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