Overview: Screening Brief Intervention and Referral to treatment

1. Overview: Screening Brief Intervention and Referral to treatment Holly Hagle, PhD Director of the Northeast ATTC

2. Objectives for this workshop • 1.Compare and contrast alcohol and other drug (AOD) use as it relates to the continuum of use, abuse, and dependency. • 2. Describe the principles of screening, brief intervention, and referral to treatment (SBIRT) process. • 3. Review the stages of change and Motivational Interviewing (MI) strategies and their implication for the intervention process. • 4. Examine the elements of effective brief interventions. • 5. Examine SBIRT for at risk individuals.

3. SBIRTAn Effective Approach • Screening • Brief Intervention • Referral • Treatment

4. SBIRT Intro to SBIRT Source: SBIRT Oregon Residency Program, 2012

5. Alcohol and US • Annual cost of alcohol related injuries: $130 billion(1) • Substance abuse is strongly associated with health problems, disability, death, accident, injury, social disruption, crime and violence (1) • 30% of trauma center admissions are intoxicated (1) • 24.255 of high school students have 5 or more drinks in a row on at least 1 day during a month (2) • 49% of men who identified as homosexual ages 25-29, reported binge drinking (3) • Sources: • H. Gill Cryer, MD, Chief of Trauma, UCLA Medical Center • CDC study - http://www.cdc.gov/hiv/youth/ • CDC studyhttp://www.cdc.gov/mmwr/preview/mmwrhtml/ss6014a1.htm?s_cid=ss6014a1_e

6. Alcohol and US • National data indicates that the rate of STD among female heavy drinkers was 7.3% (highest for women 18-25 years old) (1) • 79,000 deaths were attributable to excessive alcohol use in the US (2) • Excessive alcohol use is the third leading life-style related cause of death for the US (2) Sources: 1. CDC - http://www.cdc.gov/ncbddd/fasd/research-preventing.html 2. CDC - http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

7. DRUG Use and US • Injection drug users (IDUs) account for more than 60 percent of all new hepatitis C virus (HCV) infections in the United States. (1) • Fifty to eighty percent of new IDUs are infected within 6 to 12 months of initial injection. (1) • Of an estimated 15.9 million people who inject drugs worldwide, up to 3 million are infected with HIV (2) • 20.8% of students reported use of marijuana at least one time in the last month (3) • Ecstasy use in the past year (from 6 percent in 2008 to 10 percent in 2010). • Marijuana use among teens increased by a disturbing 22 percent (from 32 percent in 2008 to 39 percent in 2010). • Sources: • CDC- U.S. Centers for Disease Control and Prevention - http://www.thebodypro.com/content/art22608.html • Mathers, B. et al. (2008) http://www.unodc.org/documents/frontpage/Facts_about_drug_use_and_the_spread_of_HIV.pdf • CDC - http://www.cdc.gov/hiv/youth/ • Join together online - http://www.drugfree.org/join-together/addiction/national-study-confirms-teen-drug-use-trending-in-wrong-direction

8. Scope of the Problem • Alcohol and/ drugs are a factor in: • 60-70% of homicides • 40% of suicides • 40-50% of fatal motor vehicle crashes • 60% of fatal burn injuries • 60% of drownings • 40% of fatal falls Source: Virginia department of Health, Division of Injury and Violence Prevention, retrieved from http://www.vahealth.org/Injury/data/reports/documents/2008/pdf/Alcohol%20and%20Injury%20Report.pdf

9. Why SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services • For persons with substance use disorders • Those who are at risk of developing these disorders Primary care, mental health, AOD and other community settings provide opportunities for intervention with at-risk substance users Before more severe consequences occur Source: The Pacific Southwest Addiction Technology Transfer Center - SBIRT webinar slides March 2010

10. SBIRT Effectiveness • Rates of illicit drug use dropped by 67.7 percent six months after patients using illicit drugs had received help through a SBIRT program. • Heavy alcohol use dropped by 38.6 percent. • Illicit drug users receiving brief treatment or referral to specialty treatment also reported other quality of life improvements: • 29.3 percent reported feeling generally healthier • 31.2 percent reported experiencing fewer emotional problems • 15.4 percent reported improved employment status • 64.3 percent reported fewer arrests • 45.8 percent who were homeless reported no longer being homeless Madras, B.K., Compton, W.M., Avula, D. Stegbauer, T., Stein, J.B., Clark, H.W., Drug and Alcohol Dependence Volume 99, Issues 1–3, 1 January 2009, Pages 280–295.

11. Evaluations of SBIRT • Meta-analyses & reviews: • More than 34 randomized controlled trials • Focused primarily on at-risk and problem drinkers • Result: 10-30% reduction in alcohol consumption at 12 months sbirt effectiveness Study - Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005; Ppt. Source – SBIRT Oregon Residency Program, 2012

12. Why SBIRT? In a nutshell: Why SBIRT? Source – SBIRT Oregon Residency Program, 2012

13. Let’s look at the continuum of use

14. Use

15. Screening Who are we trying to reach? Advise referral Dependent 5% 8% Harmful Brief intervention 9% Risky 78% Healthy No intervention Source – SBIRT Oregon Residency Program, 2012

16. The Drinkers’ Pyramid 3-7 % alcohol dependent or harmful users 10- 15% hazardous, at-risk users 35- 40% low-risk drinkers 40% abstainers Source: World Health Organization (WHO)

17. What is a Low-Risk Limit? • No more than two standard drinks a day • Do not drink at least two days of the week NIAAA Guidelines

18. What is a Low-Risk Limit? There are times when even one or two drinks can be too much: • When operating machinery • When driving • When taking certain medicines • If you have certain medical conditions • If you cannot control your drinking • If you are pregnant

19. At Risk Drinking • Men: more than 14 drinks per week or consuming more than 4 drinks per occasion • Women (and anyone age 65+): more than 7 drinks per week or consuming more than 3 drinks per occasion • Drinking: more than 2 standard drinks per day w/o abstaining for at least 2 days per week NIAAA Guidelines

20. Source: NIAAA Guidelines

21. Abuse

22. Substance Abuse vs. Substance Dependence Substance Abuse: the misuse of an illicit drug, prescription drug or over-the-counter medication. Substance abuse often involves a pattern of harmful drug use for mood altering purposes. A person diagnosed with substance abuse is notconsidered to be addicted or dependent (otherwise the diagnosis would be substance dependence).

