InSight into Screening, Brief Intervention, Referral, and Treatment.

InSight into Screening, Brief

Intervention, Referral, and Treatment

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

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.

What is Brief Intervention?

• A 15 to 45 minute facilitated interaction– Express concern – Provide feedback– Explore the issue – Promotes change

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

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

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

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

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)

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)

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

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

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

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

Anecdotal Observations

• Adoption slow

• Time considerations with resistant versus receptive patients

• System-wide approaches – eligibility criteria?

• Little consensus on favorable outcome

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