David R Boyd, MDCM FACS, Peter Stuart MD FAAP, Rose Weahkee PhD, May 21, 2012 Rockville , MD

1. Alcohol Screening and Brief Intervention (ASBI)The IHS Approach: Tele-Presentation to the Association for Addiction Professionals ( NAADAC) David R Boyd, MDCM FACS, Peter Stuart MD FAAP, Rose Weahkee PhD, May 21, 2012 Rockville , MD

2. Trauma, Emergency and Primary Care, Behavioral Health,Alcohol and Substance Abuse, and Injury Prevention: Indian Health Service

3. IHS-ASBI • Targeted Repeat Injury Control Initiative for the Hazardous Non-Dependent Drinkers • Clinical: PC, ED and Trauma Providers • Alcohol: the Initial Abused Substance • Expandable to other SA and Dys-Behaviors • Acute Care Behavioral Health Specialist (ACBHS)

4. SBIRT vs. IHS ASBI • Both have a common conceptual source of early identification and interventions. • Both identify an optimal group that would be influenced by such interventions • ASBI “opportunity” focused on the presenting sequelae • ASBI uniquely developed for remote, marginally staffed hospitals and free-standing clinics.

5. IHS Responsibilities • 1.9 million Reservation Population • 564 Tribes in 35 States, Rural-Poverty • 44 Hospitals, 480 Clinics • Trauma Mortality 3-7 X General Pop. • Alcohol and Drugs Involved • Limited Staff in ED, Surgery and BH • Medical Staff Turnover and Burn Out

6. IHS ASBI Program • Trauma Control Initiative • Based on the work of Gentilello-Seattle, Soderstrom-Baltimore and D'Onofrio-New Haven • SBIRT Program Experience • Developed for IHS needs, accepted by Primary Care and must be Sustainable. • Alcohol is the Prime Substance Abused • Injury as the Lead Clinical Problem

7. ASBI Strategic Approach • TargetedInjury Control Initiative • Alcohol Screening in Acute Care Setting; Trauma, ED and PC Clinics • Utilizes Multiple Providers • Low Cost Implementation • Cost EffectiveIntervention • Universal Screeningfor other Substance Abuse and “Injurious Behaviors”

8. ASBI Terminology • AS: Alcohol Screening • BI: Brief Intervention • BNI: Brief Negotiated Interview (Yale) • ASBI: Alcohol Screening & Brief Intervention • SBIRT: Screening, Brief Intervention and Referral to Treatment • Trauma=Injury • Injury Recidivism = Repeat Injury

9. Injury Risk Factors for American Indians and Alaska Natives • Median age of 24 vs. 33 • Below poverty level, 32% • Risky Environment: Driving long distances on rural, isolated roadways. • Alcohol involvement is higher than other racial groups. Courtesy of Dave Wallace, MSEH; NCIP, CDC

10. Trauma Center & ED Predictability • 25-55%test+ for alcohol on TC-ED admission • 25-50% have a diagnosable alcohol use problem • These are 3.5 times more likely to be re-admitted for another trauma episode • Death from repeat trauma is 6 times greater than for the general population Courtesy of Carl Soderstrom MD, FACS RA Cowley STU, MD DOT

11. Trauma-Alcohol Related–MVA Deaths in Illinois Blood Alcohol Content (BAC) for < 25 year olds were relatively low, many within legal limits Every third MVA-Alcohol Related Death killsone other innocent passenger or bystander DR Boyd MDCM,FACS Illinois Statewide Trauma Registry, Illinois Dept of Public Health, 1970-74

12. The Spectrum of Alcohol Use: Who Are WeTargeting in ASBI? HAZARDOUS & HARMFUL (20%) DEPENDENT (10%) ABSTAINERS & MODERATE (70%) Specialized Treatment Brief Intervention Primary Prevention

13. Key Trauma Center Study Showed the beneficial results achieved with a brief intervention (BI) in Trauma Center patients demonstrating decreases in drinking at 6 months and at one year in the. • The control group returned to pre-injury level (or higher) at one year. • The experimental group had a 47% reduction in injuries requiring emergency department care or trauma center admission.   Gentilello LM, Rivara FP, Donovan DM, Jurkovich GJ, et al: Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg, 1999;230: 473-483.

14. Control Standard drinks per week BI Adverse Outcomes Controls vs. BI at 1 year Gentilello et al Ann Surg ‘99

15. R.A. Cowley Shock-Trauma Center • Showed decreased binge drinking episodes in both experimental and “control” subjects at 6 months and one year and decreases in “Hazardous” consequences. • Raising the subject of alcohol misuse and its consequences during the “opportunistic window” -after injury – seems be enough to bring about change. Soderstrom CA, DiClemente CC, Dischinger PC, et al: A prospective randomized trial of brief motivational intervention (BMI) for alcohol use problems among trauma center patients.  Alcohol Clin Exp Res 2005 May 29(5) Supplement;28:186A.

