Screening, Brief Intervention, and Referral to Treatment

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SBIRT (Screening, Brief Intervention, and Referral to Treatment) is a comprehensive approach implemented in medical settings to identify and address alcohol-related issues. The process involves universal screening using validated tools, brief interventions for risky or harmful use, and referrals for specialized treatment when dependence is identified. SBIRT focuses on addressing low to moderate risk alcohol use as a preventive measure before addiction develops. This evidence-based strategy utilizes the primary care context to capitalize on teachable moments and promote awareness and education regarding alcohol consumption.

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Screening, Brief Intervention, and Referral to Treatment April Velasco, PhD Deputy Regional Health Administrator US Dept of Health and Human Services, Region II (NY, NJ, PR, USVI)

Recent CDC report Jan. 2012 One in six Americans binge drinks four times per month Average number of drinks during binge is 8 40,000 deaths per year (binge-specific) 2006 - $167.7 billion alcohol-related costs Age group that binge drinks most often 65+ Income group with most binge drinkers - $75K+ CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

CDC Report continued binge drinking responsible for: Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS 85% of all alcohol-impaired driving episodes involved binge drinking (2010) Accounted for 50% of all alcohol consumed by adults; 90% of youth Most binge drinkers are not dependent CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61

Focus of SBIRT Dependent Use Brief Intervention and Referral to Treatment 4% Harmful or Risky Use Brief Intervention 25% Low Risk Use or Abstention No Intervention 71%

What exactly is SBIRT? SBIRT Screening, Brief Intervention, and Referral to Treatment Universal screening of patients within medical settings with use of validated screening tools If screened positive brief intervention (guided discussion) with medical provider occurs If screening reveals dependence referral to specialty substance abuse treatment provider

SBIRT: Primary Care Context Takes advantage of the teachable moment Patients aren t seeking treatment but screening opens door for awareness & education Focus on addressing low/moderate risk usage as a preventative approach before addiction occurs

SBIRT Ranked in top ten of prevention services 1. Discuss daily use of aspirin 2. Childhood immunization Series 3. Tobacco use screening and brief intervention 4. Colorectal cancer screening 5. Hypertension screening 6. Influenza immunization 7. Pneumococcal immunization 8. Problem drinking screening & brief intervention 9. Vision screening adults 10.Cervical cancer screening (Partnership for Prevention Priorities for America s Health: Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)

SBIRT and ACA Taking a closer look at the potential newly insured population post-ACA marketplace enrollment Prevalence estimates and data

PREVALENCE OF ANY MENTAL ILLNESS BY POPULATION Any Mental Illness 35% 30.5% 30% Percent with Condition 25% 21.3% 21.3% 21.2% 21.1% 20% 15% 10% 5% 0% Uninsured Adults (8,938,373) CI: 20.6-22.0% Uninsured Adults <133% FPL (3,811,510) CI: 20.3-22.4% Uninsured Adults 133-<400% FPL (4,066,602) CI: 20.1-22.2% Uninsured Adults <400% FPL (7,879,491) CI: 20.5-21.9% Medicaid Adults (6,598,793) CI: 29.4-31.6% CI = Confidence Interval Sources: 2008 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF SUBSTANCE USE DISORDER BY POPULATION Substance Use Disorder 16% 14.3% 14.4% 13.9% 13.6% 14% 11.9% Percent with Condition 12% 10% 8% 6% 4% 2% 0% Uninsured Adults (6,042,844) CI: 13.8-14.9% Uninsured Adults <133% FPL (2,433,640) CI: 12.9-14.4% Uninsured Adults 133-<400% FPL (2,756,039) CI: 13.5-15.1% Uninsured Adults <400% FPL (5,166,270) CI: 13.4-14.5% Medicaid Adults (2,574,611) CI: 11.2-12.7% CI = Confidence Interval Sources: 2008 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF ANY MENTAL ILLNESS OR SUBSTANCE USE DISORDER BY POPULATION Any Mental Illness or Substance Use Disorder 40% 36.0% 35% 30.2% 29.9% 29.8% 29.7% Percent with Condition 30% 25% 20% 15% 10% 5% 0% Uninsured Adults (12,673,186) CI: 29.4-30.9% Uninsured Adults <133% FPL (5,314,641) CI: 28.6-30.9% Uninsured Adults 133-<400% FPL (5,762,626) CI: 28.7-31.0% Uninsured Adults <400% FPL (11,075,888) CI: 29.0-30.6% Medicaid Adults (7,788,739) CI: 34.8-37.2% CI = Confidence Interval Sources: 2008 2011 National Survey of Drug Use and Health, 2011 American Community Survey

PREVALENCE OF ANY MENTAL ILLNESS AND SUBSTANCE USE DISORDER BY POPULATION Any Mental Illness and Substance Use Disorder 8% 6.5% 7% 5.5% Percent with Condition 5.4% 5.5% 5.2% 6% 5% 4% 3% 2% 1% 0% Uninsured Adults (2,308,031) CI: 5.1-5.8% Uninsured Adults <133% FPL (930,510) CI: 4.7-5.7% Uninsured Adults 133-<400% FPL (1,060,015) CI: 5.0-6.0% Uninsured Adults <400% FPL (2,007,040) CI: 5.0-5.7% Medicaid Adults (1,406,300) CI: 5.9-7.1% CI = Confidence Interval Sources: 2008 2011 National Survey of Drug Use and Health, 2011 American Community Survey

SBIRT Implementation Implementation strategies Considerations

Universal Prescreen (-) Negative Provide positive reinforcement Low risk: Provide positive reinforcement (+) Positive Moderate risk: Provide Brief Intervention Further screening with ASSIST AUDIT CRAFFT DAST Moderate high-risk: Provide Brief Therapy High risk: Refer to treatment

Effective Screening Program Typically Yields Approximately 25% of all patients will screen positive for some level of substance misuse or abuse Of those, the approximately 70% will be at-risk drinkers Most will be open to addressing their substance abuse problems (if discussed in a non- judgmental manner)

Brief Intervention Approach Uses Motivational Interviewing techniques Discuss healthy drinking levels for male/females (NIAAA standards) Weigh pros/cons of cutting down or quitting Use scaling to assess for readiness (i.e on a 1 to 10 scale .) Effects on quality of life and/or existing medical conditions Plan to talk about it more than once (at future doctor visits) Small, obtainable goals (let patient tell you want he/she can handle)

Identify Referral Resources Short-term and long-term residential treatment centers Community agencies for referrals Hospital inpatient and outpatient centers State treatment centers

Key Considerations for Starting SBI Program Reimbursement strategy & considerations Identify target population and location(s) Staff training needs and supervision Develop a Screening protocol Develop a Brief Intervention protocol Program champions and buy-in from CEO/Admin staff Identify staff to monitor and evaluate program (strong QI mgt essential)

Additional Considerations Who Will Do the Screening and Brief Intervention? SBIRT counselors/health educator model Social Workers Registered Nurses Psychologists Physicians Dedicated contracted personnel Medical Assistants Para-professionals

Challenges & Lessons Learned Buy-in issues from existing medical staff Funding for additional staffing (or train existing staff) Need for management to be supportive and influence implementation Consistent training available for new staff

Useful Resources Numerous SBIRT grantee websites with training videos, screening protocols, insurance/billing information, toolkits, etc Addiction Technology Transfer Centers (ATTC) SAMHSA funded trainings in SBIRT, MI, etc Other non-fed funded organizations offering training, resources, etc