900

1000100011001100

00 11 22 33 44 5 hr5 hr

Time After AmphetamineTime After Amphetamine

% o

f B

asa

l Re

lea

se%

of

Ba

sal R

ele

ase

DADADOPACDOPACHVAHVA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

00

100100

200200

300300

400400

00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine

% o

f B

asa

l Re

lea

se%

of

Ba

sal R

ele

ase

DADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

00

100100

150150

200200

250250

00 11 22 3 hr3 hr

Time After NicotineTime After Nicotine

% o

f B

asa

l Re

lea

se%

of

Ba

sal R

ele

ase

AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

Source: Di Chiara and ImperatoSource: Di Chiara and Imperato

Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels

100

150

200

250

0 1 2 3 4hrTime After Ethanol

% o

f B

asa

l Re

lea

se0.250.512.5

Accumbens

0

Dose (g/kg ip)

ETHANOLETHANOL

Why do some people Why do some people become addicted while become addicted while

others do not?others do not?

VulnerabilityVulnerability

Abuse andAddiction

DRUG

Environment

Biology/GenesBiology/EnvironmentInteraction

Biological and Environmental Interaction

Drug Abuse Drug Abuse

Risk and Protective Factors


Drug AbuseDrug AbuseDrug/Alcohol Related Traffic Accidents

Drug/Alcohol Related Traffic Accidents

DelinquencyDelinquency

Academic Failure and DroppingOut of School

Academic Failure and DroppingOut of School

Juvenile DepressionJuvenile Depression

Sexually Transmitted Diseases (Including HIV/AIDS)

Sexually Transmitted Diseases (Including HIV/AIDS)

Running Away From HomeRunning Away From Home

Unwanted Pregnancies Unwanted Pregnancies

Suicidal Behavior Suicidal Behavior



What Happens After Persistent or Repeated Drug Use?

CompulsiveDrug Use(Addiction)

CompulsiveDrug Use(Addiction)

VoluntaryDrug UseVoluntaryDrug Use

30

Principles of Principles of Addiction TreatmentAddiction Treatment

Treatment OutcomesTreatment Outcomes

1991-93

11 Cities

96 Programs

~10,000 Patients

All treatment types

Follow-up: 1 & 5 Yrs

Drug Abuse Treatment Outcome Studies

Is Treatment Effective?Is Treatment Effective?

• Reduces drug use by 40-60% Reduces drug use by 40-60%

• Reduces crime by 40-60% Reduces crime by 40-60%

• Increases employment prospects by Increases employment prospects by 40%40%

Treatment EffectivenessTreatment Effectiveness

Outpatient Drug-Free Treatment ProgramsOutpatient Drug-Free Treatment Programs

42

1825

9

31

1522

14

8276

19

11

0

20

40

60

80

100

Cocaine (Weekly)*

Marijuana (Weekly)*

Heavy Alcohol*

Illegal Activity*

No FTWork*

SuicidalIdeation*

Pre Post

% of DATOS Sample (N=764)*p<.001

Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997

00

1010

2020

3030

4040

5050

6060

7070

8080Low PressureLow Pressure Moderate-to-High Pressure Moderate-to-High Pressure

Legal Pressure and 90-Day Retention RatesLegal Pressure and 90-Day Retention Rates

% R

etai

ned

90 D

ays

% R

etai

ned

90 D

ays

Program A(42%)

Program A(42%)

Program B(69%)

Program B(69%)

Program C(88%)

Program C(88%)

2828

4040 3939

5555

2525

5252

Three Programs (with % of Caseload CJ Supervised)Three Programs (with % of Caseload CJ Supervised)

Source: Hiller, et al., Legal Pressure and Treatment Retention in DATOS (ASC Meeting, San Diego, Nov 1997)Source: Hiller, et al., Legal Pressure and Treatment Retention in DATOS (ASC Meeting, San Diego, Nov 1997)

Amount of Services MattersThe Delaware Therapeutic Continuum AssessmentThe Delaware Therapeutic Continuum Assessment

