Overview: Screening, Brief Intervention & Referral to Treatment18vtj92co9zb1qy8011oc0fw-wpengine.netdna-ssl.com/wp-content/uploads/... · • Integrated care teams meet to discuss

Overview:Screening, Brief Intervention

& Referral to TreatmentPam Pietruszewski

June 27, 2018

• 51% of 12th graders in MT used alcohol within the past month, and 23% used marijuana within the last 30 days. (MT Prevention Needs Assessment, 2016)

“SUD is a common chronic medical illness.” - Guiding Principle from Opportunities for Action on Substance Use Disorders in Montana, 2017

• 2.6% of individuals 12+ in MT reported being dependent or abusing illicit drugs. (Behavioral Health Barometer, Montana 2015)

• 7.6% of individuals 12+ in MT reported alcohol dependence or abuse. (Behavioral Health Barometer, Montana 2015)

The #1 predictor of adult substance use disorder = youth substance use problems.

Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health

“A child who reaches his or her 21st birthday without using drugs, tobacco or alcohol is ‘virtually certain’ never to slip into those habits.”

-Joseph A. Califano Jr. How to Raise a Drug-Free Kid

That’s where people are going

Longitudinal, family & community care

Influence

Chronic care experience

Data-oriented

Why Address Substance Use & other Behavioral Health in Primary Care?

Preventive Services RankingsBased on Clinically Preventable Burden + Cost Effectiveness

Maciosek, M. et al. Ann Fam Med 2017;15:14-22

#1 • Immunizations – children• Tobacco use screening, brief prev counseling – youth & adults

#2 • Alcohol screening & brief intervention – adults• Aspirin daily low dose – adults 50-59 at higher CVD risk• Cervical cancer screening – women 21-65• Colorectal cancer screening – adults 50-75

#3 • Chlamydia and gonorrhea screening – sexually active women ≤24 and older women at increased risk for infection

• Cholesterol screening - adults• Hypertension BP screening - adults

Blood Pressure Screening: Prevention & early intervention to reduce the risk of heart disease

“No one would refuse to screen for hypertension or diabetes out of fear it might upset a patient.”

- CDC, 2014

Medical Conditions Commonly Associated with SUD’s

Cardiovascular diseasesCancersInjuriesStrokeCirrhosis

Alcohol use disorder

ArthritisChronic painHeadacheHepatitis CMusculoskeletal disordersOpioid-related overdoses

Opioid use disorder

Respiratory deficitsCardiovascular diseasesLung cancer

Cannabis use disorder

Bahorik, J. Addiction Medicine 2017

Immediate & Direct Consequences

Heart rate, body temperature regulation, psychotic episodes,

overdose

Indirect ConsequencesImpaired judgement, DUI, unprotected sex

Longer-term Health Effects

Hypertension, liver disease, cancer, heart disease

Longer-term Societal

ConsequencesProductivity, increased health

costs, crime, violence

Alcohol&

DrugMisuse

Surgeon General’s Report on Alcohol, Drugs and HealthNovember 2016

“Does this mean I shouldn’t be seen out in public having drinks?”

“Well I was doing worse things when I was her age.”

“He’s a drug-seeker.”

“She’s a druggie.”

The Current View:Continuum of Substance Use

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Abstinence

Addiction

Responsible Use

National Addiction Technology Transfer Center (ATTC)

The SBIRT View:Continuum of Alcohol Use

Abstinent/Low risk Moderate risk High Risk

Primary Prevention

Brief Intervention

Specialized Treatment

Abuse/Dep.

40%35%

20%5%

SBIRT Target

Population

Dawson, Alcohol Clin Exp Res 2004; Grant, Drug Alcohol Dep 2004

Screening to identify patients at-risk for developing substance use disorders.

Brief Intervention to raise awareness of risks and consequences, internal motivation for change, and help set healthy lifestyles goals.

Referral to Treatment to facilitate access to specialized treatment services and coordinate care between systems for patients with higher risk and/or dependence.

