Post on 16-Dec-2015
transcript
Christine Pace, MD, MScAssistant Professor of Medicine, Boston University School of Medicine
Lee Ellenberg, LICSWTraining Manager, MASBIRT Training and Technical Assistance (TTA)
April 3, 2014
SBIRT: Addressing unhealthy substance
use in primary care
OutlineOutline
• Impact and spectrum of unhealthy substance use in primary care
• Screening, brief intervention and referral to treatment (SBIRT)– Approach– Effectiveness
• Implementation opportunities & resources
Unhealthy substance use in primary care
• Spectrum of use that risks health consequences– Cardiovascular disease, cancer, trauma, infection, more– Alcohol = 3rd leading preventable cause of death in US1
• Costly: – Societal costs of $416.5 billion annually2
• Underdiagnosed– 16% of patients ever discussed alcohol with provider3
• Undertreated– 14% with substance use disorders (SUD) in MA get
treatment4
1 http://www.prevent.org/National-Commission-on-Prevention-Priorities/Rankings-of-Preventive-Services-for-the-US-Population.aspx ;2 Bouchery, Am J Prev Med 2011:41;516-524; 3. CDC Vital Signs Report 2013 http://www.cdc.gov/vitalsigns/ ; 4. Brolin, MA Health Policy Forum 2005
Addiction:HistoricalPerspective
New concept
Risky use
No Problem
ProblemUnhealthy use
SUD
Low risk use or no use
Risky use:For alcohol—•Men < 65: >4 drinks/occasion or >14 drinks/wk•Women & >65: >3 drinks/occasion or >7 drinks/wk For drugs*--ANY use
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf
What is SBIRTSBIRT? A low intensity, low cost, public health approach to identify and intervene with people with unhealthy
substance use.
SScreening: Universal, brief questionnaire that identifies unhealthy substance use
If positive: Additional questions to determine severity and consequences of use
BBrief IIntervention: Brief conversation to raise awareness of risks & build motivation to change RReferral to TTreatment: For those with more serious problems, when appropriate
Why is SBIRT important?
Patients often don’t understand impact of alcohol and drug use on health
Particularly unaware of drinking guidelines
Clinician suspicion of alcohol problems has poor sensitivity (27%) for identifying patients with (+) screen for unhealthy alcohol use1
Lack of confidence in substance use assessment and intervention is associated with lower MD satisfaction in working with patients with SUD2
1 Vinson, D, Annals of Fam Med. 2013; 2 Saitz, R, J Gen Intern Med. 2002.
The key to SBIRT: Brief intervention
….a brief, non-judgmental, non-confrontational, directive conversation, using Motivational Interviewing (MI) principles & techniques to enhance a patients’ motivation to change their use of alcohol and other drugs.
Brief interventionBrief intervention
Feedback: provide personalized feedback based on screening results; state concern regarding medical risks/consequences of use
Advice: ask permission; then, make explicit recommendation for change in behavior; discuss patient’s reaction
Seal the Deal: enhance motivation for behavior change; elicit ideas & negotiate plan with patient, schedule follow-up
SBIRT has been found to: Help patients reduce alcohol use1,2,
Increase proportion with SUD who get treatment3
Reduce healthcare costs4,5: Alcohol SBI in primary care reduces ED visits and inpatient days,
and saves $3 for every healthcare dollar spent.6
Most effective for lower severity alcohol use in primary care 7,8
Ongoing research: Drugs, other settings & severities, teens
USPSTF recommends alcohol SBI (grade B)
Why is SBIRT important?
1 Babor, T Sub Abuse 2007; 2 Mertens, J Alc Clin Exp Res 2005; 3 Krupski, A Drug Alc Dep 2010; 4 Solberg, L, Am J Prev Med, 2008; 5 Estee, S Medical Care 2010; 6 Fleming, M, Medical Care. 2000; 7 Kaner, E Drug Alc Review 2009; 8 Saitz, R Ann Intern Med 2007; USPSTF=US Preventive Services Task Force
SBIRT effectiveness
# Service Public Benefit ROI
1 Childhood immunizations 5 5
1 Smoking cessation 5 5
1 Aspirin in high risk patients to prevent heart attack & stroke
5 5
2 Alcohol screening & intervention 4 5
101 = lowest; 5 = highest
Ranked higher than:•Screening for high BP or cholesterol•Screening for breast, cervical, or colon cancer•Adult flu, pneumonia, or tetanus immunization
Maciosek, Am J Prev Med, 2006; Solberg, Am J Prev Med 2008; http://www.prevent.org/content/view/43/71
Adapted from Partners in Integrated Care
Rankings of 25 Preventive Services Recommended by USPSTF
SBIRT implementation challenges & opportunities
Challenges• Limited reimbursement
• Workflow challenges
• Training gaps
• Poor access to specialty substance use treatment
Opportunities
• New payment models
• Team-based care
• Broad-based behavioral health integration efforts (enhance training opportunities, access)
Implementing SBIRT: Challenges and opportunities
• Front desk: Gives screen to patient– Single-item alcohol and drug questions– PHQ-2 for depression
• Medical assistant: Scores screen, gives follow-up tool for any (+) response – AUDIT, DAST-10 and/or or PHQ-9
• Provider: Scores any follow-up tool; as needed, conducts BI and/or places referral.
SBIRT in action: BMC Primary Care
Supported by MA DPH: Bureau of Substance Abuse Services (BSAS) to build statewide SBIRT awareness and capacity to
– implement and integrate SBIRT into diverse settings and organizations,
– and promote clinician SBIRT skills and competency.
www.maclearinghouse.com
MASBIRT Training & Technical Assistance (TTA)
(www.masbirt.org)
Conclusions• SBIRT is an evidence-based, cost-saving
intervention to reduce unhealthy substance use among primary care patients
• SBIRT training and implementation should emphasize brief intervention
• Healthcare reform and behavioral health integration efforts present opportunities for broad implementation of SBIRT
• MASBIRT TTA is a resource to support implementation (www.masbirt.org)
Conclusions