2121 K Street, NW, Suite 210 Washington, DC 20006

1. Center for Integrated Behavioral Health Policy Department of Health Policy, George Washington University Medical Center 2121 K Street, NW, Suite 210 Washington, DC 20006

2. Implementing Alcohol Screening and Brief Intervention in Your EAP Chesapeake EAPA January 6, 2011 Eric Goplerud PhD Tracy L. McPherson, PhD

3. Presenters • Eric Goplerud, PhD Research Professor and Director Center for Integrated Behavioral Health Policy Ensuring Solutions to Alcohol Problems Department of Health Policy George Washington University Medical Center Washington, DC goplerud@gwu.edu • Tracy L. McPherson, PhD Assistant Research Professor Center for Integrated Behavioral Health Policy Ensuring Solutions to Alcohol Problems Department of Health Policy George Washington University Medical Center Washington, DC esap1234@gmail.com

4. Today’s Objectives: • Learn about and receive a copy of the World Health Organization’s AUDIT-C/AUDIT – a brief, validated alcohol screening tools that can be integrated into routine EAP practice to identify risky alcohol use. • Learn to relate appropriate levels of brief intervention to level of alcohol use risk.

5. Today’s Objectives: • Learn to use SBIRT protocols informed by Motivational Interviewing (MI) to assist clients in behavioral change. • Learn about NIAAA’s alcohol education and self-management resources (e.g., “Rethinking Drinking”) for clients.

6. Bonus Elements: • Learn about the “BIG” Initiative EAP learning collaborative and how you can benefit • Learn about (and take-away) “BIG” materials and resources to help you integrate alcohol SBIRT in your EAP practice. • Learn about research findings and implementation tips from EAP pilot tests.

7. Agenda • Background and Rationale • Workplace SBIRT Project • The BIG Initiative • What is SBIRT? • Alcohol Screening Tools • Components of Brief Intervention • Motivational Interviewing Strategies • SBIRT Protocols Using AUDIT (with/without MI)

8. Bonus Elements • Implementation Tips from Pilots • EAP Pilot Test Findings • More “BIG” Resources • Demonstrating Impact and Value • Easy-to-Use Outcome Measures

9. Workplace Alcohol SBI Project Partners: The BIG Initiative • Seed Funding: • NHTSA • CSAT • SAMHSA • NETS • Alkermes • Corporate Sponsors • Pilot Sites: • Aetna • OptumHealth • ValueOptions • Trainer: • Denise Ernst PhD, Training and Consultation http://www.deniseernst.com

10. NHTSA/CSAT Workplace SBI Project (2006-2010) • Overall Aim: • Adapt alcohol SBIRT approaches developed in medical settings for work-related settings: • EAP • Occupational health & safety • Health promotion and wellness • Disease management

11. cont… • Conducted extensive literature review, surveys, interviews, convened advisory panel. • Developed a conceptual model (a feasible approach) of workplace SBI.

12. A Feasible EAP Approach (telephonic or face-to-face)

13. cont… • Developed protocols that could be seamlessly integrated into existing EAP practice. • Conducted “proof of concept” studies to pilot test approaches and protocols in EAPs. • Launched “BIG Initiative” to facilitate EAP adoption of alcohol SBIRT through dissemination of materials and pilot test findings, and training.

14. What is “BIG”? • EAP industry-wide initiative kicked-off in Dallas at EAPA to adopt alcohol SBIRT as routine practice by 2011. • Learning collaborative facilitated by GW which brings together 80+ organizations in the SBIRT “supply chain”.

15. “BIG” Members • EAPs/MBHOs • Employers • Professional Associations • Clinicians • SBIRT/MI Experts • Researchers and Consultants • Pharmaceutical Companies • Federal Agencies

16. Brief Intervention Group (“BIG”) National Highway Traffic Safety Administration Substance Abuse and Mental Health Services Administration Network of Employers for Traffic Safety Aetna Behavioral Health/EAP OptumHealth/UBH ValueOptions Office of Drug and Alcohol Policy and Compliance, Department of Labor Office of Demand Reduction, Office of National Drug Control Policy, Executive Office of the President U.S. Nuclear Regulatory Commission Department of Defense Maine State Government Federal Occupational Health (FOH) University of Maryland School of Social Work Chestnut Behavioral Health First Sun EAP SELECT, Inc CIGNA Magellan Anthem/WellPoint Masi Consulting Burke Consulting Caterpillar Northrup Grumman Johns Hopkins University and Hospital JP Morgan Chase Hawaii Business Health Council National Business Group on Health UPS Amtrak Continental Airlines RAND Corporation Baltimore Gas & Electric Halliburton 3M EAPA EASNA Center for Clinical Social Work NAADAC Association of Flight Attendants AON St John’s Mercy First Advantage The Rainier Group Reckitt-Benckiser

