SBIRT: The why, what, where, and how. Melissa Cheng MD, MOH, MHS Occupational Medicine University of Utah

Transcription

1 SBIRT: The why, what, where, and how Melissa Cheng MD, MOH, MHS Occupational Medicine University of Utah Cheng SBIRT 2018

2 Conflict of Interest: No commercial interest Program Director for 2 SBIRT training grants. U N I V E R S I T Y O F U T A H H E A L T H,

3 SBIRT Public health approach: Universal screening to identify people who have or at-risk for substance use disorder (SUD) to provide early intervention and treatment. S: Screen- using validated screening tools to quickly assesses use and severity of alcohol, tobacco, illicit drugs and prescription drug misuse and abuse. BI: Brief Intervention/ Motivational Interviewing to raise awareness and move toward positive behavior. RT: Referral to Treatment for SUD Cheng SBIRT 2018

4 U.S. Workforce Feels Fallout of Opioid Crisis (Source: efficientgov.com, Fox A, 2016) Source: CDC Source: CDC Cheng SBIRT 2018 Hser JI, 2017 Source: CDC

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6 Why is screening for substance use disorder important? We screen for other health problems Hypertension (HTN) How many Americans have HTN? How many people die each year from HTN? How much money does the US spend on HTN? Cheng SBIRT 2018

7 Prevalence of HTN vs SUD in U.S. (in millions) 100 million 75 million Hypertension & Risky alcohol, tobacco and substance use Cheng SBIRT 2018

8 1,000, ,000 DEATH RATE FROM HTN VS SUD: UNITED STATES 800, , , , , , , , , ,000 0 HTN (High Blood Pressure/Hypertension) <1,000 deaths a day. SUD (Substance Use Disorder) Cheng SBIRT 2018

9 Direct & Indirect Cost: HTN vs SUD (in billions/year) $1,000 $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 $46 BILLION HTN $740 BILLION SUD <4% spent on prevention & early intervention & Cheng SBIRT 2018

10 Rethinking the drug problem use in America. 1. Public health issue not just criminal justice issue 2. Understanding the prevalence of substance use Abstinence or abuser No middle ground Cheng SBIRT 2018

11 Rethinking the problem for substance use. Substance use disorder Risky users Cheng SBIRT 2018

12 Who accounts for most of the problems? Cheng SBIRT 2018

13 Goal of SBIRT: to move away from addiction Identify our patients who are at risk for addiction and motivate them toward positive behavior change. Identify our patients with a substance use disorder and refer them for treatment. Why? Personal health Social health Cheng SBIRT 2018

14 Cost of addiction? its expensive. Increase health care resources Chronic disease Hospitalization Emergency Room Increase in criminal justice 80% of offenders abuse drugs and/or alcohol. Decrease in workers productivity WCI Absenteeism and presentisms For every dollar spent on substance use and addiction- 96% goes to dealing with the consequence and less than 4% goes to prevention. Cheng SBIRT 2018

15 SBIRT has been proven to be effective Overall SBIRT has been proven to be very effective for alcohol and tobacco. USPSTF Grade B. Studies show fewer heavy drinking episodes Evidence for other substances are promising. Few studies. Some showing effectiveness- 68% reduction in illicit drug use at 6-month f/u (Madras 2009). Other studies showing no effect. Research vary depending by providers characteristics, patient population and health care setting and methodology. SBIRT Colorado: 1. Reduction in substances at 6-month follow-up 2. 90% of patients had a positive experience with the SBIRT health educator and found the experience informative and beneficial. Cheng SBIRT 2018

16 SBIRT has been proven to be costeffective Cheng SBIRT 2018

17 Who approves of SBIRT? Substance abuse and Mental Health Administration, Institute of Medicine, WHO United States Preventive Services Task Force, American Society for Addiction Medicine, American College of Surgeons, American Congress of Obstetrician and Gynecologist. American Academy of Pediatrics American Academy of Family Physician National Council for Behavioral Health Cheng SBIRT 2018

