St. Elizabeth’s Medical Center-Boston College Screening, Brief Intervention & Referral to

Treatment Collaborative Information Session(Boston, Massachusetts)

Boston College, Fulton Hall, Room 511Sunday September 19th, 2010

4:00 PM to 6:00 PM

SBIRT Mission SBIRT Mission StatementStatement

Screening, Brief Intervention & Referral to Treatment (SBIRT) is a proven assessment and intervention methodology targeted to persons at-risk for substance use-related health problems. The St. Elizabeth's Medical Center-Boston College SBIRT Collaborative aims to recruit mature college students and other qualified candidates from Allston-Brighton and surrounding communities in order to equip them with the tools, resources, and training necessary to engage SEMC patients, Greater Boston residents, and their undergraduate peers regarding the potential consequence of excessive alcohol consumption and related substance behaviors. These volunteers will learn to engage individuals identified as at-risk for substance use through best practices in health care communication in order to help such patients avoid the pitfalls of dependency and addiction. Numerous peer-reviewed studies have consistently indicated that short-term interventions can significantly decrease risk behaviors among substance users while simultaneously reducing health care costs for this historically needy patient population. The SEMC-BC SBIRT Collaborative looks to empower all patients toward informed self-sufficiency with special emphasis on their unique personal, cultural and spiritual contexts.

Program GoalsProgram Goals•To improve institutional responsiveness to substance use-related health care issues in Allston-Brighton, particularly regarding Boston College students & the university-community relationship.

•To encourage increased voluntary access to alcohol and drug services for BC students who screen positive for at-risk substance use criteria.

•To decrease overall emergency room visits and related costs at SEMC by encouraging patients to act in their own long-term self-interest.

• To perfect a groundbreaking framework of substance use and patient relations training for health care professionals through wellness-based substance care and an improved health care provider-patient dynamic

First known fermented drink: 7000 BC (in China)

Fun Fact: that’s twice the age of the Giza pyramids in Egypt

Health Fact: Back in the Middle Ages people were actually encouraged to drink beer & wine because fermented beverages were much healthier than often-contaminated H2O

Alcohol 101: How Long Has It Been Around?

From Nightcap to NightmareAs of 2004, SAMHSA estimates that approximately 19 million individuals ages 12 and older report as either alcohol abusive or alcohol dependent

Only 17% of them received treatment during the previous year – despite the fact that more than 700,000 persons were admitted nationwide for alcohol dependence on any given day

The NIAAA reported to Congress back in 2000 that alcohol abuse results in more than 100,000 preventable deaths each year in the US. That works out to more than 11 people per hour – 24 hours a day, 7 days a week, 365 days a year

The Wino Demographic Myth

Not-Fun Fact: Alcohol dependence most prevalent in high school/college

“It’s Not That Bad. You’re Lying.”

A few more Not-Fun Facts courtesy of the American College of Emergency Physicians (www.acep.org):

• 500,000 students aged 18-24 are unintentionally injured each year while under the influence of alcohol• 1,400 of them die due to those alcohol-related injuries• 600,000 students are assaulted each year by another student that has been drinking• 22.8% of young adults reported driving under the influence• More than 44% of full-time college students reported consuming 5 or more drinks on at least one occasion over a 30-day period

And Now for the Other ShoeACEP also separately noted alcohol as a factor in:

60-70% of homicides40% of suicides

40-50% of fatal motor vehicle crashes60% of fatal burn injuries

60% of drownings40% of fatal falls

They also found that nearly 50% of severely injured trauma patients were injured while under the influence of alcohol

Death & Injury Don’t Impress Me. Got More?

