Substance Use Disorders, Primary Care, Screening and Brief Intervention

Norman Wetterau, MD, FASAM

President: New York Society of Addiction Medicine

Health Care Reform

Better Health

Less cost

Alcohol brief screening and interventions

• AT SIX MONTHS, MEN DOWN FROM 21.3 TO 14.4 DRINKS A WEEK, WOMEN FROM 14.8 TO 8.4

• HEALTH CARE UTILIZATION: 20% LESS ER VISITS 37% FEWER HOSPITAL DAYS

• CONTROL GROUP: 55% MORE CRASHES (31 VS. 20) 46% MORE ARRESTS (41 VS. 28)

• BENEFIT: MEDICAL $712 MINUS $166 COST= $546

• SOCIETAL $7,985 PER PATIENT MINUS $205 COST

LONG TERM EFFICACY AND BENEFIT - COST ANALYSIS MICHAEL FLEMING ET AL. ALCOHOL CLIN. EXP RES. VOL 26 NO 1 PP 36-43

US Preventive Task Force: SBIRT

• Score of 9 out of 10 for cost effectiveness and usefulness

• Only Immunizations, and discussing aspirin and tobacco received 10

• Paps: 7 breast cancer 6 diabetes 2

• Solberg et al American J of Prev. Med.34: 143-152

NCQA requirements for certification as a medical home

To be certified as a medical home NCQA will require screening for alcohol and other substance use and an attempt to address the issue and treat or refer.

Much Federal Money to implement SBIRT programs in Ers, Hospitals, Practices and residencies

OUTLINE

• 1. What is screening and brief intervention about?

• 2. Who does it? How is it done?• 3. Screening: single question or AUDIT• 4. Assess: Audit or abuse, dependency

questions• 5.Advise and Assist• 6 Follow-up• 7. Our role

What is SBIRT

• We ask questions to determine if people are nondrinkers, safe drinkers, at risk drinkers, harmful drinkers or dependent drinkers

• For those who are at risk, we provide a brief intervention

• For those whose drinking is harmful or dependant, we still do a brief intervention but may also refer the patient for further treatment.

Safe Drinking

• Men: 14 standard drinks a week, no more than 4 on one occasion

• Women and men over age 64: 7 drinks a week, no more than 3 on one occasion

Demand Treatment!-The Risk Paradigm

• A shift toward earlier detection, brief intervention, and strategic follow up…..

Initial Screening Questions

• Do you sometimes drink beer, wine or other alcoholic drinks?

• How many times in the last year have you had (Men 5, woman 4) or more drinks?

• Or Give them the first 3 questions of the audit (positive score woman 4, men 8)

• Or give them the whole audit

For positive screens

• Access using the audit or abuse, dependency questions

• If at risk, provide a brief intervention

• If harmful or dependent, consider referral

• Follow-up

• Consider offering medications

WHO DOES THIS?

• Initial screen: anyone– Ask or hand out audits to everyone– Can be part of other questions that are

asked of all patients

Rest of process: physician, assistant, booklet or online. It is very helpful if the physician is involved in some part of this.

Rethinking Drinking

• On one page they list the pros and cons

• Ready or not: keep track, notice how drinking affects you, make or remake a list of pros and cons about drinking

• Ask for support from your doctors, a friend or someone else you trust

strategies for cutting down

• Keep track• Count and measure• Set goals• Pace and space• Include food• Find alternatives• Avoid triggers• Plan to handle urges• Known your no

Planning for changeFrom rethinking drinking

List goals

Timing: I will start on

Reasons: My most important reasons to make these changes

Strategies

People who can help

Signs of Success

Approach & Purpose: Alcohol Screening and Brief Intervention

• STEP 1-ASK ABOUT ALCOHOL USE & Safe Drinking……………

Safe Drinking:Men: 14 drinks/weekno more than 4 on one occasionWomen: 7 drinks/weekno more than 3 on one occasion

Alcohol Screening and Brief Intervention

Ask about alcohol and Drug Use

Specific Screening Questions• How many drinks do you consume in an average week?• What is the most drinks you have had on one occasion in the past

month?• Has alcohol ever caused any problems for you?• Do you use any drugs other than those prescribed by a

physician?

• If they drink over the safe amount we give patient the Audit.

Demand Treatment!-The Risk Paradigm

• A shift toward earlier detection, brief intervention, and strategic follow up…..

