Screening, Brief Intervention, and Referral to Treatment

April Velasco, PhDDeputy Regional Health Administrator

US Dept of Health and Human Services, Region II (NY, NJ, PR, USVI)

Recent CDC report – Jan. 2012

• One in six Americans binge drinks four times per month

• Average number of drinks during binge is 8• 40,000 deaths per year (binge-specific)• 2006 - $167.7 billion alcohol-related costs • Age group that binge drinks most often – 65+ • Income group with most binge drinkers - $75K+CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

CDC Report continued – binge drinking responsible for:

• Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS

• 85% of all alcohol-impaired driving episodes involved binge drinking (2010)

• Accounted for 50% of all alcohol consumed by adults; 90% of youth

• Most binge drinkers are not dependentCDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

Focus of SBIRT

Dependent Use

4%

25%

71%

Brief Intervention

Brief Intervention andReferral to Treatment

No Intervention

Harmful orRisky Use

Low Risk Useor Abstention

What exactly is SBIRT?

• SBIRT—Screening, Brief Intervention, and Referral to Treatment

• Universal screening of patients within medical settings with use of validated screening tools

• If screened positive – brief intervention (guided discussion) with medical provider occurs

• If screening reveals dependence – referral to specialty substance abuse treatment provider

SBIRT: Primary Care Context

• Takes advantage of the “teachable moment”

• Patients aren’t seeking treatment but screening opens door for awareness & education

• Focus on addressing low/moderate risk usage as a preventative approach before addiction occurs

SBIRT Ranked in top ten of prevention services

1. Discuss daily use of aspirin 2. Childhood immunization Series3. Tobacco use screening and brief intervention4. Colorectal cancer screening5. Hypertension screening6. Influenza immunization7. Pneumococcal immunization8. Problem drinking screening & brief intervention9. Vision screening – adults10.Cervical cancer screening

(Partnership for Prevention – Priorities for America’s Health: Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)

SBIRT and ACA

• Taking a closer look at the potential newly insured population post-ACA marketplace enrollment

• Prevalence estimates and data

PREVALENCE OF ANY MENTAL ILLNESS BY POPULATION

Uninsured Adults(8,938,373)

CI: 20.6-22.0%

Uninsured Adults<133% FPL(3,811,510)

CI: 20.3-22.4%

Uninsured Adults133-<400% FPL

(4,066,602)CI: 20.1-22.2%

Uninsured Adults<400% FPL(7,879,491)

CI: 20.5-21.9%

Medicaid Adults(6,598,793)

CI: 29.4-31.6%

0%

5%

10%

15%

20%

25%

30%

35%

21.3% 21.3% 21.1% 21.2%

30.5%

Any Mental Illness

Perc

ent w

ith C

ondi

tion

CI = Confidence IntervalSources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF SUBSTANCE USE DISORDER BY POPULATION

Uninsured Adults(6,042,844)

CI: 13.8-14.9%

Uninsured Adults<133% FPL(2,433,640)

CI: 12.9-14.4%

Uninsured Adults133-<400% FPL

(2,756,039)CI: 13.5-15.1%

Uninsured Adults<400% FPL(5,166,270)

CI: 13.4-14.5%

Medicaid Adults(2,574,611)

CI: 11.2-12.7%

0%

2%

4%

6%

8%

10%

12%

14%

16%14.4% 13.6%

14.3% 13.9%

11.9%

Substance Use Disorder

Perc

ent w

ith C

ondi

tion

CI = Confidence IntervalSources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF ANY MENTAL ILLNESS OR SUBSTANCE USE DISORDER BY POPULATION

Uninsured Adults(12,673,186)

CI: 29.4-30.9%

Uninsured Adults<133% FPL(5,314,641)

CI: 28.6-30.9%

Uninsured Adults133-<400% FPL

(5,762,626)CI: 28.7-31.0%

Uninsured Adults<400% FPL

(11,075,888)CI: 29.0-30.6%

Medicaid Adults(7,788,739)

CI: 34.8-37.2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

30.2% 29.7% 29.9% 29.8%

36.0%

Any Mental Illness or Substance Use Disorder

Perc

ent w

ith C

ondi

tion

CI = Confidence IntervalSources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF ANY MENTAL ILLNESS AND SUBSTANCE USE DISORDER BY POPULATION

Uninsured Adults(2,308,031)CI: 5.1-5.8%

Uninsured Adults<133% FPL(930,510)

CI: 4.7-5.7%

Uninsured Adults133-<400% FPL

(1,060,015)CI: 5.0-6.0%

Uninsured Adults<400% FPL(2,007,040)CI: 5.0-5.7%

Medicaid Adults(1,406,300)CI: 5.9-7.1%

0%

1%

2%

3%

4%

5%

6%

7%

5.5% 5.2% 5.5% 5.4%

6.5%Any Mental Illness and Substance Use Disorder

Perc

ent w

ith C

ondi

tion

CI = Confidence IntervalSources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American Community Survey

SBIRT Implementation

• Implementation strategies • Considerations

Universal Prescreen

Provide positive reinforcement

(+) Positive

Further screening with• ASSIST• AUDIT

• CRAFFT• DAST

Low risk: Provide positive reinforcement

Moderate risk: Provide Brief Intervention

Moderate high-risk: Provide Brief Therapy

High risk: Refer to treatment

• (-) Negative

Effective Screening Program Typically Yields…

• Approximately 25% of all patients will screen positive for some level of substance misuse or abuse

• Of those, the approximately 70% will be “at-risk” drinkers

• Most will be open to addressing their substance abuse problems (if discussed in a non-judgmental manner)

Brief Intervention Approach

• Uses “Motivational Interviewing” techniques • Discuss healthy drinking levels for male/females (NIAAA

standards) • Weigh pros/cons of cutting down or quitting• Use “scaling” to assess for readiness (i.e – on a 1 to 10

scale….)• Effects on quality of life and/or existing medical conditions• Plan to talk about it more than once (at future doctor visits) • Small, obtainable goals (let patient tell you want he/she can

handle)

Identify Referral Resources

Community agencies for referrals

Short-term and long-term residential treatment centers

Hospital inpatient and outpatient centers

State treatment centers

Key Considerations for Starting SBI Program

• Identify target population and location(s)

• Develop a Screening protocol

• Develop a Brief Intervention protocol

• Identify staff to monitor and evaluate program (strong QI mgt essential)

• Reimbursement strategy & considerations

• Staff training needs and supervision

• Program “champions” and buy-in from CEO/Admin staff

Additional Considerations

Who Will Do the Screening and Brief Intervention?

• “SBIRT” counselors/health educator model• Social Workers• Registered Nurses• Psychologists• Physicians • Dedicated contracted personnel• Medical Assistants • Para-professionals

Challenges & Lessons Learned

• Buy-in issues from existing medical staff

• Funding for additional staffing (or train existing staff)

• Need for management to be supportive and influence implementation

• Consistent training available for new staff

Useful Resources

• Numerous SBIRT grantee websites with training videos, screening protocols, insurance/billing information, toolkits, etc…

• Addiction Technology Transfer Centers (ATTC) – SAMHSA funded trainings in SBIRT, MI, etc…

• Other non-fed funded organizations offering training, resources, etc…

Questions/Discussion

For additional information and resources.

Contact: April Velasco 212-264-2560 april.velasco@hhs.gov