A Steep Price Tag…

…Keeps Getting SteeperCost Categories Average Annual

Increase

Criminal activities + 7.7% per year

Medical consequences + 6.1% per year

Specialty alcohol services

+ 5.0% per year

Alcohol-related illnesses

+ 4.0% per year

Premature death + 2.6% per year

Accidents & legal expenses

+ 1.4% per year 2009 estimate: $281.7 billion – up 52.6% over 11 years

…But Not Everyone’s GuiltyAlcohol Consumption Norms for U.S. Adults (NIAAA, 2005)

Maximum # of drinks per week

Men Women

Zero (Abstinent)

30% 37%

One 53% 70%

Two 62% 78%

Four 69% 85%

Six 76% 89%

Eight 81% 92%

Ten 84% 94%

Twelve 88% 95%

Fourteen 89% 96%

Evidence BaseEvidence BaseEvidence-based medicine aims to apply the best available evidence gained from the scientific method to medical decision making:

assessing the quality of evidence of risks and benefits of treatment (including lack of treatment)

clarifying those parts of medical practice subject to scientific methods

applying methods that ensure the best prediction of outcomes

Standardized validated screens are key elements in achieving EBM

Gentilello et al. Annals Surgery1999; 230: 473-483

“Alcohol Interventions in a Trauma Center as a Means of Reducing Risk of Injury

Recurrence”

Admitted injured patients who tested and/or screened positive for alcohol problems were randomized (n=732)Results at 12 months (54% follow-up rate):

(I) ↓alcohol consumption 21.8 drinks/week vs (C) 6.7 (p=0.03)

Gentilello• Reduction most apparent in mild-moderate drinkers: ↓21.6 drinks/week vs 2.3↑drinks/week in controls (p<0.01)• 47% reduction in new injuries requiring ED visit or readmission to the trauma service (p=0.07)• 48% reduction in new injuries requiring hospitalization at 3-year follow-up

Fleming et al. JAMA 1997; 277: 1039-

1047“Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices”BI in 17 practices with 64 physicians

Intervention included: educational workbook, (2) 15 minute visits one month apart, and (2) nurse follow-up calls, 2 weeks after the visit

FlemingResults at 12 months (n=723)Consumption:

(I) ↓19.1 drinks/wk to 11.5 vs (C) 18.9 to 15.2

Episodes of binge drinking during prior 30 days:(I) ↓5.7 to 3.1 vs (C) 5.3 to 4.2

Monti et al, J Consulting and Clinical Psychology 1999

“Brief intervention for harm reduction with alcohol-positive older adolescents in an ED” 94 patients (18-19 years) were randomized(I) group had a significant reduction in alcohol use (p<.001) at 6 month f/u and were less likely to report:•having driven after drinking ( p<0.05)•having had alcohol involved in an injury (p<0.01) •to have had alcohol-related problems (p<0.05)

Longabaugh R, et al. J Stud Alcohol

2001; 62: 806-816• n=539 injured ED patients with an AUDIT score of >8 or BAC > 0.03 mg/dl or reported ingestion 6 hours prior to injury• 3 groups: standard care vs brief intervention (40-60 minutes) vs brief intervention with booster 7-10 days after initial BI (BIB) • 1 year f/u = 84%• All 3 groups reduced days of heavy drinking• BIB subjects had fewer DrInC consequences (2.24 vs 2.4 (BI) and 2.52 (SC))• BIB had fewer alcohol-related injuries than SC (0.456 vs 0.165) The average at baseline for whole sample 1.6

Brief InterventionBien et al. (Addiction 1993)32 trials of BI in 14 nationsBI found to be more effective than no counseling, and often as effective as more extensive treatment

Wilk et al. (J Gen Intern Med 1997)Pooled outcome data from 12 RCTs of BI odds ratio 1.9 (95% CI 1.61-2.27) in favor of BI

D’Onofrio & Degutis (Acad Emerg Med)Review of 39 clinical trials: 30 (RCT) & 9 (Cohort)32 studies found positive effect for BI

World Health Organization(Am J Pub Health 1996)

“A cross-national trial of brief interventions with heavy drinkers”Multinational study in 10 countries (n=1,260)

Interventions included simple advice, brief & extended counseling compared to control group

Results: Consumption decreased21% with 5 minutes advice, 27% with 15 minutes

compared to 7% controlsSignificant effect for all interventions

COST-BENEFIT ANALYSIS OF BRIEF MOTIVATION

Fleming MF, et al. Medical Care 2000; 38: 7-18.RCT (n=774)

primary care practice, managed care settingproblem drinkerseconomic cost of intervention = $80,210 ($205 each)economic benefit of intervention = $423,519$193,448 in ED and hospital use$228,071 avoided costs in motor vehicle crashes and crime5.6 to 1 benefit to cost ratio$6 savings for every $ invested

The Obvious Question: Why NOT?

