Screening and Brief Intervention for Substance Abuse: Overview of Practical and Conceptual Issues

1. Screening and Brief Intervention for Substance Abuse: Overview of Practical and Conceptual Issues Thomas Babor, PhD, MPH

2. Discuss SBIRT programs in relation to a public health approach to substance abuse Describe progress made in the past two decades in the development of concepts, screening tools, intervention techniques, and implementation for SBIRT Discuss implications for traffic safety Objectives

3. Screening—How, Who, and When? Treatment matching linked to screening results Brief intervention Brief treatment Referral to standardized assessment and more intensive treatment Continued monitoring Basic Elements of SBIRT

5. Phase I (1980’s) Development of screening tests PhaseII (1985-current) Clinical trials of brief intervention with risky drinkers and drug users Phase III (1990-current) Feasibility research on barriers to implementation of SBIRT Phase IV (2000-current) Development and evaluation of national plans for alcohol SBIRT program initiatives in health care systems in both developed and developing countries Spurt – a sudden burst of energy or activityA Brief History of SBIRT

6. Treatment vs. prevention Alcoholism vs. heavy drinking; Addiction vs. recreational drug use Disease conditions vs. risk factors Individual vs. public health perspectives Distinctions / Dichotomies

7. Adequate definition of problem and operational criteria for diagnosis Natural history of problem understood, as well as risk factors and populations at risk Screening tests available: brief, easy to administer, reliable, valid Effective intervention and treatment methods available Preconditions for a Public Health Approach to Screening and Early Intervention

8. Evaluating a SBIRT Program

9. Key Terms and Definitions

10. The Drinkers’ Pyramid Dependent Drinkers At-Risk Drinkers Responsible Drinkers Abstainers

11. Illicit Drug Use PyramidConnecticut Adults Age 18 to 39 Illicit drug abuse requiring formal treatment 3% (24,912) 14% (104,653) Current illicit drug use 83% (619,313) No illicit drug use Note: Figures based on Connecticut 1996 adult household telephone surveys and 2000 US census of adults age 18 to 39.

12. Identify both hazardous/harmful drinking or drug use and those likely to be dependent Use as little patient/staff time as possible Create a professional, helping atmosphere Provide the patient information needed for an appropriate intervention Goals of Screening

13. Alcohol AUDIT, CAGE, TWEAK, et. al. Drugs DAST Combined Substances (Tobacco, Alcohol, Other Drugs) ASSIST, CAGE-AID, SASSI Common Self-Report Screening Assessments

14. Malmo Study (1982) WHO AMETHYST Project (1985-1996). Other trials (Wallace et al., Fleming et al.) Meta-analyses and review papers A Short History of SBIRT: Phase IIAlcohol Brief Intervention Trials

15. Sequence of Study and Procedures Associated with Each Condition Screening Recruitment WHO Composite Interview Schedule Stratified Random Assignment GROUP I Control group • GROUP II • Simple Advice • Review interview results • Explain Sensible Drinking • Leaflet (5 min) GROUP III Brief counselling Review interview results Explain Sensible Drinking leaflet (5 min) Introduce Problem Solving Manual (15 min) Mention Diary cards and identify a helper Mention six-month follow-up interview Ask patient to fill out Health and Daily Living Questionnaires Six month follow-up

16. Brief interventions (BI) can reduce risky alcohol use by about 20% for at least 12 months Approach is effective with younger and older adults, men and women. Results mixed on longer-term health care utilization and reduction of alcohol-related harm. Results consistent across providers (professional/nonprofessional), settings (PHC, ED, Trauma, hospitals), and cultural groups Alcohol Brief Intervention Trials, Results of Meta-analyses

17. Brief intervention trials with at-risk drug users Combined health behavior risk factor brief intervention research Brief treatment trials with substance users Motivational Enhancement Therapy (NIAAA-funded Project MATCH) Brief Marijuana Treatment (SAMHSA-CSAT-funded MTP study) Subsequent Brief Intervention Trials and Other SBIRT Research

18. MTPMarijuana Treatment Project A Multi-site Study of the Effectiveness of Brief Treatment for Cannabis Dependence A Cooperative Agreement funded by SAMHSA-CSAT

