overview: screening, brief intervention & referral to...
TRANSCRIPT
Overview:Screening, Brief Intervention
& Referral to TreatmentPam Pietruszewski
June 27, 2018
• 51% of 12th graders in MT used alcohol within the past month, and 23% used marijuana within the last 30 days. (MT Prevention Needs Assessment, 2016)
“SUD is a common chronic medical illness.” - Guiding Principle from Opportunities for Action on Substance Use Disorders in Montana, 2017
• 2.6% of individuals 12+ in MT reported being dependent or abusing illicit drugs. (Behavioral Health Barometer, Montana 2015)
• 7.6% of individuals 12+ in MT reported alcohol dependence or abuse. (Behavioral Health Barometer, Montana 2015)
The #1 predictor of adult substance use disorder = youth substance use problems.
Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health
“A child who reaches his or her 21st birthday without using drugs, tobacco or alcohol is ‘virtually certain’ never to slip into those habits.”
-Joseph A. Califano Jr. How to Raise a Drug-Free Kid
That’s where people are going
Longitudinal, family & community care
Influence
Chronic care experience
Data-oriented
Why Address Substance Use & other Behavioral Health in Primary Care?
Preventive Services RankingsBased on Clinically Preventable Burden + Cost Effectiveness
Maciosek, M. et al. Ann Fam Med 2017;15:14-22
#1 • Immunizations – children• Tobacco use screening, brief prev counseling – youth & adults
#2 • Alcohol screening & brief intervention – adults• Aspirin daily low dose – adults 50-59 at higher CVD risk• Cervical cancer screening – women 21-65• Colorectal cancer screening – adults 50-75
#3 • Chlamydia and gonorrhea screening – sexually active women ≤24 and older women at increased risk for infection
• Cholesterol screening - adults• Hypertension BP screening - adults
Blood Pressure Screening: Prevention & early intervention to reduce the risk of heart disease
“No one would refuse to screen for hypertension or diabetes out of fear it might upset a patient.”
- CDC, 2014
Medical Conditions Commonly Associated with SUD’s
Cardiovascular diseasesCancersInjuriesStrokeCirrhosis
Alcohol use disorder
ArthritisChronic painHeadacheHepatitis CMusculoskeletal disordersOpioid-related overdoses
Opioid use disorder
Respiratory deficitsCardiovascular diseasesLung cancer
Cannabis use disorder
Bahorik, J. Addiction Medicine 2017
Immediate & Direct Consequences
Heart rate, body temperature regulation, psychotic episodes,
overdose
Indirect ConsequencesImpaired judgement, DUI, unprotected sex
Longer-term Health Effects
Hypertension, liver disease, cancer, heart disease
Longer-term Societal
ConsequencesProductivity, increased health
costs, crime, violence
Alcohol&
DrugMisuse
Surgeon General’s Report on Alcohol, Drugs and HealthNovember 2016
“Does this mean I shouldn’t be seen out in public having drinks?”
“Well I was doing worse things when I was her age.”
“He’s a drug-seeker.”
“She’s a druggie.”
The Current View:Continuum of Substance Use
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Abstinence
Addiction
Responsible Use
National Addiction Technology Transfer Center (ATTC)
The SBIRT View:Continuum of Alcohol Use
Abstinent/Low risk Moderate risk High Risk
Primary Prevention
Brief Intervention
Specialized Treatment
Abuse/Dep.
40%35%
20%5%
SBIRT Target
Population
Dawson, Alcohol Clin Exp Res 2004; Grant, Drug Alcohol Dep 2004
Screening to identify patients at-risk for developing substance use disorders.
Brief Intervention to raise awareness of risks and consequences, internal motivation for change, and help set healthy lifestyles goals.
Referral to Treatment to facilitate access to specialized treatment services and coordinate care between systems for patients with higher risk and/or dependence.
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What is SBIRT?
