SBIRT: A Look at the Evidence – and Gaps to Address Richard L. Brown, MD, MPH Director of WIPHL Professor of Family Medicine & Community Health School of Medicine and Public Health wellsys.biz University of Wisconsin CEO and Chief Medical O ffi cer, Wellsys LLC
R i c h a rd L . B ro w n , M D , M P H - “ R i c h ” 22 years of practice as a family doctor Tenured Professor at UW since 1990 NIH-funded researcher Past President, AMERSA AMERSA McGovern Awardee Director, Project MAINSTREAM Director, Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL) 2
Wisconsin Initiative to Promote Healthy Lifestyles Wisconsin Department of Health Services Three federally funded projects: Results: Patient satisfaction: 4.3 to 4.9 of 5 points • $14M since 2006 • Helped 44 clinics deliver BSI 20% 15% 55% • Screened >100,000 patients Binge Marijuana Depression • Delivered >25,000 interventions use drinking symptoms Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs 3 Brown, American Journal of Managed Care, 2014; Paltzer, unpublished
Conflict of Interest Disclosure Owner and CEO of Wellsys, LLC (wellsys.biz) Provides training, consultation and software to help healthcare settings and workplaces deliver SBIRT and similar services for other behavioral risks and disorders This presentation will be evidence-based 4
Outline The problem Intervention SBIRT - an overview Referral to treatment Screening Brief treatment Brief assessment Implementation & spread
Outline The problem Intervention SBIRT - an overview Referral to treatment Screening Brief treatment Brief assessment Implementation & spread 6
Drinking and Drug Use Continuum Loss of control High Low Absti- Problem Not dependent Cravings Dep risk Dep risk nence use Preoccupation use use Addicted Addicted No addiction Abstinent x 1 mo Abstinent x 2 yr 7
Need for SBIRT - US Adults (Use in Past Month) Binge alcohol use Illicit drug use About 1 in 3 adults 25% 9% would benefit from alcohol or drug services Marijuana use Other illicit drug use 7% 3% 8 SAMHSA, National Survey on Drug Use and Health, 2012-2013
Prevalence of Alcohol/Drug Disorders – US Adults – Alcohol Drugs 7.1% 2.6% Abuse or Dependence 9 SAMHSA, National Survey on Drug Use and Health, 2012-2013
Receipt of Alcohol/Drug Treatment – US Adults – Alcohol Drugs Untreated: Untreated: 95% 89% Treated: Treated: 5% 11% 10 SAMHSA, National Survey on Drug Use and Health, 2012-2013
Economic Impacts - $412 Billion $161B Healthcare $34B Alcohol Productivity $25B $11B $61B Other $120B Societal Drugs 11
Outline The problem Intervention SBIRT - an overview Referral to treatment Screening Brief treatment Brief assessment Implementation 12
SBIRT Overview Screen Brief Assessment Abstinence High risk or mild to Dependence or or low risk moderate disorder severe disorder (Brief Treatment) Brief Intervention Referral to Treatment Follow-up and Support 13
Outline The problem Intervention SBIRT - an overview Referral to treatment Screening Brief treatment Brief assessment Implementation & spread 14
Screening Indicates who MIGHT be at risk or have a disorder Enhances efficiency of SBIRT by quickly identifying those needing no additional services Ideally minimizes false negatives, allowing more false positives 15
Alcohol Screening - CAGE Cut down - Misses risky drinking Annoyed - Other screens Guilt are briefer and more Eye-opener accurate 16
Alcohol Screening - AUDIT-C 0 1 2 3 4 1 How often do you Never Monthly 2 - 4 times 2 - 3 times 4 or more have a drink or less a month a week times a containing alcohol? week 2 How many drinks 1 or 2 3 or 4 5 or 6 7 to 9 10 or more containing alcohol do you have on a typical day when you are drinking? 3 How often do you Never Less than Monthly Weekly Daily or have more than monthly almost daily X drinks on one occasion? Positive screen: ≥ 4 points for men, ≥ 3 points for women 17
Alcohol Screening - Single Alcohol Screening Question How many times in How many times in the past year have the past year have you had more than you had more than 4 drinks in an 3 drinks in an occasion? occasion? __ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times Modified from: 18 http://pubs.niaaa.nih.gov/publications/practitioner/PocketGuide/Pocket.pdf
