[PPT] - SBIRT: A Look at the Evidence and Gaps to Address Richard L. PowerPoint Presentation

SLIDE 1

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  University of Wisconsin CEO and Chief Medical Officer, Wellsys LLC

SBIRT:

wellsys.biz

SLIDE 2

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)

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SLIDE 3 3

Three federally funded projects:

$14M since 2006
Helped 44 clinics deliver BSI
Screened >100,000 patients
Delivered >25,000 interventions

Wisconsin Department 

f Health Services

Results: Patient satisfaction: 4.3 to 4.9 of 5 points Binge  drinking

20%

Marijuana  use

15%

Depression  symptoms

55%

Wisconsin Initiative to  Promote Healthy Lifestyles

Brown, American Journal of Managed Care, 2014; Paltzer, unpublished

Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs

SLIDE 4

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

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SLIDE 5

Outline

The problem SBIRT - an overview Screening Brief assessment Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 6

Outline

The problem SBIRT - an overview Screening Brief assessment

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Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 7 7 No addiction Addicted Abstinent x 1 mo Addicted Abstinent x 2 yr

Loss of control Cravings Preoccupation

Drinking and Drug Use Continuum

Not dependent

Dep Absti-  nence Dep Low  risk  use High  risk  use Problem  use

SLIDE 8 8

Need for SBIRT - US Adults 

(Use in Past Month) Binge alcohol use

25%

Illicit drug use

9%

Marijuana use

7%

Other illicit drug use

3%

SAMHSA, National Survey on Drug Use and Health, 2012-2013

About 1 in 3 adults  would benefit from  alcohol or drug services

SLIDE 9

Prevalence of Alcohol/Drug Disorders 

– US Adults –

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Alcohol Drugs 7.1% 2.6%

Abuse or Dependence

SAMHSA, National Survey on Drug Use and Health, 2012-2013

SLIDE 10 10

Alcohol

Untreated: 95% Treated: 5% Untreated: 89% Treated: 11%

Receipt of Alcohol/Drug Treatment 

– US Adults –

Drugs

SAMHSA, National Survey on Drug Use and Health, 2012-2013

SLIDE 11

Economic Impacts - $412 Billion

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$11B

$120B $61B $34B $161B

$25B

Alcohol Drugs Healthcare Productivity Other  Societal

SLIDE 12

Outline

The problem SBIRT - an overview Screening Brief assessment

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Intervention Referral to treatment Brief treatment Implementation

SLIDE 13 13

SBIRT Overview

Screen Brief Assessment Abstinence 

r low risk

High risk or mild to  moderate disorder Dependence or  severe disorder Brief Intervention Referral to Treatment Follow-up and Support

(Brief Treatment)

SLIDE 14

Outline

The problem SBIRT - an overview Screening Brief assessment

14

Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 15 15

Screening

Indicates who MIGHT be at risk

r have a disorder

Enhances efficiency of SBIRT by quickly identifying those needing no additional services Ideally minimizes false negatives,  allowing more false positives

SLIDE 16 16

Alcohol Screening - CAGE

Cut down  Annoyed  Guilt  Eye-opener

Misses risky

drinking

Other screens

are briefer  and more  accurate

SLIDE 17 17

Alcohol Screening - AUDIT-C

1 2 3 4 1 How often do you have a drink containing alcohol? Never Monthly 

r less

2 - 4 times  a month 2 - 3 times  a week 4 or more times a week 2 How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3 How often do you have more than  X drinks on one

ccasion?

Never Less than monthly Monthly Weekly Daily or almost daily

Positive screen: ≥4 points for men, ≥3 points for women

SLIDE 18

How many times in the past year have you had more than 4 drinks in an

ccasion?

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__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times

Modified from:  http://pubs.niaaa.nih.gov/publications/practitioner/PocketGuide/Pocket.pdf

Alcohol Screening -  Single Alcohol Screening Question

How many times in the past year have you had more than 3 drinks in an

ccasion?

SLIDE 19

How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?