19. Study Design

20. Outcomes: Baseline, 4, 9 & 15-months% of Days Smoked Marijuana

21. Brief interventions and brief treatments are effective with smokers, drinkers and results are promising with marijuana users. SBIRT poised for implementation Two decades of clinical research, program development Effective screening tests, brief intervention and brief treatment protocols available Training programs developed There is general agreement on the need to “broaden the base” of treatment (expand treatment and early intervention services to less severe cases and populations at risk) A Short History of SBIRT:Time for Implementation Efforts

22. R.A. Senft et al., primary care, 1997 Prescription for Health Initiative, RWJ/AHRQ (2002 – present) Vital Signs, UConn, dental clinics (2002–2004) Cutting Back, RWJ, 2002-2005 SBIRT Implementation Trials –

23. It can be done, but it’s not easy Staff participation in planning is critical Training does change beliefs and builds capacities; practice reinforces change Many factors contribute to success & problems Outcomes may be somewhat less than in tightly managed trials Costs are low compared to many services What is being learned from implementation research?

24. Expert committee reports Standards and practices National alcohol screening day SBIRT National demonstration program Phase IV: The Future Has ArrivedUSA Policy Implications

25. Primary care clinicians should screen all adults and pregnant women for alcohol misuse and refer them for counseling if necessary Women who drink more than 7 drinks per week or more than 3 drinks per occasion and men who drink more than 14 drinks per week or more than 4 drinks per occasion are considered to be risky or hazardous drinkers The term alcohol misuse includes risky drinking as well as harmful drinking Effective counseling sessions for risky drinkers should include advice to reduce current drinking; feedback about current drinking patterns; explicit goal-setting, usually for moderation; assistance in achieving the goal; and followup through telephone calls, repeat visits, and repeat monitoring. US Preventative Services Task Force Recommends that Primary Care Clinicians Screen and Counsel Adults to Prevent Misuse of Alcohol AHRQ, April, 2004

26. Insurance policy legislation can restrict or facilitate SBIRT American College of Surgeons, Committee on Trauma, recommends new standards requiring Level 1 and level 2 trauma centers to "include identification and intervention for problem drinkers." Standards and Practices

27. The largest and most visible SBIRT activity in the USA Established in 1999 Three objectives: Administer free and anonymous alcohol screening in an accessible setting Provide referrals for treatment Provide public education about the impact of alcohol on health National Alcohol Screening Day

28. Burden due to major risks Cost-effectiveness of relevant interventions Policy implications World Health Report 2002

29. Leading 12 selected risk factors as causes of disease burden = Major NCD risk factors High Mortality Developing Countries Low Mortality Developing Countries Developed Countries 1UnderweightAlcohol Tobacco 2Unsafe sex Blood pressure Blood pressure 3Unsafe water TobaccoAlcohol 4Indoor smoke UnderweightCholesterol 5Zinc deficiency Body mass index Body mass index 6 Iron deficiency Cholesterol Low fruit & veg. intake 7 Vitamin A deficiency Low fruit & veg intake Physical inactivity 8 Blood pressureIndoor smoke - solid fuels Illicit drugs 9 TobaccoIron deficiency Unsafe sex 10 CholesterolUnsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Childhood sexual abuse

30. Cost Effectiveness of Brief Intervention with Risky Drinkers From: Chisholm, D., Rehm, J., Van Ommeren, M. & Monteiro, M. (2004) Reducing the global burden of hazardous alcohol use: A comparative cost-effectiveness Analysis. Journal of the Studies on Alcohol 65:782-793.

31. Driver education programs – early intervention DUI specific SBI, e.g., screening items, intervention techniques Referral to alcohol assessment Referral to treatment Implications and Applications of SBIRT for DUI Countermeasures

32. A successful example of translational research Meets requirements of a public health approach to secondary prevention, but needs to focus on high risk groups in high volume settings for maximum effect Consistent with IOM vision of “Broadening the Base” of treatment, and SAMSHA/CSAT Access To Recovery Initiative Could serve as a major feeder to treatment system, AND an additional secondary prevention component Alcohol SBI as a Trojan Horse to drug SBI Direct and indirect applications to drink-driving countermeasures POLICY AND CLINICAL IMPLICATIONS