Approach & Purpose

STEP 2: ASSESS FOR ALCOHOL

RELATED PROBLEMS

1. At Risk Drinking….More than safe amount but no problem yet….

2. Harmful Drinking…..

3. Dependence….

Approach & Purpose

STEP 2: ASSESS FOR ALCOHOLRELATED PROBLEMS: Use Audit Plus:

Medical Problems such as………Depression, hypertension, sexual problems,

trauma, sleep disorders

Behavioral Problems such as…….Work, family, school, accidents

BIG THREE

• Smoking

• Drinking

• Obesity

• Anxiety

• Depression

• Drinking

Approach & Purpose

STEP 2: ASSESS FOR ALCOHOLRELATED PROBLEMS : AUDIT

Positives on 1-3 (quality questions) - AT RISK

Score of 15-20 can be harmful or dependentAny drinking that causes problems is HARMFUL

Positives of 4-6 or score over 20 suggest ALCOHOL DEPENDENCE

Demand Treatment!-The Drinkers’ Pyramid

SAFE DRINKING: MEN 2 DRINKS A DAY, 4 ON ONE OCCASION WOMEN 1 DRINK A DAY, 3 ON ONE OCCASION

STEP 3: ADVISE, ARRANGE, ASSIST

• State your concerns

• Give clear advice to cut down or abstain

• Agree on a specific plan of action

SOLICIT THEIR RESPONSE

• Do the WHO guidelines seem low to you?• Are there changes you might make that could

reduce your risk of alcohol related problems?• How hard would that be?

• OFFER SUGGESTIONS TO ACCOMPLISH THEIR GOALS

OFFER CHOICES

• I could order tests but there is a good chance that if you reduce your alcohol intake, the symptoms would go away.

• We can prescribe life long medication, but it might not be necessary if you are able to reduce you alcohol use.

• I would like to prescribe this medication but I cannot unless you are able to stop drinking

EXPLORING PROS AND CONS

• WHAT DO YOU LIKE ABOUT DRINKING? Acknowledge what they said

• WHAT DO YOU LIKE LESS ABOUT DRINKING? IS THERE ANYTHING ELSE?

• SUMMARIZE: on the one hand you said... but then you said …Where does this leave you?

Who should be strongly advised to abstain rather than just cut back?

1. Those who have failed before to cut back and to remain cut back

2. Those who are pregnant, hypertensive or have abnormal liver function

3. Those taking medicine that should not be taken with alcohol

4. Those who are depressed5. Those who might be depressed

Who should be referred?

1. Those with alcohol dependence

2. Those who try to cut down or quit and are unable to follow through

3. Those who have multiple alcohol related problems who are unable to stop drinking

4. Patients who have been prescribed medication for anxiety or depression, have been advised to stop drinking, and are unable to do so.

Example 1. If patient presents with a problem that has some relationship to alcohol, you could deal with it quickly.

The patient will likely be more responsive right then.

    “…. your blood pressure is high today. I noted on your screen that you drink 20 or so drinks a week.

Although one drink a day might help the heart, 20 a week can contribute to high blood pressure and harm

the hear ……. Would you be able to cut back or possibly abstain from alcohol until we sort this problem out?….”

PRACTICAL CONCERNS: TIME AND YOUR STYLE

Example 2.     “…. . I can see that your anxiety (or depression) is a real problem. Do you ever have a drink to

calm you down or make your feel better? …….. Alcohol may make you feel better for a short while, but it actually

increases depression and anxiety levels. I would like to help you with your problem, but would like to ask you to stop all alcohol use for a while. Is this something you could  do?….

  If the person has a significant problem or high audit score you might say,… “In addition to  some counseling around your problems, I could give you someone to work with you

in trying to cut down or stop drinking…..”

PRACTICAL CONCERNS: TIME AND YOUR STYLE

Example 3.     . . If the person is simply at risk, you can provide some advice in just a few minutes, and if necessary, give them some material and let them know you could talk to them later about this if they wish;

If you have 5 minutes, you can do a brief intervention and have them come back later

PRACTICAL CONCERNS: TIME AND YOUR STYLE

Specific Protocol

• THE AUDIT– 1. WHERE WILL THEY BE KEPT?– 2. WHO WILL GIVE THEM TO THE AT

RISK PATIENT?

Specific Protocol:

Specific Questions on Logistics

• Who will you screen?• Will this be in a questionnaire format or will the

questions be asked in an interview?• Who will do the screening? (e.g. nurse,

physician)• What specific questions will you ask?• If drinking is above safe limits, what will you do

next?• Where will materials be kept?

BILLING• 214: 1 new complicated problem or 3 chronic problems

• Update at least one element of past history

• Review of at least 2 systems

• USE WRITTEN SCREEN AS YOUR DOCUMENTATION OF PAST HISTORY

• IF SCREEN IS POSITIVE, YOU HAVE A NEW PROBLEM AND A 214

• ON FOLLOWUP, USE ALCOHOL ABUSE AS ONE OF THREE CHRONIC CONDITIONS YOU ADDRESS.