18 Why do we need SBIRT education? Many physicians and healthcare providers are not prepared to identify and handle a substance use disorder Study show that < 20% of primary care physician described themselves as very prepared to identify alcoholism or illegal drug use ~90% of people with a SUD will NOT receive treatment >50% of patients with substance use disorders said their primary care physician did nothing to address their substance abuse. (Shaperio 2013) Cheng SBIRT 2018

19 SBIRT Clinical Flow Chart

20 Example of clinic flow Cheng SBIRT 2018

21 Screening tools Alcohol AUDIT (10 questions) AUDIT- C (3 questions) CAGE (5 questions) MAST (13 questions) RAPS (4 questions) Drugs ASSIST DAST- 10 OARS ORTS

22 Screening Tools- how to pick one? Patient Population? Demographics Age Language Literacy Culture Substance prevalence Time? Do you have 1 minute or 10 minutes? Depends on prevalence in your community. Format? Paper, in-person or electronic

23 Pre-screen: Do you drink alcohol? How much is a drink? What are the recommended limits of alcohol per week for men? women? What is binge drinking?

24 How much is a drink? What are the recommended limits of alcohol per week for men or women? Men: <14 drinks/week Women: <7 drinks/week >65 years old: < 7 drinks/week What is binge drinking? Men: >/= 5 drinks/sitting Women: >/=4 drinks/sitting >65 years old: >/= 4 drinks/sitting

25 Illicit drugs for prescreen: 1. How many times in the last year have you used marijuana, heroine or other drugs? 2. How many times in the last year have you used prescription medication for nonmedical reasons or more than directed? 3. Do you currently smoke, chew or vape tobacco? U N I V E R S I T Y O F U T A H H E A L T H,

26 + Pre-screen: What to do next? Alcohol Prescreening: -AUDIT, AUDIT-C - CAGE Drug Prescreening: - DAST, DAST-10 -Opioids What if they say yes to everything? - ASSIST Cheng SBIRT 2018

27 Alcohol Use Disorder Identification Test Alcohol screening questionnaire (AUDIT) Our clinic asks all patients about alcohol use at least once a year. Drinking alcohol can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below. Patient name: Date of birth: One drink equals: 12 oz. beer 5 oz. wine 1.5 oz. liquor (one shot) 1. How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? or 4 5 or or more 3. How often do you have four or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily 4. How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily 10 questions to evaluate for at-risk drinking. Translated to 5 languages AUDIT-C: 3 questions. Brief screening for high risk use. 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? Never Never Never Never No No Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, in the last year Yes, in the last year Have you ever been in treatment for an alcohol problem? Never Currently In the past I II III IV M: W: Cheng SBIRT 2018

28 AUDIT Score Alcohol AUDIT-C: In men, a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders. n In women, a score of 3 or more is considered positive (same as above). HealthInsight- SBIRT Cheng 9/11/18

29 CAGE Having at least 1 YES is positive for risky alcohol/drug use. Have you ever felt you should Cut down on your drinking/drug use? Have people annoyed you by criticizing your drinking/drug use? Have you ever felt had or Guilty about your drinking/drug use? Have you ever had a drink/drug use first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? CON: Only looks for alcohol/drug dependence.

30 DAST: Drug abuse screening test 20 questions derived from the MAST (Michigan Alcohol Screening Test) looking at drug use in the last 12-months. DAST-10. They have adult and adolescent versions. They are free and provided today. Screening and assessment tool. HealthInsight- SBIRT Cheng 9/11/18

31 Drug Screening Questionnaire (DAST) Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below. Which recreational drugs you have used in the past year? methamphetamines (speed, crystal) cocaine cannabis (marijuana, pot) narcotics (heroin, oxycodone, methadone, etc.) inhalants (paint thinner, aerosol, glue) hallucinogens (LSD, mushrooms) tranquilizers (valium) other 1. Have you used drugs other than those required for medical reasons? No Yes 2. Do you abuse more than one drug at a time? No Yes 3. Are you unable to stop using drugs when you want to? No Yes 4. Have you ever had blackouts or flashbacks as a result of drug use? No Yes 5. Do you ever feel bad or guilty about your drug use? No Yes 6. Does your spouse (or parents) ever complain about your involvement with drugs? No Yes 7. Have you neglected your family because of your use of drugs? No Yes 8. Have you engaged in illegal activities in order to obtain drugs? No Yes 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? No Yes 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? No Yes I Cheng SBIRT II 3 6 III IV