Amount of Services MattersThe Delaware Therapeutic Continuum AssessmentThe Delaware Therapeutic Continuum Assessment

Drug Use*Drug Use* Arrests**Arrests**

HIV EducationHIV EducationKeyKeyCrestCrestKey-Crest Key-Crest

-- no TC-- no TC-- in-prison TC only-- in-prison TC only-- work release TC only-- work release TC only-- both TCs-- both TCs

Source: Inciardi, J.A. (1995) Therapeutic community: An effective model for corrections-based drug abuse treatment. In K.C. Hass and G.P. Albert (eds.), The Dilemmas of Punishment (406-417), Prospect Heights, IL: Waveland Press.

Source: Inciardi, J.A. (1995) Therapeutic community: An effective model for corrections-based drug abuse treatment. In K.C. Hass and G.P. Albert (eds.), The Dilemmas of Punishment (406-417), Prospect Heights, IL: Waveland Press.

HIV Education Key Crest Key-Crest .0

20

40

60

80

100

83%

66%

54%

25%

HIV Education Key Crest Key-Crest .0

20

40

60

80

100

64%

54%

40%

28%

(18 month follow-up)(18 month follow-up)

* Used drugs one or more times during the last 18 months* Used drugs one or more times during the last 18 months** One or more new arrests and/or probation violations during the last 18 months** One or more new arrests and/or probation violations during the last 18 months

Length of Stay MattersLength of Stay Matters

55

28

53

19 159

54

24

0

20

40

60

80

100

Cocaine (Any Use)*

UA+ (Any Drug)*

Alcohol (Daily Use)*

Any Jail*

< 90 Days 90+ Days

% of Sample

*p<.001

N=342; Simpson, Joe, & Brown, 1997, PAB

Long Term Residential Setting

We Have A Variety Of Effective Treatment Options In The Clinical Toolbox

Behavioral and Pharmacological Therapies

Behavioral Approaches Behavioral Approaches to Drug Treatmentto Drug Treatment

• Behavioral therapy continues to constitute bulk of U.S. treatment

• Behavioral therapy remains the sole available treatment for most classes of drug addiction

• No pharmacotherapies exist for cocaine, marijuana, hallucinogens, amphetamines, inhalants, and sedatives

Evidence-Based Behavioral TreatmentsEvidence-Based Behavioral Treatments

• Behavioral Treatments for MJ Abuse

• Behavioral Treatments for Smoking Cessation

• Cognitive-Behavioral Treatment*

• Combined Pharmacotherapies and Behavioral Therapies

• Complementary and Alternative Treatments

• Multisystemic Therapy

• Contingency Management Treatments*

• Dialectical Behavioral Therapy

• Drug Counseling

• Family Treatments

• Group Behavior Therapy

• HIV Risk Reduction

• Motivational Interviewing/Enhancement*

• Seeking Safety (PTSD)

• Work Therapy

Drug Courts:Drug Courts:An Innovative ApproachAn Innovative Approach

• Reduced re-arrest rates of up to 14% compared to non-participants (Guydish, et al, 2001).

• Odds of staying in treatment for 6 months or more were nearly 3 times greater for clients referred from the most coercive drug court programs (Young & Belenko, 2002).

PharmacotherapyPharmacotherapyAlcohol: • Naltrexone• Disulfiram (antabuse)• Acamprosate (newly approved)

Opiates:• Methadone (agonist)• Naltrexone (antagonist)• Clonidine (non-opioid agonist)• Buprenorphine

42

Toward a Recovery Paradigm:Toward a Recovery Paradigm:

Implications for Service DeliveryImplications for Service Delivery

What Do We Mean by “Recovery”?What Do We Mean by “Recovery”?What Do We Mean by “Recovery”?What Do We Mean by “Recovery”?

Recovery from alcohol and drug problems is a process of change through which an

individual achieves abstinence and improved health, wellness, and quality of life.