17. What does “BIG” do? • Four Committees • Board of Directors –thought leaders, industry decision-makers provide direction of BIG strategy • Clinical – change EAP provider and network affiliate practice • Systems and Operations – change call center and internal EAP practice • Quality Improvement – identify common metrics (program performance, client outcomes)

18. How can you benefit from “BIG”? • www.EAPBIG.org • FREE SBIRT Training Materials and Resources • Connect with BIG members on LinkedIn • Earn CE/PDHs by participating in BIG events • EAPA chapter meetings; regional and national conference events • EASNA annual meeting

19. So…Why Should EAP Providers Care About Alcohol SBIRT and BIG? • Heavy drinking (5+ drinks on one occasion) increases risk of depression, sleep problems, hypertension, and cancer • 3 in 10 adults drink at levels that increase risk of physical, mental health, and social problems (NIAAA)

20. Alcohol Problems Nearly as Prevalent as Diabetes 18.2 million2 17.6 million1 Alcohol Abuse & Dependence Diabetes References: Grant BF, et al. Alcohol Res. and Health. 2006; 29:77. National Center for Chronic Disease and Prevention and Health Promotion. National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/estimates.htm. Accessed June 25, 2008. A

21. 8% 92% How Many Get identified? ~ 8% of U.S. adults has a diagnosable alcohol use disorder (NSDUH, 2005)

22. How Many Get Identified? Health plans identify <1% of members (NCQA, 2007)

23. Office of Applied Studies. (2004). Results from the 2003 National Survey on Drug Use and Health: National findings. Rockville, MD: Substance Abuse and Mental Health Services Administration.

24. more reasons… • Alcohol problems have a profound impact on the workplace, its employees and their families: • 80% of problem drinkers are employed • 60% of alcohol-related absenteeism, tardiness, and poor work quality are caused by at-risk drinkers • 20% of employees have covered for a coworker, required to work harder, or injured due to coworkers drinking

25. Economic Costs of Alcohol Problems $185 billion1,2 $11 billion2 $98.1 billion2 $40 billion2 Alcohol Abuse & Dependence References: National Institute on Alcohol Abuse and Alcoholism. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. http://pubs.niaaa.nih.gov/publications/economic-2000. Accessed June 25, 2008. The George Washington University Medical Center. Ensuring Solutions to Alcohol Problems. Primer 1: Treating Alcoholism as a Chronic Disease. http://www.ensuringsolutions.org/usr_doc/PDF_Version_of_Primer.pdf. Accessed June 18, 2008. High Blood Pressure Diabetes Greater than High Blood Pressure, Asthma and Diabetes… …Combined Asthma

26. more reasons… • EAPs play a vital role to employers and workers • Millions of workers rely on EAP for confidential help for mental health, substance use, work stress and family issues. • Employers see EAP as a crucial resource. • EAPs are uniquely positioned to “case find” (alcohol misuse is not a common presenting problem).

27. More reasons… • Brief, evidence-based approaches exist for EAP providers to enhance existing practice and increase value of services. • “BIG” provides EAP providers with materials and resources to do SBIRT. • Making the right thing to do, the easy thing to do.

28. “BIG” Challenges • Alcohol identification rates by EAP providers remain abysmal! • ~ 160,000 EAP alcohol cases each year (Amaral 2009) • Baseline identification <1 to 5% (GW pilot studies) • Historically EAP providers have focused on workers with alcohol addiction. • EAP providers have not focused on early intervention to identify at-risk drinkers but don’t meet diagnostic criteria.

29. 5% (6.25 million) Daily Harmful Drinking or dependence behavior 20% (26.25 Million) At Risk Exceed daily limits 70 % ( 87.5 Million) Occasional or non drinkers, seldom exceed daily limits for alcohol consumption Who Are We Trying to Reach? • 1% Historical EAP focus • 25% engaged in • risky, harmful or hazardous drinking • 32.5 million people could benefit from brief intervention Spectrum of Alcohol Use 1%(1.25) Addicted

30. How do we identify workers at risk? “Case Finding” through SBIRT

31. What is SBIRT? • S:Screening using a validated tool • BI:Brief Intervention using an evidence-based framework • RT:Referral to Treatment • SBIRT:Screening, Brief Intervention and Referral to Treatment • Follow-up:administrative, clinical, outcomes • MI:Motivational Interviewing

32. What is SBIRT? • Approach developed in the medical setting (trauma, ED), backed by scientific evidence of effectiveness. • Recent efforts to adapt for EAP and other behavioral settings (e.g., community health centers).