Drug Screening - Single Alcohol Screening Question How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? __ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times 19 Modified from: Smith, Archives of Internal Medicine, 2010
Outline The problem Intervention SBIRT - an overview Referral to treatment Screening Brief treatment Brief assessment Implementation & spread 20
AUDIT - Questions 1 to 3 0 1 2 3 4 1 How often do you Never Monthly 2 - 4 times 2 - 3 times 4 or more have a drink or less a month a week times a containing alcohol? week 2 How many drinks 1 or 2 3 or 4 5 or 6 7 to 9 10 or more containing alcohol do you have on a typical day when you are drinking? 3 How often do you Never Less than Monthly Weekly Daily or have more than monthly almost daily X* drinks on one occasion? * For X, substitute 3 for women, 4 for men 21
AUDIT - Questions 4 to 8 0 1 2 3 4 Never Less than Monthly Weekly Daily or monthly almost daily 4 How often during the last year have you found that you were not able to stop drinking once you had started? 5 How often during the last year have you failed to do what was normally expected of you because of drinking? 6 How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session? 7 How often during the last year have you had a feeling of guilt or remorse after drinking? 8 How often during the last year have you been unable to remember what happened the night before because of your drinking? 22
AUDIT - Questions 9 to 10 0 2 4 No Yes, but not in Yes, during the last year the last year 9 Have you or someone else been injured because of your drinking? 10 Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? 23
AUDIT - Scoring Points Interpretation Men up to Women and age 64 older men 0 to 7 0 to 6 Low risk - reassure 8 to 15 7 to 15 Medium risk - intervene Medium high risk – intervene & 16 to 19 follow 20 to 40 High risk – refer for assessment 24
DAST - Questions 1 to 5 Points In the past 12 months … Yes No 1 Have you used drugs other than those required for medical reasons? 1 0 2 Do you abuse (use) more than one drug at a time? 1 0 3 Are you always able to stop using drugs when you want to? 0 1 4 Have you had “blackouts” or “flashbacks” as a result of drug use? 1 0 5 Do you ever feel bad or guilty about your drug use? 1 0 25
DAST - Questions 6 to 10 Points In the past 12 months … Yes No 6 Has your spouse or parents ever complained about your involvement 1 0 with drugs? 7 Have you neglected your family because of your use of drugs? 1 0 8 Have you engaged in illegal activities in order to obtain drugs 1 0 (other than possession) ? 9 Have you experienced withdrawal symptoms (felt sick) when you 1 0 stopped taking drugs? 10 Have you had medical problems as a result of your drug use (eg, 1 0 memory loss, hepatitis, convulsions, bleeding, etc …)? 26
DAST - Scoring Score Extent of Problems Recommended Clinical Related to Drug Use Service 0 None Reinforcement 1 Low Brief Intervention (BI) 2 Low BI 3 to 5 Moderate BI and Follow-up 6 to 8 Substantial Referral for Assessment 9 to 10 Severe Referral for assessment 27
AUDIT & DAST - Advantages & Disadvantages Advantages - AUDIT is well validated in many countries - AUDIT is translated into many languages - AUDIT and DAST scores guide subsequent service delivery Disadvantages - DAST is not well validated in primary care/general populations - Some DAST items are poorly worded - Scores mask important differences in symptom patterns - Feedback on scores is meager 28
Alternative Brief Assessment Alcohol, Substance and Smoking Involvement Screening Test (ASSIST) Quantity-Frequency questions on alcohol 29
NIDA-ASSIST For tobacco, alcohol and 10 categories of drugs: Lifetime use Use in past 3 months Strong desire or urge Health, social, legal or financial problems Failed to do what was normally expected Friend or relative expressed concern Loss of control Final question on injection use 30
NIDA-ASSIST For each category: low, moderate and high risk Focus on tobacco might increase acceptance Same questions for tobacco, alcohol and drugs Complicated skip patterns - best delivered by computer Does not distinguish dependence well 31
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