Source: CSAT National Summit on Recovery, 2005

Recovery-Based Service SystemsRecovery-Based Service Systems

Services that attend to long-term recovery shift the question from “How do we get the client into

treatment?” to “How do we support the process of “How do we support the process of recovery within the person’s environment?”recovery within the person’s environment?”

Benefits of a Recovery-Based ApproachBenefits of a Recovery-Based Approach

• Most clients undergo 3 to 4 episodes of care before reaching a stable state of abstinence ¹

• Chronic care approaches, including self-management, family supports, and integrated services, improve recovery outcomes 2

• Integrated and collaborative care has been shown to optimize recovery outcomes and improve cost-effectiveness 3

¹ Dennis, Scott & Funk, 20032 Lorig et al, 2001; Jason, Davis, Ferrari, & Bishop; 2001; Weisner et al, 2001; Friedmann et al, 20013 Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

0

100

Time

Person’s Entry into treatment

Discharge

Severe

Remission

Resource: Tom Kirk, Ph.D

Sy

mp

tom

s

A Traditional Course of Treatment for a A Traditional Course of Treatment for a Substance Use DisorderSubstance Use Disorder

0

100

Sym

pto

ms

Acute symptoms

Discontinuous treatment

Crisis management

Severe

Remission

A Traditional Service ResponseA Traditional Service Response


Promote Self Care, Rehabilitation

A Recovery-Oriented ResponseA Recovery-Oriented Response

0

100

Sym

pto

ms

Continuous treatment response


Severe

Remission

Improved client outcomes

Severe

Remission

Recovery ZoneRecovery Zone

Sym

pto

ms

Time

Helping People Move Into A Recovery ZoneHelping People Move Into A Recovery Zone


Components of a Recovery-Based Components of a Recovery-Based Care SystemCare System

V

Recovery-Based Care System:Recovery-Based Care System:Person-centered and self-directedPerson-centered and self-directed

IndividualFamily

Community

Recovery

Wellness Health

Recovery-Based Care System: Recovery-Based Care System: Comprehensive menu of services and supports recoveryComprehensive menu of services and supports recovery

IndividualFamily

Community

Family/Child Care

Housing/Transportation

Financial

Legal Case Mgt

VSO & Peer Support

Physical Health Care

PTSD &Mental Health

Alcohol/Drug Services

VocationalEducation

Spiritual HIV Services

Services & Supports

Recovery

Wellness Health

Recovery-Based Care System: Interface of multiple systems

IndividualFamily

Community

Family/Child Care


Financial

Legal Case Mgt

VSO & Peer Support

Health Care

PTSD & Mental Health

Alcohol/Drug Treatment

VocationalEducational

Spiritual

Addiction Services System

Mental HealthSystem

Primary Care System

Child Welfareand FamilyServices

Housing System

Social Services

Health Insurance

DoD & Veterans Affairs

Indian HealthServices

Criminal JusticeSystem

Vocational Services

HIV ServicesFaith Community

HealthWellness

Services & Supports

Systems of Care

Recovery

Recovery-Based Care System: Outcomes-driven approaches to care

IndividualFamily

Community

Family/Child Care


Financial

Legal Case Mgt

VSO & Peer Support

Health Care

PTSD &Mental Health


Vocational

Educational

Spiritual


Mental HealthSystem

Primary Care System

Child Welfareand FamilyServices

Housing Authority

Social Services

Health Insurance




Abstinence

Employment

ReducedCrime

Safe & Drug-freeHousing

Evidence-Based Practice

Cost Effectiveness

PerceptionOf Care

Social ConnectednessAccess/Capacity

Retention

Vocational Services

HIV ServicesFaith Community

Menu of Services

Systems of Care

Recovery

Wellness Health

Recovery-Based Care System: Recovery-Based Care System: Ongoing process of systems improvementOngoing process of systems improvement