33. Aim of SBIRT • Increase early identification of clients at risk for alcohol problems. • Build awareness and educate clients on U.S. guidelines and risks associated with alcohol use. • Motivate at-risk clients to reduce unhealthy, risky alcohol use; adopt health promoting practices. • Motivate clients to seek help for alcohol use.

34. http://pubs.niaaa.nih.gov/publications/arh28-1/toc28-1.htm Evidence behind SBIRT http://pubs.niaaa.nih.gov/publications/arh28-2/toc28-2.htm

35. Aetna Pilot Findings • Identification Rates at 5 months approached U.S. population estimates • 18.5% using AUDIT screening tool • 6% based on “presenting problem” • At baseline: < 1% (prior vendor data) McPherson, T.L., Goplerud, E., Derr, D., Mickenberg, J., Courtemanche, S. (in press, 2010). Telephonic Screening and Brief Intervention for Alcohol Misuse Among Workers Contacting the Employee Assistance Program: A Feasibility Study. Drug and Alcohol Review.

36. Findings at 5 Months • 78% agreement to follow-up by EAP clinician • 72% set an appointment for • face-to-face counseling McPherson, T.L., Goplerud, E., Derr, D., Mickenberg, J., Courtemanche, S. (in press, 2010). Telephonic Screening and Brief Intervention for Alcohol Misuse Among Workers Contacting the Employee Assistance Program: A Feasibility Study. Drug and Alcohol Review.

37. OptumHealth EAP Replicated Findings Greenwood, G., Goplerud, E., McPherson, T.L., Azocar, F., Baker, E., & Dybdahl, S. (in press, 2010). Alcohol Screening & Brief Intervention (SBI) in Telephonic EAP. Journal of Workplace Behavioral Health.

38. Alcohol use to intoxication (5+ drinks) declined 38.4% Use of any illegal drugs decreased 49.6% Nearly 50% of those who received a BI changed patterns of misuse Federal SBIRT Demonstration Findings Adapted from Tom Stegbauer, DHHS, 2008 N = 11 States

39. QUESTIONS?

40. Components ofSBIRT

41. SBIRT Core Components Brief Intervention/ Brief Treatment Cognitive behavioral, medications with clients who acknowledge risks and are seeking help Moderate Brief Intervention Raises awareness of risks and reinforces staying at low risk Screening Identification of behavioral problems/risk (alcohol, tobacco,drugs, depression) Low High Referral to TXReferral of those with more serious or complicated mental or substance use conditions Adapted from Tom Stegbauer, DHHS, 2008

42. Heterogeneity of Alcohol Use DSM-IV Abuse/Dependence Mild (“At-risk”) Moderate (Harmful use) Severe (Dependence) Chronicdependence None 70% ~21% ~5% ~3% ~1% • Daily or neardaily heavydrinking • Chronic orrelapsing • 6-7 criteria • Functionalimpairment • Daily or neardaily heavydrinking • Impairedcontrol • 3-5 criteria • Exceedsdaily limits • Harmful • Exceedsdaily limits • No distressor harm Never exceedsdaily limits EAP and Workplace BH Programs

43. NIDA Single-Item Drug Use "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Identifies overall drug use Positive screen = 1 or more Provide BI /RT Barclay, Laurie (2010). Single Screening Question May Identify Drug Use in Primary Care. Arch Intern Med. 2010;170:1155-1160

44. NIAAA Single-Item Alcohol Use "How many times in the past year have you had X or more drinks in a day?" X = 5 for men, 4 for women Identifies unhealthy alcohol use Positive screen = 1 or more (provide BI) Barclay, Laura (2009). Single Screening Question May Accurately Identify Unhealthy Alcohol Use. J Gen Intern Med.

45. Alcohol Screening(handout) • AUDIT-C • AUDIT

47. AUDIT Alcohol Use Disorder Identification Test Developed by WHO English:http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf Spanish:http://www.who.int/substance_abuse/activities/en/AUDITmanualSpanish.pdf Detects Alcohol Problems in the Last Year AUDIT-C <2 min AUDIT <5 min 47

48. AUDIT Domains

49. AUDIT-C Hazardous Use (AUDIT Items 1-3)

50. AUDIT-C Scoring Items # 1-3 scored 0-4 points Add up points Positive prescreen = 4+ men 3+ women and adults over age 65 Administer remaining AUDIT items # 4-10 Provide BI, if using only AUDIT-C