32 DAST scores

33 Opioids screening tools COWS- clinical opiate withdrawal scale Free and included in materials section. 11 questions regarding the patient s signs & symptoms to determine level of withdrawal. COMM- current opioid misuse measure Free and included in materials section. 17 questions to measure current aberrant drug-related behavior. Useful to document current compliance and appropriate use for opioids. - Signs & Symptoms of Intoxication, Emotional Volatility, Evidence of Poor Response to Medications, Addiction, Healthcare Use Patterns, Problematic Medication Behavior Con- high false positive. OARS- opioid abuse and risk screener $$$- app or website. 43 questions that also evaluate depression, anxiety and red flag responses. ORT- opioid risk tool Free and included in materials section. 10 questions to determine if the patient is at risk for opioid addiction. TO BE USED BEFORE OPIOID PRESCRIPTION

34 Swiss Army Knife ASSIST V3.1: Alcohol, Smoking, and Substance Involvement Screening Test Eight questions covering tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants (including ecstasy) inhalants, sedatives, hallucinogens, opioids and 'other drugs use in their lifetime and past 3-months. NIDA-modified: no alcohol or tobacco but asks about Rx meds. A risk score is provided for each substance, and scores are grouped into 'low risk', 'moderate risk' or 'high risk. The risk score determines the level of intervention recommended ('treatment as usual', 'brief intervention' or 'brief intervention plus referral to specialist treatment'). Validated in 9 languages: English, Arabic, Chinese, Farsi, French, German, Hindi, Portuguese and Spanish ADULT ONLY

35 Adolescent population CRAFFT- Car, Relax, Alone, Friends/family, Forget and Trouble. Free Advocated by American Academy of Pediatrics. AUDIT- Alcohol Use Disorder Identification Test HealthInsight- SBIRT Cheng 9/11/18

36 CRAFFT A SCORE OF 2/3 IS CONSIDERED + FOR RISKY DRUG/ALCOHOL USE. Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? Do you ever use alcohol or drugs while you are by yourself (ALONE)? Do you ever FORGET things you did while using alcohol or drugs? Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or drugs? HealthInsight- SBIRT Cheng 9/11/18

37 Pregnant women 17 screening tools found. SURP-P: Substance Use Risk Profile-Pregnancy Scale: 3-questions that can differentiate between populations of pregnant women at low risk or high risk for substance use. Free Have you ever smoked marijuana? In the month before you knew you were pregnant, how many beers, how much wine, or how much liquor did you drink? Have you ever felt that you needed to cut down on your drug or alcohol use? 4 P s Plus: Parents, Partner, Past and Pregnancy $$$- licensing fee Did either of your parents ever have a problem with alcohol or drugs? Does your partner? Have you ever drunk beer, wine, or liquor? and In the month before you knew you were pregnant, how many cigarettes/beer/wine/liquor did you drink?

38 Screening Tools Hundreds of screenings tool available. Screening tool database: What do you want to screen? Alcohol, marijuana, illicit drugs, prescription medication Start with pre-screen Cheng SBIRT 2018

39 SBIRT flow chart

40 Brief Intervention Brief Intervention is a brief motivational and awareness-raising intervention given to risky or problematic substance users. It is a semi structured interview process based on motivational interviewing that is a proven evidence-based practice and can be completed in 5 15 minutes. 1. Build rapport raise the subject. Explore the pros and cons of use. 2. Provide feedback. 3. Build readiness to change. 4. Negotiate a plan for change.

41 Brief Treatment for moderate to high risk Moderate risk: BI- is 1-5 session to educate patients and increase their motivation to reduce risky behavior. High risk: BT- involves 5-12 sessions is to change not only the immediate behavior or thoughts about a risky behavior but also to address long-standing problems with harmful drinking and drug misuse and help patients with higher levels of disorder obtain more long term care. May correlate with other chronic disease problems. For Example: We are having a hard time controlling your HgA1C because of the unhealthy alcohol consumption.