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What is SBIRT?

Negative = F <3 F, M <4Positive = F 3±, M 4±

Negative = 0-1Positive = 2 ±

Negative = 0Positive = 1 ±

Screening Example: AUDIT-C + 2

Negative screen Low or no use

Positive feedback, reinforce low risk levels of use

Positive screen Use at levels that can impact health

Brief intervention to reduce use and/or lower risk

High-Positive screenUse at levels that are most likely to impact health

Brief intervention to engage in further assessment

1. Begin the conversation, build rapport“Tell me more about your use…with whom, how much...”

2. Provide feedback, clinical recommendations– Ask permission– Connect to health, reason for visit

3. Support patient goal setting/plan“What have you considered… what might be your next step…”

Brief Intervention

Referral to Treatment

A process involving

proactive and collaborative coordination

between SBIRT providers and those providing

substance use disorder treatment to ensure a person has

access to and engages in an appropriate higher level of care

regarding the consequences associated with their substance use.

http://www.integration.samhsa.gov/sbirt/tap33.pdf

Shared decision making about options, other services:

• Medications

• Individual therapy

• Peer support

• Group-based treatment

• No treatment but possible self-management with continued primary care support and monitoring

Management & Follow-Up Monitoring (Referral to Treatment 2.0)

SBIRT is a Paradigm Shift

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• Not looking for addiction• Looking for unhealthy substance use patterns• Looking for opportunities for intervention• Meeting people where they are

Endorsed by Experts• Ntl Institutes of Health • World Health Org• US Surgeon General and US Prev

Services Task Force• Am Public Health Assoc• Society for Adol Health and

Medicine• Emergency Nurses Assoc• Substance Abuse and MH Svcs

Admin• White House Office of National

Drug Control Policy• Am Medical Assoc• Am Academy of Fam Phys

• Am College of Physicians• Am Psychiatric Assoc• Am College of Emergency

Physicians• Am College of Surgeons

Committee on Trauma• Am College of OB-GYN• Am Society of Addiction Medicine

• The Am Academy of Pediatrics and Ntl Institute on Alcohol Abuse and Alcoholism explicitly endorse the use of SBIRT with young people.

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What Happens When SBIRT Sticks

• Replaces less effective screening methods

• Views substance use on a continuum, with biological and behavioral factors

• Improves clinical care

• Transforms culture

• Prepares your organization and workforce for health care changes

Levels of Integration from the Integrated Practice Assessment Tool (IPAT)

Coordinated Co-located Integrated

1

Minimal Collaboration

2

Basic Collaboration

at a Distance

3

Basic Collaboration

Onsite

4

Close CollaborationOnsite with

some System

Integration

5

Close CollaborationApproaching

an Integrated

Practice

6

Full Collaboration

in a Transformed /

Merged Integrated

Practice

Level 1: SBIRT example

• Behavioral health provider from partner organization contracted to be onsite 2 days a week.

• Select patients are screened and information is documented in separate system.

• Brief interventions occur when BH is onsite and referrals go to external BH provider.

Level 4: SBIRT Example

• Behavioral health provider from partner organization is contracted to be onsite 5 days a week.

• Has adopted the culture of the health center and is in close connection with the team.

• Information is documented in shared medical record.

• Integrated care teams meet to discuss some cases.

Level 6: SBIRT Example• BH provider is a core member of the team.

• All patients are screened routinely, information is documented & shared among the integrated care team

• Screening and brief intervention are not seen as a “burden”.

• Data collected on health improvement, cost savings, and provider satisfaction and shared regularly.

• SBIRT training is embedded in onboarding new staff.

• Integration is a process that occurs over time in the entire organization.

• More than having a good referral partner, care capacity, or a co-located site.

• More than a particular tool (e.g., PHQ 9), diagnostic combination (e.g., depression and diabetes), or evidence-based program (e.g., IMPACT, SBIRT).

• Continually evolving with populations, partners, challenges, opportunities.