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__ Never __ Once or twice __3 to 5 times __ 6 to 20 times __ More than 20 times

Modified from: Smith, Archives of Internal Medicine, 2010

Drug Screening -  Single Alcohol Screening Question

SLIDE 20

Outline

The problem SBIRT - an overview Screening Brief assessment

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Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 21 21 1 2 3 4 1 How often do you have a drink containing alcohol? Never Monthly 

r less

2 - 4 times  a month 2 - 3 times  a week 4 or more times a week 2 How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more 3 How often do you have more than  X* drinks on one

ccasion?

Never Less than monthly Monthly Weekly Daily or almost daily

AUDIT - Questions 1 to 3

* For X, substitute 3 for women, 4 for men

SLIDE 22 22 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? 1 2 3 4 Never Less than monthly Monthly Weekly Daily or  almost daily

AUDIT - Questions 4 to 8

SLIDE 23 23 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? 2 4 No Yes, but not in the last year Yes, during the last year

AUDIT - Questions 9 to 10

SLIDE 24 24

AUDIT - Scoring

Points Interpretation Men up to age 64 Women and

lder men

0 to 7 0 to 6 Low risk - reassure 8 to 15 7 to 15 Medium risk - intervene 16 to 19 Medium high risk – intervene & follow 20 to 40 High risk – refer for assessment

SLIDE 25 25

DAST - Questions 1 to 5

In the past 12 months … Points Yes No 1 Have you used drugs other than those required for medical reasons? 1 2 Do you abuse (use) more than one drug at a time? 1 3 Are you always able to stop using drugs when you want to? 1 4 Have you had “blackouts” or “flashbacks” as a result of drug use? 1 5 Do you ever feel bad or guilty about your drug use? 1

SLIDE 26 26

DAST - Questions 6 to 10

In the past 12 months … Points Yes No 6 Has your spouse or parents ever complained about your involvement with drugs? 1 7 Have you neglected your family because of your use of drugs? 1 8 Have you engaged in illegal activities in order to obtain drugs  (other than possession)? 1 9 Have you experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 1 10 Have you had medical problems as a result of your drug use (eg, memory loss, hepatitis, convulsions, bleeding, etc …)? 1

SLIDE 27 27

DAST - Scoring

Score Extent of Problems Related to Drug Use Recommended Clinical Service 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

SLIDE 28

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

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SLIDE 29

Alternative Brief Assessment

Alcohol, Substance and Smoking Involvement Screening Test (ASSIST) Quantity-Frequency questions on alcohol

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SLIDE 30

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

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SLIDE 31

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

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SLIDE 32

Alternative Brief Assessment

Quantity-Frequency questions Short Index of Problems (SIP) or  Short Index of Problems-Alcohol & Drugs (SIP-AD) Severity of Dependence Scale (SDS)

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SLIDE 33

Quantity-Frequency Questions

Alcohol:

Days per week in the last month (X)
Standard drinks on an average drinking day (Y)
Maximum standard drinks - past 3 months (Z)
(X) x (Y) = average standard drinks per week

High risk: >14 for men, >7 for women

(Z) = maximum consumed in a day

High risk: > 4 for men, >3 for women Drugs:

Days per week in the last month for each substance

SLIDE 34

SIP-AD (Short Index of Problems - Alc/Drugs)

Over the last 12 months …

1. have you been unhappy because of your drinking 
r drug use?
2. lost weight or not eaten properly because of your

drinking or drug use?

3. failed to do what is expected because of your

drinking or drug use? Never  (0) Once or a  few times  (1) Once or  twice a week  (2) Daily or  almost daily  (3)

SLIDE 35

SIP-AD (Short Index of Problems - Alc/Drugs)

4. has your personality changed for the worse when

drinking or using drugs?

5. have you taken foolish risks when drinking or

using drugs?

6. you said harsh or cruel things to someone when

drinking or using drugs? Over the last 12 months … Never  (0) Once or a  few times  (1) Once or  twice a week  (2) Daily or  almost daily  (3)

SLIDE 36

SIP-AD (Short Index of Problems - Alc/Drugs)

7. have you done impulsive things you regretted

when drinking or using drugs?