IndividualFamily

Community

Ongoing Systems Improvement

Family/Child Care


Financial

Legal Case Mgt

VSO & Peer Support

Health Care

PTSD & Mental Health


VocationalEducational

Spiritual


Mental HealthSystem

Primary Care System

Child Welfare and FamilyServices

Housing Authority

Social Services

Health Insurance




Abstinence

Employment

ReducedCrime

Safe & Drug-freeHousing

Evidence-Based Practice

Cost Effectiveness

PerceptionOf Care

Social ConnectednessAccess/Capacity

Retention

Vocational ServicesHIV Services

Services & Supports

Systems of Care

Recovery

Wellness Health

21.1 Million Needing But Not Receiving 21.1 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol UseTreatment for Illicit Drug or Alcohol Use

3.0%

Felt They Needed Treatment and Did

Make an Effort(314,000)

Did Not Feel Did Not Feel They Needed They Needed

TreatmentTreatment(20,114,000)(20,114,000)

Did Not Feel Did Not Feel They Needed They Needed

TreatmentTreatment(20,114,000)(20,114,000)

Felt They Needed Treatment and Did Not Make an Effort

(625,000)

1.5%95.5%95.5%

The Treatment Gap:The Treatment Gap:Most People in Need of Treatment Do Not Receive ItMost People in Need of Treatment Do Not Receive It

Working Cross-Systems:Substance Use-Related Visits to Emergency Department

• In 2005 there were nearly 400,000 ED visits that involved alcohol in combination with another drug.

• Alcohol was most frequently combined with cocaine, marijuana, and/or heroin

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).

* Includes single- and multi-ingredient products

Opiate Reports in Emergency Department Visits Related to Drug Misuse/Abuse

Unweighted reports from 243-445 U.S. hospitals

Source: U.S. SAMHSA; DAWN Live! Oct 2, 2007

0

10,000

20,000

30,000

40,000

2004 2005 2006

225

5,085 Hydrocodone*

36,007 Heroin

5,694 Methadone

5,066 Oxycodone*

Buprenorphine*

Traditional Substance Abuse InterventionTraditional Substance Abuse Intervention

40% Abstainers

35% Low Risk Drinkers

20% At-Risk Drinkers

5% Alcoholics

Adapted from Babor,T,F., Higgins-Biddle,J.C., (2001), Brief Intervention for Hazardous and Harmful Drinking: A manual for use in primary care . p 33. WHO/MSD/MSB/01.6b World Health

Screening, Brief Intervention & Referral to Screening, Brief Intervention & Referral to Treatment (SBIRT)Treatment (SBIRT)

• Embeds screening, brief intervention & treatment of substance abuse problems within primary care settings (e.g., ED, CHC, Trauma Centers).

• Identifies patients who don’t perceive a need for treatment.

• Offers a solid strategy to reduce or eliminate substance abuse.

• Helps move them into appropriate services.

SBIRT Takes Advantage of SBIRT Takes Advantage of the “Teachable Moment”the “Teachable Moment”

A moment of educational opportunity – a time at which a person is likely to be

particularly disposed to learn something or particularly responsive to being taught or

made aware of something.

Source: MSN Encarta Online Dictionary, Retrieved 3/25/08 from http://encarta.msn.com

SPIRT Effectiveness:SPIRT Effectiveness:Alcohol UseAlcohol Use

• A meta-analysis suggests an overall reduction of 56% in number of drinks.

• The effect size for motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months

Burke et. al., 2003

SBIRT Effectiveness:Drug Use

• Research is promising.• Bernstein, et al. 2005: Randomized Controlled Trial

(RCT)• WHO study, 2008: Randomized Controlled Trial

(RCT) in Multiple Sites Internationally• SAMHSA SBIRT program: Program outcome data

6 Month Abstinence Among Those Screening Positive for At Baseline

Brief Motivational Intervention at a Clinic Reduces Cocaine and Heroin Use

p < .05

Bernstein et al. Drug and Alcohol Dependence 2005

Total Illicit Substance Involvement Scores – BI and Control at Baseline and Follow-

up (N=628)

