Substance Abuse Disorders in Primary Care Substance Abuse Disorders in Primary Care Improving Evidence Based PracticeImproving Evidence Based Practice

David W. Oslin, MDUniversity of Pennsylvania, School of Medicine

And

Philadelphia, VAMC

Hazelden Research Co-Chair on Late Life Addictions

Which Hat?Which Hat?

Geriatrics

Primary Care

Addictions

Introduction Introduction Alcohol use and abuse costs the nation $150

Billion / annum

Alcohol use and abuse is common in primary care practices

Very little research has focused on illicit substance use disorders in the context of primary care

90-Day Prevalence in Primary Care90-Day Prevalence in Primary Care(n=21,282 patients in 88 primary care clinician offices)(n=21,282 patients in 88 primary care clinician offices)

Manwell, et al. Journal of Addictive Diseases. 1997;17:67-81.

Low-risk Drinkers

38%Abstainers

40%

At-risk Drinkers 9%

Problem Drinkers 8% Alcohol

Dependent 5%

The Bad NewsThe Bad News

Individuals with alcohol disorders or problem drinking who seek help

ECA: 11% specialty mental health/addictive services; 8% voluntary support network

NLAES: 10% RAS: 7%-10%

Rates of Early Drop-out from Alcoholism Treatment (less than four sessions) range from 44 - 75%

Breaking down the ProblemBreaking down the Problem

Identification

Assessment

Initial Intervention

Referral and Follow-up

How is Identification Accomplished? How is Identification Accomplished?

Systems VA, Kaiser, Group Health

Individual Practitioners

State, City, other agencies

Examples: Screening InstrumentsExamples: Screening Instruments

Michigan Alcoholism Screening Test (MAST)

Health Screening Survey (including other health behaviors, e.g. nutrition, exercise, smoking, depressed feelings)

CAGE (Cut down, Annoyed by others, feel Guilty, need ‘Eye-opener’)

AUDIT-C/AUDIT

Identify What?Identify What?

Abstinence

Moderate Drinking

At – risk drinking

Problem drinking / alcohol abuse

Alcohol Dependence

VA ExperienceVA Experience

Prior to 2003 – CAGE

11/03 AUDIT-C 2781 screens in those that drink over a 4

month period 32.6% positive

The First ChallengeThe First Challenge

Assessing individuals to understand what level of care is needed

BEHAVIORAL HEALTH

LAB

Research to Practice:Research to Practice:Behavioral Health LaboratoryBehavioral Health Laboratory

BHL is designed to provide clinical services to support providers in Primary Care and Behavioral Health

It is intended to be analogous to Clinical Chemistry or Radiology Laboratories

The BHL is an automated telephone assessment, triage, and monitoring service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.

The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

How it works at the PVAMCHow it works at the PVAMC

Mechanisms for requesting an assessment Screening Referral Disease management

The BHL receives a printed consult request.

The BHL reports findings, provides interpretation, and recommendations.

Where appropriate, BHL staff facilitate referral or the appropriate level of intervention.

What does the Service Provide?What does the Service Provide?

Assessment of major illnesses – depression, anxiety, substance use

Screening for other domains – cognition, smoking, psychosis, mania

Initial Treatment recommendations Patient engagement Monitoring of initial treatment for depression –

adherence, adverse effects, symptoms

BHL FlowBHL FlowAnnual Screening Direct consult New treatment for depression

Consult request

Full Assessment

Referral to ARU

Recommendations to PCP and Patient

At-Risk DrinkerReferral to Specific Research

No Treatment Recommended

Brief Intervention Watchful Waiting – 8 weeks

Referral Management

ReferralsReferrals

0

50

100

150

200

250

300

Feb Apr June Aug Oct Dec Feb

5 Month Referral Success5 Month Referral Success

Total Referred for Depression

Referred forAlcohol

Referred for Depression &

Alcohol

p value

Sample size N=605 N=472 N=75 N=58Percentage of total cases

100.0 78.0 12.4 9.6

Completed Interviews (% within category)

74.0 75.2 64.0 77.6 0.263

Age >65 (% ) 20.8 23.3 16.0 6.9 0.008

Characteristics of PatientsCharacteristics of Patients

Referred for Depression

Referred forAlcohol

Depression & Alcohol

p value

N=355 N=48 N=45Age (% > 65) 21.4 14.6 8.9 .091Race (% White) 45.9 27.1 26.7 .004MDD 45.0 25.6 55.8 .014Alcohol dependence 7.1 39.6 51.1 .000Anxiety disorder (Panic or PTSD) 21.5 6.3 31.1 .010Psychosis 13.6 10.4 26.7 .044

Mania 7.9 2.1 17.8 .020High Risk Suicide 14.5 11.6 20.9 .439In MH/SA care (last 12 months) 27.3 14.6 22.2 .379On antidepressant 38.1 23.3 23.3 .036

Does the BHL change practice?Does the BHL change practice?

