Improving Brief Intervention Reducing Alcohol Related Morbidity and Mortality in Primary Care

1. Improving Brief InterventionReducing Alcohol Related Morbidity and Mortality in Primary Care J. Paul Seale, M.D.Principal InvestigatorDepartment of Family MedicineMercer University School of Medicine Funded by Grant R25 AA014915-01A1 National Institute for Alcohol Abuse & Alcoholism National Institutes of Health

2. Georgia Harold DuCloux MD William McAfee PhD Randy Robinson MD Harry Strothers MD Texas Carlos Dumas MD Lisa Davis MD Rebecca Gladu MD Robert McClellan MD Co-Principal investigator Mary M. Velasquez, PhD, Co-PI Site Coordinators

3. Module 1 Objectives • Describe the importance of alcohol misuse as a health issue • Examine the evidence base for alcohol screening and brief intervention (SBI) • Outline the rationale for implementing SBI in primary health care • Provide an overview of the steps in “Improving Brief Intervention” Project

4. What is SBI? • Screening - identifying patients who are at risk because of their pattern of alcohol consumption • Intervention – Assisting patients in achieving abstinence or reducing their drinking to low risk levels

5. Relationship between alcohol problems and alcohol use Problems Alcohol Use Severe Heavy Moderate Moderate Few Light None None

6. Who needs attention? 14 million people 5% Alcohol dependent

7. Who needs attention? 47 million people 17% At Risk drinking

8. NIAAA (2005) definition of At risk drinking • Men ≤65 • More than 4 standard drinks in a day &/or • More than 14 standard drinks in a week • Men>65 and All Women • More than 3 standard drinks in a day &/or • More than 7 standard drinks in a week A standard drink is 14 grams of pure alcohol

9. a glass of wine 5 oz

10. Why is management of alcohol misuseimportant to Family Physicians? • Prevalence • Morbidity and Mortality • Cost • Potential for effective intervention

11. Alcohol Misuse is commonly encountered by Family Physicians • 7-20% of primary care patients exhibit patterns of alcohol misuse • 30-40% of patients in ERs • 50% of trauma patients Fiellin, et al, 2000; D’Onofrio et al, 1998

12. Prevalence of Alcohol Misuse in Primary Care Possibly dependent 5% Alcohol Misuse At Risk drinkers 17% Low risk Drinkers 38% Abstainers 40% Manwell, Fleming, Johnson, Barry, 1998

13. Why important: Morbidity & Mortality • Alcohol is the third leading cause of preventable death in the US (CDC), (76,000 deaths, or 5% of all deaths in 2001) • Alcohol is the third leading preventable cause of healthy years lost to death & disability in developed nations (WHO).

14. 5% Alcohol Dependent Patients Significant morbidity, mortality, and economic cost 47 million people Alcohol dependent

15. At risk Drinkers:Why do they need attention? At risk for short and long term health problems May put others at risk 47 million people 17% At Risk drinking

16. Chronic liver disease & cirrhosis 8 specific cancers Heart disease Pancreatitis Stroke Depression Injuries Homicide, suicide Family Violence Major Causes of Alcohol-related Morbidity & Mortality MMWR Weekly Sept 24, 2004/ 53(7); 866-870 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm Naimi, 2002

17. Morbidity & Mortality due to chronic alcohol misuse • 46% of total deaths • 35% of years of life lost • Leading cause of liver disease

18. Morbidity & Mortality due to acute alcohol misuse • 54% of total deaths • 65% of years of life lost • Leading cause of MVAs in US

19. Why important: Morbidity • Alcohol interacts with many medications • Exacerbates numerous chronic medical conditions (HTN, DM, PUD, etc.)

20. Economic cost: $185 billion annually Mokdad et al, 2000; Harwood, 2000

21. Increasing patient recognition of alcohol as a health issue • Expectation that health care providers will give sound advice about alcohol • Potential benefits for cardiovascular conditions • Potential breast cancer risk among women

22. Patients’ Sense of Screening’s Importance % Higgins-Biddle, 2005

23. Patients’ Comfort with Screening %

24. What is the Evidence Base for SBI? • Does SBI really change patients’ drinking behavior?

25. Brief Intervention Works! SBI meta-analyses & reviews: • More than 34 randomized controlled trials • Focused primarily on at risk and problem drinkers • Result in 10-30% reduction in alcohol consumption at 12 months Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

26. Net percentage reduction in mean drinks per week (USPSTF review) • 9 high quality studies reviewed • 3 single intervention studies resulted in reductions in weekly alcohol consumption ranging from 6-19% • 6 multi-contact intervention studies resulted in reductions in weekly alcohol consumption ranging from 7-34% Whitlock et al, 2004