WHO ASSIST Phase III Technical Report, 2008: Pooled data

(F(1,624) = 7.6, p<0.01, observed power = 78.4%, alpha=0.05

Cannabis Specific Substance Involvement Scores – BI Cannabis Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=328and Control at Baseline and Follow-up (N=328))


F(1,326) = 4.2, p<0.05, observed power 53%, alpha=0.05

Stimulant Specific Substance Involvement Scores – Stimulant Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=229) BI and Control at Baseline and Follow-up (N=229)

Control

Brief Intervention

10

11

12

13

14

15

16

17

18

19

20

Baseline Follow-Up

Scor

e

Control (n=119)

BriefIntervention(n=110)


F(1,227) = 9.4, p<0.005, observed power 86%, alpha=0.05

Opioid Specific Substance Involvement Scores – BI Opioid Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=73) and Control at Baseline and Follow-up (N=73)


F(1,71) = 3.4, p=0.07, observed power 45%, alpha=0.05

Program Data, Six SAMHSA SBIRT Sites, Program Data, Six SAMHSA SBIRT Sites, Baseline and F/U Substance UseBaseline and F/U Substance Use

Among Those Screening Positive for Drugs At Baseline (N = 6,262)

%

SAMHSA/CSAT SBIRT GPRA Data, August 2007

P < 0.001

SBIRT: Core Clinical ComponentsSBIRT: Core Clinical Components

• Screening: Very brief screening that identifies substance related problems

• Brief Intervention: Raises awareness of risks and motivation of client toward acknowledgement of problem

• Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help

• Referral: Referral of those with more serious addictions

Screening Brief Intervention Referral to Treatment Screening Brief Intervention Referral to Treatment (SBIRT) Core Components(SBIRT) Core Components

Screen

Identification of substance related

problems

Brief InterventionRaises awareness of risks and motivates

client toward acknowledgement

Referral to Tx Referral of those with more serious

addictions

Brief Treatment Cognitive behavioral work with clients who

acknowledge risks and are seeking help

• Quick method to identify individuals who may be at risk for developing problems

• Screening plus immediate feedback

• Screening is performed using a brief questionnaire (e.g., AUDIT, DAST, ASSIST) about the context, frequency, and amount of alcohol or other drugs used by an individual.

SBIRT: ScreeningSBIRT: Screening

SBIRT: Brief InterventionSBIRT: Brief Intervention

• Healthcare provider uses the results of a screening questionnaire to motivate an individual to begin to do something about his/her substance use behavior

– Typically 1-3 sessions, not more than 5 sessions

• Low-cost, effective treatment alternative for alcohol and other drug problems

Feedback about screening results, impairment, and risks while clarifying the findings

Inform patient about hazardous consumption limits and offer advice about change

Assess the patient's readiness to change

Negotiate goals and strategies for change

Arrange for follow-up treatment

Components of Brief InterventionsComponents of Brief Interventions

SBIRT: Brief TreatmentSBIRT: Brief Treatment

• Based on moderate to high risk screening scores

• Involves motivational discussion and client empowerment

• Similar to brief intervention, but more comprehensive

• Includes assessment, education, problem solving, and building a supportive social environment

• Examples include:– Brief cognitive-behavioral therapy– Brief psychodynamic therapy– Brief family therapy

SBIRT: Referral to TreatmentSBIRT: Referral to Treatment

• Use results of a screening questionnaire to refer an individual to a specialized treatment setting.

• Proactive process facilitates access to specialty treatment for individuals requiring more extensive resources than can be provided in a primary care setting.

Reimbursing for SBI in Health Care Settings Reimbursing for SBI in Health Care Settings

• HCPCS Codes (Medicaid)

- H0049: Alcohol &/or Drug Screening ($24)

- H0050: Brief Intervention:15 mins. ($48)

• CMS G-Codes (Medicare)

- G0396: 15-30 mins ($29.42)

- G0397: > 30 mins ($57.69)• CPT Codes (Commercial Health Plans)

- 99408: 15-30 mins ($33.41)

- 99409: > 30 mins ($65.51)

SBIRT State and Campus Grantees SBIRT State and Campus Grantees

State Grants

Massachusetts

Delaware

Connecticut

College/University Grants To date, over 600,000 patients screened

CSAT SBIRT WebsiteCSAT SBIRT Website

• Information regarding the SBIRT Initiative, core clinical components, and screening instruments, and how to establish an SBIRT program.