25% reduction in the number of patient not screened for depression

10% increase in the screen positive rate for depression

Significant increase in the identification of patients with suicidal ideation

Possible improvement in EPRP measures for depression

Engagement in CareEngagement in Care

Overall Required an appointment

Requested an

appointment

p value

Patients needing an appointment (% of total # of assessments)

N=254(44.3%)

N=200(35.0%)

N=54(9.3%)

Patients refusing appointment 12.5%

Proportion seen in MH/SA care within 3 months of the BHL assessment

N=119(55.0%)

N=92 (52.6%)

N=27(50.0%)

0.741

Proportion seen in primary care within 3 months of BHL assessment

N=117(51.1%)

N=87(49.7%)

N=30(55.6%)

0.453

ConclusionsConclusions

BHL is a flexible, evidence based program Fills gaps in the VHA system Provides valid information and documentation

Acceptable to veterans Valued by provider

Can function at low cost across diverse settings Useful for outreach Can provide coordination as well as assessment

Disease Management Referral Management

Valuable as a tool for improving system performance

But?But?

The number of patients referred doesn’t match those assessed.

Referrals for depressionReferrals for depression

3008 already in MH/SA care

17,543 Patients Screened

1232 positive screens (7%)

740 Patients referred to the BHL (60%)

104 Unable to contact (14.1%)56 Refused 7.6%)

580 Completed Assessment

Referrals for Alcohol MisuseReferrals for Alcohol Misuse

In MH/SA care not an option

2781 patients who drank screened

906 positive screens (32.6%)

118 Patients referred to the BHL (13%)

17 Unable to contact (14.4%)7 Refused (5.9%)

94 Completed Assessment

What about the Instrument?What about the Instrument?

Q#1: How often did you have a drink containing alcohol in the past year?

Never (0 points)

Monthly or less (1 point)

Two to four times a month (2 points)

Two to three times per week (3 points)

Four or more times a week (4 points)

What about the Instrument?What about the Instrument?

Q#2: How many drinks did you have on a typical day when you were drinking in the past year?

1 or 2 (0 points)

3 or 4 (1 point)

5 or 6 (2 points)

7 to 9 (3 points)

10 or more (4 points)

What about the Instrument?What about the Instrument?

Q#3: How often did you have six or more drinks on one occasion in the past year?

Never (0 points)

Less than monthly (1 point)

Monthly (2 points)

Weekly (3 points)

Daily or almost daily (4 points)

Is the Screener to “sensitive”Is the Screener to “sensitive”

0

10

20

30

40Pe

rcen

tage

of B

HL

Ref

erra

l

4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00

Total AUDIT-C Score

2 Drinks/day 3-4 Drinks/day with binges 10+ Drinks/day

Does the Type of Provider Matter?Does the Type of Provider Matter?

0

5

10

15

20

Perc

enta

ge o

f BH

L R

efer

ral

Type of Primary Care Clinician

Other MD CRNP/PA Residents/ Fellows

Choices:MDCRNP/PAResidents/ FellowsOther

Do Clinician Beliefs Matter?Do Clinician Beliefs Matter?

Low Referral Pattern

(n=19)

Moderate Referral Pattern

(n=10)Age 46.8 46.9

Gender (% female) 78 50

Provider type (%CRNP or PA)

63 20

Do Clinician Beliefs Matter?Do Clinician Beliefs Matter?

Low Referral Pattern

(n=19)

Moderate Referral Pattern

(n=10)Beneficial Drinking 6.2 3.2

Inpatient - Yeah! 78 40

Outpatient - Yeah! 67 90

Starting a New PracticeStarting a New Practice

Identify a thought leader / Champion Define practice specific needs – screening, referral, resources

Define practice specific procedures

Announce the availability of the service Face-to-face Email Letters / Brochures

Other Marketing StrategiesOther Marketing Strategies

Business cards for patients Business cards for

providers ELM interface Listing of providers Staff in practice / Screening

of patients 877 number

Pens Sticky pads Business size card for

computer Monthly email reminders Clinic feedback In-service by staff on MH/SA

topics Website

A Platform for other activitiesA Platform for other activities

Telephone disease management for problem drinking Supported by VA HSR&D

Developing watchful waiting strategies Supported by Robert Wood Johnson Foundation

ExTENd – Use of naltrexone in managing alcohol dependence Supported by NIAAA – R01

DIADS – depression of Alzheimer’s disease Supported by NIMH R01

Family caregiver Support

Depression Treatment Monitoring

PTSD

Referral Management