Negative = F <3 F, M <4Positive = F 3±, M 4±
Negative = 0-1Positive = 2 ±
Negative = 0Positive = 1 ±
Screening Example: AUDIT-C + 2
Negative screen Low or no use
Positive feedback, reinforce low risk levels of use
Positive screen Use at levels that can impact health
Brief intervention to reduce use and/or lower risk
High-Positive screenUse at levels that are most likely to impact health
Brief intervention to engage in further assessment
1. Begin the conversation, build rapport“Tell me more about your use…with whom, how much...”
2. Provide feedback, clinical recommendations– Ask permission– Connect to health, reason for visit
3. Support patient goal setting/plan“What have you considered… what might be your next step…”
Brief Intervention
Referral to Treatment
A process involving
proactive and collaborative coordination
between SBIRT providers and those providing
substance use disorder treatment to ensure a person has
access to and engages in an appropriate higher level of care
regarding the consequences associated with their substance use.
http://www.integration.samhsa.gov/sbirt/tap33.pdf
Shared decision making about options, other services:
• Medications
• Individual therapy
• Peer support
• Group-based treatment
• No treatment but possible self-management with continued primary care support and monitoring
Management & Follow-Up Monitoring (Referral to Treatment 2.0)
SBIRT is a Paradigm Shift
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• Not looking for addiction• Looking for unhealthy substance use patterns• Looking for opportunities for intervention• Meeting people where they are
Endorsed by Experts• Ntl Institutes of Health • World Health Org• US Surgeon General and US Prev
Services Task Force• Am Public Health Assoc• Society for Adol Health and
Medicine• Emergency Nurses Assoc• Substance Abuse and MH Svcs
Admin• White House Office of National
Drug Control Policy• Am Medical Assoc• Am Academy of Fam Phys
• Am College of Physicians• Am Psychiatric Assoc• Am College of Emergency
Physicians• Am College of Surgeons
Committee on Trauma• Am College of OB-GYN• Am Society of Addiction Medicine
• The Am Academy of Pediatrics and Ntl Institute on Alcohol Abuse and Alcoholism explicitly endorse the use of SBIRT with young people.
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What Happens When SBIRT Sticks
• Replaces less effective screening methods
• Views substance use on a continuum, with biological and behavioral factors
• Improves clinical care
• Transforms culture
• Prepares your organization and workforce for health care changes
Levels of Integration from the Integrated Practice Assessment Tool (IPAT)
Coordinated Co-located Integrated
1
Minimal Collaboration
2
Basic Collaboration
at a Distance
3
Basic Collaboration
Onsite
4
Close CollaborationOnsite with
some System
Integration
5
Close CollaborationApproaching
an Integrated
Practice
6
Full Collaboration
in a Transformed /
Merged Integrated
Practice
Level 1: SBIRT example
• Behavioral health provider from partner organization contracted to be onsite 2 days a week.
• Select patients are screened and information is documented in separate system.
• Brief interventions occur when BH is onsite and referrals go to external BH provider.
Level 4: SBIRT Example
• Behavioral health provider from partner organization is contracted to be onsite 5 days a week.
• Has adopted the culture of the health center and is in close connection with the team.
• Information is documented in shared medical record.
• Integrated care teams meet to discuss some cases.
Level 6: SBIRT Example• BH provider is a core member of the team.
• All patients are screened routinely, information is documented & shared among the integrated care team
• Screening and brief intervention are not seen as a “burden”.
• Data collected on health improvement, cost savings, and provider satisfaction and shared regularly.
• SBIRT training is embedded in onboarding new staff.
• Integration is a process that occurs over time in the entire organization.
• More than having a good referral partner, care capacity, or a co-located site.
• More than a particular tool (e.g., PHQ 9), diagnostic combination (e.g., depression and diabetes), or evidence-based program (e.g., IMPACT, SBIRT).
• Continually evolving with populations, partners, challenges, opportunities.