• Online resources (e.g., training guides) links to curricula, organizations, publications, and references.

• SAMHSA/CSAT specific information, such as SBIRT Cooperative Agreements, grantee profiles, key CSAT SBIRT staff, meetings, training opportunities, and news.

http://sbirt.samhsa.gov

80

Cross-System Cross-System Collaborative OpportunitiesCollaborative Opportunities

Access to Recovery (ATR) Access to Recovery (ATR)

• Presidential Initiative designed to promote client choice through: – the expansion of treatment capacity; – the implementation of a voucher system;– the inclusion of non-traditional substance abuse

treatment providers, such as faith- and community based organizations.

AK

Virgin IslandsVirgin Islands

Puerto RicoPuerto Rico

HI

WA

OR

ID

MTND

MNMN

WY

SD

NV

UTCO

AZNM

TX

NEIA

WI

IL IN

MI

OK

MO

TN

KYY

OH

AR

MSAL

LAFL

GA

SC

NC

VAWV

PA

NY

DCDC

MDMD

CTCTRIRI

MAMA

MEVTVT

NHNH

KS DEDENJNJ

CA

2007 CSAT TCE/HIV Grantees2007 CSAT TCE/HIV Grantees

States with 2007 Grantees

HIV/AIDS Outreach – TCE/HIVHIV/AIDS Outreach – TCE/HIVEvidences of SuccessEvidences of Success

National Outcome Measures (NOMs)

% at Intake

6-Month Follow-up

(%)

Difference

Clients reporting no substance use

31.9% 56.1% Increased Increased 75.9%75.9%

Clients reporting being employed


Clients reporting being housed


Clients reporting no arrests


Clients reporting being socially connected


Risk Behavior % at Intake 6-Month Follow-up (%)

Difference

Clients reporting injection drug use 11.6% 4.4% Decreased Decreased 62.3%62.3%

Clients reporting having unprotected sex

68.9% 61.7% Decreased Decreased 10.4%10.4%

Clients reporting having unprotected sex with an HIV+ individual


Clients reporting having unprotected sex with an IDU


Clients reporting having unprotected sex with an individual high on some substance


TCE/HIV and HIV OutreachTCE/HIV and HIV OutreachChanges in Risk BehaviorsChanges in Risk Behaviors

Source: SAIS data FY 2004 through 3/21/08

Incorporating SBIRT into Incorporating SBIRT into HIV Primary Care SettingsHIV Primary Care Settings

• 1223 adult participants from 10 HIV care clinics in 3 large US cities.

• Self-reported rates of discussion of alcohol use with provider.

• 35% reported discussing alcohol use.• Only 52% of problems drinkers reported such a

discussion.

Metch et al., Drug and Alcohol Dependence, 95, 37-44

Residential Treatment for Pregnant and Residential Treatment for Pregnant and Postpartum Women (PPW)Postpartum Women (PPW)

• Gender and culturally specific residential treatment program for pregnant and postpartum women.

• Comprehensive services to women during pregnancy significantly improves the lives of women, children, and their families.

• Post birth services since alcohol and drug use continue to have negative consequences for women, their children, and the entire family.

Closing ThoughtsClosing Thoughts

• Addiction can lead to significant individual and public health consequences (e.g., HIV, STDs, and other infectious diseases).

• Proper attention to these consequences requires cross-system collaboration.

• Workforce development programs can benefit from enhanced collaborations.

impact of addiction on diseases and services

Documents

drug use health

drug abuse

alcohol abuse

injection drug use

millionbinge use

maternal cocaine use

w millionheavy use

heavy use estimates