23. Definitions: Drinking Episodes • A drinking “binge” is a pattern of drinking that brings blood alcohol concentrations (BAC) to 0.08 or above. • Typical adult males: 5 or more drinks in over a 2 hour period • Typical adult females: 3 or more • For some individuals, the number of drinks needed to reach “binge” level BAC is lower • University of Oklahoma “Police Notebook” BAC Calculator www.ou.edu/oupd/bac.htm

24. Addiction

25. Chemical Dependency • According to the National Epidemiologic Survey on Alcohol and Related Conditions • 8.5 percent of adults in the United States meet the criteria for an alcohol use disorder • 2 percent of adults met the criteria for a drug use disorder • 1.1 percent of adults met the criteria for both

27. Stereotype

28. Lincoln on Alcoholism “In my judgment such of us who have never fallen victim (of alcoholism) have been spared more by the absence of appetite than from any mental or moral superiority over those who have.”(remarks to the Springfield, Illinois Washingtonian Society, February, 1842)

32. Addiction is Manageable Recovery Happens • Addiction is Manageable and, with treatment, has good outcomes. ….all this bad news! Is there no hope? Of course there is hope! Recovery is all around us. “No known cure” doesn’t mean not “untreatable.” We don’t cure diabetes, we manage it with proper diet, blood sugar monitoring and other acts of discipline.

33. Recovery • Recovery from alcoholism and drug addiction is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. (SAMHSA/CSAT)

34. Why don’t we screen and Intervene?

35. Don’t Ask-Don’t Tell? Alcohol and Drug Abuse problems are often unidentified • In a study of 241 trauma surgeons, only 29% reported screening most patients for alcohol problems* • In a study of 7,371 primary care patients, only 29% of patients reported being asked about their use of alcohol or drugs in the past year** (*Danielson et al., 1999; **D’Amico et al., 2005)

36. Question to the Group What barriers get in the way of screening?

37. Why We Don’t Screen & Intervene: Barriers • Lack of awareness and knowledge about tools for screening • Discomfort with initiating discussion about substance- use/misuse • Sense of not having enough time for carrying out interventions

38. Why We Don’t Screen & Intervene: Barriers • Healthcare negative attitudes toward substance abusers • Pessimism about the efficacy of treatment • Fear of losing or alienating patients • Lack of simple guidelines/procedures for brief intervention

39. Why We Don’t Screen & Intervene:Barriers • Uncertainty about referral resources • Limited or no insurance company reimbursement for the screening for alcohol and other drug use. • Lack of education and training about the nature of addiction or addiction treatment

40. Why We Don’t Screen & Intervene: Opportunities • When AOD screening becomes more routine, you typically can expect: • Greater patient and family satisfaction • Better patient management and follow-up

41. Why We Don’t Screen & Intervene: Opportunities • The concern shown by healthcare providers, even during brief intervention, can provide patients with significant motivation for change or referral for further assessment and treatment.

42. Why We Don’t Screen & Intervene: Opportunities • The costs of AOD counseling for patients in relation the costs for AOD related hospitalization are small, but the value in terms of prevention may be great.

43. Role of Healthcare Profession in Drug and Alcohol Use–What Can We Do To Help? 1. Identify use, misuse, and problematic use; screen with simple direct methods 2. Connect use/misuse to health related issues 3. Encourage consumption reduction 4. Conduct a Brief Intervention 5. Refer for formal assessment

44. Identification of use, misuse, and problematic use:How Can We Approach This Process? There are many screening tools that are brief and easy to use that can help to determine the involvement of a person with AOD.

45. Goals of Screening • 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 • Use “teachable moments”

46. SBIRTAn Effective Approach • Screening • Brief Intervention • Referral • Treatment

47. SBIRT Effectiveness “Alcohol screening and counseling (is) one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.” - American Journal of Preventive Medicine

48. SBIRT Effectiveness • Rates of illicit drug use dropped by 67.7 percent six months after patients using illicit drugs had received help through an SBIRT program. • Heavy alcohol use dropped by 38.6 percent. Madras, et.al. (2009) Harris County (Texas) Hospital District Study: • Patients reporting any days of heavy drinking dropped from 70% at intake to 37% at 6-month follow-up • Patients reporting any days of drug use dropped from 82% at intake to 33% at follow-up Spence, et. al. InSight Project Research Group (2009)

49. SBIRT Saves Money • Literature reports a 4 to 1 savings with SBIRT approach • 2002 study published in the journal Alcoholism: Clinical and Experimental Research (Vol. 26, No. 1), researchers found that every dollar invested in an SBIRT-like approach saved $4.30 in future health care costs. These reduced costs are associated with changes in: • Alcohol use • ED visits • Hospital days • Legal events • Motor vehicle accidents

50. SBIRT as a Response Option Primary Prevention Brief Intervention AODA Treatment Abstinence Infrequent use Problematic use AbuseDependence