42 Referral to Treatment What is treatment?

43 Referral to Treatment What is treatment? Counseling and other psychosocial rehabilitation services Medications Involvement with self-help (AA, NA, Al-Anon) Complementary wellness (diet, exercise, meditation) Combinations of the above

44 When you patient is ready Make a plan with the patient. Warm handoff. Be active in the referral process. The warmer the referral handoff, the better the outcome. Decide how you will interact/communicate with the addiction medicine provider. Confirm your follow-up plan with the patient. Decide on the ongoing follow-up support strategies you will use.

45 Things to consider when referring someone

46 Its in the details Language ability/cultural competence Family support Services that meet the patient s needs Record of keeping primary care provider informed of patient s progress and ongoing needs Accessible location/transportation Payment

47 Keep in mind! Don t: Rush into action and making a treatment referral when the patient isn t interested or ready Refer to a program that is full or does not take the patient s insurance Not considering pharmacotherapy in support of treatment and recovery Seeing the patient as resistant or selfsabotaging instead of having a chronic disease Abstinence does not equal CURED

48 Future of SBIRT in Utah

49 HB 175 Passed in 2017 Utah Legislative session (i) Beginning with the licensing period that begins after January 1, 2024, as a condition precedent for license renewal, each controlled substance prescriber shall complete at least 3.5 continuing education hours in an SBIRT-training class that satisfies the requirements of Subsection (5). (ii) Completion of the SBIRT-training class, in compliance with Subsection (2)(b)(i), fulfills the continuing education hours requirement in Subsection (4) for the licensing period in which the class was completed. (iii) A controlled substance prescriber: (A) need only take the SBIRT-training class once during the controlled substance prescriber's licensure in the state; and (B) shall provide a completion record of the SBIRT-training class in order to be reimbursed for SBIRT services to patients, in accordance with Section and Section

50 Get SBIRT trained Free online SBIRT training (CME $$$) Cheng SBIRT 2018 U N I V E R S I T Y O F U T A H H E A L T H,

51 SBIRT CPT codes- show me the $$$

52 Questions? Thank you

53 References: Agerwala, S., McCance-Katz, E., Integrating Screening, Brief Intervention and Referral to Treatment into Clinical Pracice Setting: A brief Review. J Psychoactive Drugs ; 44(4): Shapiero, B., Coffa, D., McCance-Katz, E., A Primary Care Approach to Substance Misuse. American Family Physician July 2015;88(2): Facts on Drugs and Crim in America. National Assoication of Drug Court Professionals. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;9: doi: /j.drugalcdep Guide For PolicyMakers: Prevention, Early Intervention and Treatment of Risky Substance Use and Addiction. December Fiellin, L.E., Tetrault, J.M., Becker,W.C., Fiellin, D., Hoff, R.A., Prior use of alcohol, cigarettes, and marijuana and subsequent abuse of prescription opioids in young adults. J. Adolesc. Health 52 (2), The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) 2011l. Adolescent substance use: America's #1 public health problem. (Retrieved from) Utah Department of Substance Abuse and Mental Health report. Agerwala, S., McCance-Katz, EF. Integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) into Clinical Practice Settings: A Brief Review. J Psychoactive Drugs Sep-Oct;44(4): SBIRT Fact Sheet July 2012, whitehouse.gov Reducing Medical Costs with the SBIRT Program. Institute for Clinical Systems Improvement Fleming, et al, Benefit Cost Analysis of Brief Physician Advice with problem drinks in primary care setting. Medical Care, 38(1), Medical Care: January 2010 (48) pg Estee, S. Wickizer, T. He, L., et al. Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment Project: Cost Outcomes for Medicaid Patients Screened in Hospital Emergency Departments. Med Care Jan;48(1):18-24 World Health Organization (WHO). (2010). Framework for action on interprofessional education & collaborative practice. Geneva: World Health Organization. AAP Committee on Substance Use and Prevention, Substance use screening, brief intervention, and referral to treatment. Pediatrics 138 (1), e Merten, J., Chi, F., Weiser, C., et al. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe ccluster randomized controlled implementation trial. Addiction Science and Clinical Practice :26 Shapiero, B., Coffa, D., McCance-Katz, E., A Primary Care Approach to Substance Misuse. American Family Physician July 2015;88(2): SAMHSA.gov