InSight into Screening, Brief Intervention, Referral, and Treatment.
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Transcript of InSight into Screening, Brief Intervention, Referral, and Treatment.
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InSight into Screening, Brief
Intervention, Referral, and Treatment
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IOM Recommendations - Providers
• Organizations should (Chapter 4):– Increase use of valid and reliable
patient questionnaires
– Use measures of process and quality to continuously improve the quality of care they provide
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What is Screening?
Screening is performed using a distinct valid brief questionnaire (AUDIT, DAST, ASSIST)
• Method of identifying individuals at-risk.
• Determine level of risk.
• Provides an opportunity for feedback.
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What is Brief Intervention?
• A 15 to 45 minute facilitated interaction– Express concern – Provide feedback– Explore the issue – Promotes change
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Brief Intervention Evidence
• World Health Organization (Am J Pub Health 1996) Multinational study of heavy drinkers Simple advice, brief & extended counseling
compared to control group (N = 1,260)
Consumption decreased: 21% with 5 minutes of advice 27% with 15 minutes of advice 7% among controls
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Cost of intervention: $166 per patient (includes patient costs)
Net benefit: $546 in medical costs, $7780 if societal costs included (mainly motor vehicle)
*36 months. >20 drinks (men), >13 drinks (women) per week - Fleming MF et al., 2002.
At 4 years… Control Intervention
Hospital Days (p<0.05) 663 420
ED Visits (p<0.08) 376 302
Risky Drinking* (p<0.001) 35% 23%
Efficacy and Cost of Advice
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Intervention in Trauma Patients• Gentilello et al. (Ann Surg 1999)
– Admitted trauma patients 46% screened positive for alcohol problem – 30’ intervention psychologist
– Intervention ~50% decrease in trauma and subsequent hospitalization
American College of Surgeons Level I Trauma Center Verification process now requires
Screening and Brief Intervention
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Brief Intervention and Drug Use
• Meta Analysis of 5 studies – Moderate decrease in drug use– Large effect on social outcomes
• Review of 17 trials– 14 of 17 with positive results– Increased treatment involvement– Increased abstinence– Reduced drug-related problems
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Mesa Grande
• 361 controlled studies – evaluated at least one treatment for AUD – compared it with an alternative condition – used a procedure designed to create
equivalent groups before treatment – reported at least 1 outcome measure of
drinking or alcohol-related consequences
Miller, WR Addiction 2002 97(3)
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Mesa Grande• Methodological quality of studies was significantly but
modestly correlated with the reporting of a specific effect of treatment
• The strongest evidence of efficacy was found for BI, social skills training, the community reinforcement approach, behavior contracting, behavioral marital therapy and case management
• Most strongly supported approaches included: opiate antagonists (naltrexone, nalmefene) and acamprosate
• Least supported were methods designed to educate, confront, shock or foster insight regarding the nature and causes of alcoholism
Miller, WR Addiction 2002 97(3)
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Trends in SBI: Lessons from the FieldBarnett et al. 2004Brief motivational feedback better than Internet-based educational intervention to motivate students enter counseling
Borsari and Carey 2005
Brief individual motivational sessions reduced consumption more at 3 months and 6 months than did standard alcohol education
McNally and Palfai 2003
Small-group feedback sessions were effective at reducing alcohol use among heavy-drinking students at 4-week follow-ups.
Murphy et al. 2004Reductions in drinking with mailed motivational feedback and in-person feedback interviews
Neighbors et al. 2004a
Reduced use at 3- and 6-month follow-ups with computerized feedback compared with an assessment-only control group
White et al., 2006
Students in brief motivational interview (BMI) intervention and a written feedback-only (WF) intervention reduced alcohol, cigarette and marijuana use, and problems related to use
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Brief Review of the Evidence
Screening can identify people drinking risky amounts, problems or alcohol use disorders
Screening followed by a brief (nonjudgmental) intervention can result in reduced drinking
Evidence varies by setting
For drug use and related problems/disorders evidence for efficacy is more limited
For adolescents there is limited data
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Request For Applications – SAMHSA/CSAT
• Expand the State’s continuum of care to include screening, brief intervention, referral, and brief treatment (SBIRT) in general medical and other community settings
• Identify systems and policy changes to increase access to treatment in generalist and specialist settings
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SBIRT GPRA SUMMARY*
AREATARGET TO
DATEACTUAL TO
DATEPERCENTAGE
SCREENING 171,876 305898 178%
BRIEF INTERVENTION 42,926 56,432 131%
BRIEF TREATMENT 6,604 9,443 143%
REFERRAL TO TREATMENT 6,094 10,883 178%
*SBIRT GPRA Summary as of 5/15/06
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Anecdotal Observations
• Adoption slow
• Time considerations with resistant versus receptive patients
• System-wide approaches – eligibility criteria?
• Little consensus on favorable outcome
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Future Directions - Research• Outcomes & costs for system-wide SBI
• Public versus Private• When treatment of dependence included• Line item versus billable service
• Long-term effectiveness• Dosing (number and length of sessions)• Differences adults and adolescents• Multiple lifestyle interventions