27. US Preventive Services Task Force: SBI recommended for all PC patients • Class B recommendation (flu shots, cholesterol screening, SBI) • “…good evidence that screening in PC can accurately identify patients whose levels of alcohol consumption…place them at risk for increased morbidity and mortality” • “…good evidence that brief behavioral counseling interventions…produce small to moderate reductions in alcohol consumption” USPSTF, 2004

28. Nursing Involvement Significantly Increases Clinician Intervention Rates • Vital Signs Study: clinicians were 12x more likely to intervene if nurses screened for at-risk drinking as part of vital signs • Healthy Habits Study: clinicians were 3x more likely to intervene with at-risk drinkers if given alcohol assessment results by the nurse Seale et al, 2005; Seale et al, 2006

29. What does this mean for your patients? Calculate based on the numbers of adult patients you see per week… For example, if • You see on average 40 patients per week • 4-8 of these patients are at risk (10-20%) • With brief intervention, 1-3 patients weekly are likely to lower their risk

30. Other Benefits of SBI 1. Fewer hospitalizations & ER visits 2. Cost savings Total benefit: $1170 / patient Screening & intervention cost: $177 / patient Benefit: cost ratio: 6.6/1 Fleming, et al, 2002

31. SBI is underutilized in Primary Care • Less than half of self-reported problem drinkers are asked by their PC physicians about their alcohol consumption or advised to quit drinking or cut back. • Most PC physicians prefer not to counsel nondependent problem drinkers themselves. D’Amico et al, 2005; Spandorfer et al, 1999

32. Baseline Screening & Intervention Data from Your Individual Residency Program, 2006 • N= patients __% of patients reported at risk drinking __% of patients screened for tobacco use by their physicians __% of patients screened for alcohol use by their physicians __% reported ever having received intervention for their alcohol use by their physician __% reported receiving an alcohol intervention on the day interviewed

33. SBI can be effectively implemented in Primary Care • Effective models exist for implementing screening and brief intervention in residency training. • Trained clinicians typically intervene with more than 70% of patients. Seale et al, 2005; Adams et al, 1998

34. Key to implementation: Systems approach targeting both the clinicians & office system • Train clinicians & clinic staff in SBI • Create office system that will support SBI • Screening & prompting system • Assessment instruments • Intervention materials • Reminder system for re-assessment & reinforcement

35. 4 Basic Components of this project’s SBI system • Prescreening of all patients using single question screen • Screeningof all prescreen-positive patients using the Alcohol Use Disorders Identification Test (AUDIT) • Brochure-based Clinician Interventions for all screen-positive patients • Follow-up (re-assessment & reinforcement) at future visits

36. Summary of Module 1 • Alcohol misuse is a major cause of morbidity & mortality in the US • SBI is effective in decreasing at risk drinking & its related consequences • Clinician training & systems intervention are effective in implementing primary care SBI protocols • Training Modules 2-4 will equip this clinic to effectively perform SBI—stay tuned!

37. Module 2 The procedures of Screening and Brief Intervention

38. Objectives for Module 2 • Describe the four procedures of SBI • Practice using and scoring the Healthy Habits Prescreen and the Healthy Lifestyles Screen (AUDIT) • Review the steps of the intervention for at risk drinkers • Practice conducting an intervention for an at risk drinker (clinicians) or asking a patient to complete the 7-day diary (nursing staff)

39. 4 Basic Components of this project’s SBI system • Prescreening (single question screen) • Screening(Alcohol Use Disorders Identification Test or AUDIT) • Clinician Interventions for all screen-positive patients • Follow-up assessment/reinforcement at future visits

40. STEP 1: Prescreen is routine part of the vital signsPerformed by nursing staffTool: single alcohol screening question (NIAAA)

41. Single Question: • “How many times in the past year have you had X or more drinks in a day?” • X = 5 for men age 65 and under • X = 4 for men over 65 and all women • Positive screen = one or more times in the past year

42. a glass of wine 5 oz

43. Healthy Habits Prescreen VS Format

44. 3 Step Process when prescreen is positive • Give patient the Healthy Lifestyles Screen (AUDIT), folded in half • Ask pt to complete it and give to their clinician • Place colored dot on problem list or on patient summary sheet (for clinics with paper charts)

45. Expected results of prescreen 85% negative Prescreen Screen (15%)

46. STEP 2: SCREENING

48. Instrument: Healthy Lifestyles Screen (AUDIT) • Adapted from World Health Organization • Validated in numerous studies worldwide • Fits American guidelines for at risk drinking • Content • 3 Quantity & frequency questions • 3 questions probing signs of dependency • 4 questions about alcohol-related problems

49. SCREENING PROCEDURES • Patient completes form in exam room • Patient gives form to clinician • Clinician notes items circled • Clinician calculates the score • Clinician obtains & documents alcohol & drug history

50. Audit Screen - Scoring • Note numbers in top shaded row • Enter checked number for each question • Enter total score of 10 questions • Ask the 3 questions under Provider Use Only (frequency, quantity, drugs)