Multiple Obstacles to Staff-Based SBIRT in Medical Mainstream

#1. Cost/Funding – budgetary needs are up-front investments; future deferred health care expenses are diffuse & uncapitalized. Many SBIRT programs are supported via federal grant funding base. Example: Boston Medical Center

#2. Physicians/staff are not trained to perform SBIRT or have effective knowledge of available supportive services (Join Together report Screening & Brief Intervention: Making a Public Health Difference)

#3. Physicians do not have the time to perform SBIRT (Join Together)

#4. The Bombshell: “The most effective approaches conflict with physicians’ preferred styles” (Join Together)

SBIRT Components of Collaboration

SEMC BC

Health care access Catholic Mission Human capital/students - SECAP/SUD Shared patient access Graduated treatment options - Mental health Improved patient care Feedback - Tertiary care Administrative endorsement Long-term assessment Infrastructural support Support for recovery Outcome monitoring Volunteer Services Spiritual presence Transportation Treatment space Experiential learning Meeting space Clinical supervision Engaged community Marketing/recruitment SBIRT Networking Prevention Media resources Staff engagement Utilization forecasting

SBIRT Core Components

SCREEN • Brief Survey• Yields Score• Identify & Quantify Substance Abuse/Associated Problems

BRIEF INTERVENTION• Feedback• Risk Awareness• Motivation • Establish Goals• Strategies for Change• Engaged Spirituality

REFERRAL TO TREATMENT• (Brief Treatment)• Administrative Intervention, BC• Detox/SUD Services• Mental Health Services

MILD

MODERATE/SEVERE

What does SBIRT look like?

Patient Encounter- Screening

Aspects of Patient Screening:•Reflective listening and conversational interviewing to obtain a background.

•Provides context for patient encounter allowing screener to adapt strategies accordingly•Works to identify any deeper issues.

•Employment of recognized screening tools to establish quantitative and useful substance use related data.

•Quantitatively defines substance use behavior in a way that the screener can utilize as context for intervention.•Provides recognized and interpretable data for further analysis in social health context.

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Patient Encounter- Brief Intervention

Aspects of Brief Intervention:•Establishing discrepancies between substance use behavior and goals.•Making patient aware of risks associated with given substance use behavior.•Establishing the patients readiness to change any aspect of their substance use behavior given the discrepancies and risks identified.•Creation of goals for change, self-affirmed given the feedback provided the screener.•Identification of strategies to ensure success in change goals as well as potential barriers to said success.

What does SBIRT offer?• In-depth patient contact experience as staff support component

• Validated methodology, training, & screening encounter tools

• Bimonthly meetings for clinical supervision and program self-evaluation

• Leadership opportunities (Vinodh – Lead Screener)

• Multimedia/outreach opportunities (Teja – video role-play scenario, FAQ)

• National exposure: 2010 Catholic Health Assembly (Dan – CHA presenter)

What does SBIRT require?Prior practical health care experience: EMT-Basic certification and/or completed training regimen, clinical practicums, equivalent experience

Solid foundation of health care competencies, functional knowledge is an essential prerequisite for SBIRT training

No persons actively undergoing EMT-Basic training will be accepted, in the interests of those candidates’ academic/personal well-being b/c of scheduling conflict for Sunday evening SBIRT program meetings

EMT-Certification: Boston College Eagle EMSInternships & Practicums: Human Resources & Nursing Education

SBIRT – Further InformationSBIRT shifts are Fri/Sat evenings, Sat/Sun

mornings (ED) with mandatory meetings on alternate Sundays from 7pm to 9pm

www.steward.org/sbirt