16. Billings IHS Area Injury Death Study • Fatal Injuries occurred after a previous IHS Service Unit ETOH encounter without prevention counseling within; 6 months (38%). Recommendations: • Injury-Prevention activities should be initiated at the time of any health-system contact in which alcohol use is identified. • Intervention strategies should be developed that convey the immediate risk of death from injury in these patients. Analysis of Prior Health System Contacts as a Harbinger of Subsequent Fatal Injury in American Indians. TL Sanddal, J Upchurch,ND Sanddal and TJ Esposito; Journal of Rural Health, 2005

17. Lasting Effect on DUI Recidivism • Patients who receive BI during a trauma center admission are less likelyto be arrested for DUI within 3 yearsof discharge. • BI represents a viable intervention to reduce DUI after trauma center admission. Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. Schermer CR, Moyers TB, Miller WR, Bloomfield LA. J Trauma. 2006 Jan;60(1):29-34.

18. Billings Area CHS Injury Expenditures FY04 by Age

19. ASBI Opportustic for Target Population • Young Adults and Teens • Non-dependent Alcohol Abusers • Hazardous or Harmful Behavior • Injury Causing to themselves or others • Injury Presentation to an IHS-Tribal Emergency Department, Urgent, Ambulatory and Primary Care • Are in the “Teachable Moment”

20. ASBI TARGET PATIENT • Acute Injury Related Patient Encounter • Clinical Assessment • Injury Related to Risky Behavior • Risky Behavior has an Alcohol Basis • Not a Diagnosis on “Alcoholism” • Not an Assessment of “Intoxication.” • Blood Alcohol (BAC) Not Required

21. ASBI Process • Alcohol Screening (AS) Eclectic ~AUDIT • Brief Intervention (BI) ~ Yale Brief Negotiated Interview (BNI) • AS & BI together or staged as follow on • Not Counseling • Referral to Behavioral Health, Psychology and Psychiatry as indicated • Recorded in IHS EHR and RPMS

22. Alcohol Screening and Brief Intervention (ASBI) Project BNI Training Manual Gail D’Onofrio MD, MS1 Michael V. Pantalon Ph.D. 2 Linda C. Degutis DrPH1 David Fiellin MD3 Patrick G. O’Connor MD3 1Department of Surgery, Section of Emergency Medicine, 2Department of Psychiatry, Division of Substance Abuse & 3Department of Medicine, Yale University School of Medicine New Haven, CT

23. Key Steps of the Yale BNI • Raise The Subject • Provide Feedback • Enhance Motivation • Negotiate And Advise • Follow on and Referral as Indicated

24. Behavioral Health Follow On, Boosters & Reassessment • Full AUDIT Recommended • Secondary Goals • Identify Alcohol Dependent Patient • Identify Co-Morbidity (Dual Diagnoses) • Other Substance Abuse • Other Mental Health Diagnoses • Introduce an Otherwise Resistant Referral • Perform BNI and establish a Follow On BH Plan • “Booster Shots”, When, Where, Who?

25. ASBI Literature Review* • Prochaska and DiClemente (1983) • Bien et al (1993) • Gentilello* (1999) • D’Onofrio* and Degutis* (2002, 2005) • Dischinger* and Soderstrom* (2001) • Moyer et al (2002) • Soderstrom* and DiClemente*, (2005) • Sanddal(s)* and Upchurch*, (2005) • Schermer*, (2006) *IHS ASBI Implementation and Operational Manual

26. Acute Care Behavioral Health Specialist (ACBHS) • Registered Nurse familiar with medical interventions with added physiologic, pharmaceutical and Behavioral Health education. • Trauma Nurse Coordinator model adapted to ASBI functions. • Case management, coordination and follow up.

27. ASBI Goal “ALCOHOL SCREENING AND A BRIEF NEGOTIATED INTERVIEW, DURING THE TEACHABLE MOMENT, AFTER INJURY, CAN BE EFFECTIVE IN REDUCING RE-INJURIES (RECIDIVISM) UP TO 50% FOR SEVERAL YEARS” DR Boyd MDCM, FACS

28. WHY NOT SBIRT ? • SBIRT Developed on a Research Design • Extensive Data and Administrative Load • No Consistent BI Methodology • Referral for Treatment NOT Indicated • Referral for Treatment NOT Accepted • ASBI Goal to Prevent Injury and Death • ASBI is Practical and Accepted by ED~PC

29. Thank You David R. Boyd MDCM, FACS National Trauma Systems Coordinator Emergency Service Indian Health Service 801 Thompson Ave Suite 320 Rockville, MD  20852 David.Boyd@ihs.gov 301-443-1557