8. have you had money problems because of

drinking or drug use?

9. has your physical appearance been harmed

because of drinking or drug use? Over the last 12 months … Never  (0) Once or a  few times  (1) Once or  twice a week  (2) Daily or  almost daily  (3)

SLIDE 37

SIP-AD (Short Index of Problems - Alc/Drugs)

10. has your family been hurt by your drinking or drug

use?

11. has a friendship or close relationship been

damaged by your drinking or drug use?

12. have you lost interest in activities or hobbies

because of your drinking or drug use? Over the last 12 months … Never  (0) Once or a  few times  (1) Once or  twice a week  (2) Daily or  almost daily  (3)

SLIDE 38

SIP-AD (Short Index of Problems - Alc/Drugs)

13. has your drinking or drug use gotten in the way of

your personal growth?

14. has your drinking or drug use damaged your

social life, popularity or reputation?

15. have you spent too much money or lost money

because of your drinking or drug use? Over the last 12 months … Never  (0) Once or a  few times  (1) Once or  twice a week  (2) Daily or  almost daily  (3)

SLIDE 39

SDS - Severity of Dependence Scale

Never or  almost never  (0) Some-  times  (1) Once or  twice a week  (2) Always or  almost always  (3)

1. do you think your use of ___ was out of control?
2. has the prospect of missing a drink/fix/dose made

you anxious or worried?

3. have you worried about your drinking/use of ___?
4. have you wished you could stop drinking/using ___?

Over the last 12 months …

SLIDE 40

SDS - Severity of Dependence Scale 5. How difficult do you find it to stop or go  without ____?

Not  difficult  (0) Quite  difficult  (1) Very  difficult  (2) Impossible    (3) Adults: Total score of 3 or more = likely dependent Teens: Total score of 4 or more = likely dependent

SLIDE 41

Brief Alcohol and Drug Assessment

Questionnaire Assesses for Category, if positive Q/F High risk use At least  high risk use SIP-AD Negative consequences At least  problem use SDS Dependence Likely dependence

SLIDE 42

Gap in Screening/Assessment Studies

Typical Study Clinical  environment Research  environment Recruit subjects ✓ Administer instrument  to be tested ✓ Apply “gold standard” diagnostic process ✓ Research Question When responses to the instrument are not shared  with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?

SLIDE 43

Gap in Screening/Assessment Studies

Typical Studies Needed Studies Clinical  environment Research  environment Clinical  environment Research  environment Recruit subjects ✓ ✓ Administer instrument  to be tested ✓ ✓ Apply “gold standard” diagnostic process ✓ ✓ Research Question When responses to the instrument are not shared  with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians? When responses to the instrument are shared  with clinicians, to what extent does the instrument predict the result obtained by the “gold standard,” the result of which is not shared with clinicians?

SLIDE 44

Two-Item Conjoint Screen (TICS)

1. In the last twelve months, have you ever drunk

alcohol or used drugs more than you meant to? __ Yes __ No 

2. In the last twelve months, have you felt you

wanted or needed to cut down on your  drinking or drug use? __ Yes __ No

Single Alcohol Screening Question Single Drug Screening Question Two-Item  Conjoint Screen + + WIPHL: Adding the TICS to the screen for risky/problem drinkers

Increases identification of drug users from 80% to 90%, as

compared to the ASSIST

Reduces false negatives by half

SLIDE 45 45

WIPHL’s Experience

Among patients who saw WIPHL health educators and participated in confidential 6-month follow-up phone calls 

Higher reports of lifetime substance use when information

was not shared with clinicians  Adding the TICS to the screen for risky/problem drinkers 

Increased identification of drug users from 80% to 90%,

as compared to the ASSIST 

Reduced false negatives by half

SLIDE 46

Outline

The problem SBIRT - an overview Screening Brief assessment

46

Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 47

Alcohol Interventions - Effectiveness

Dozens of studies and several meta-analyses: 10% to 30% declines in binge drinking Declines last up to 4 years with 1 to 3 booster sessions Reductions in 

Injuries
Vehicular crashes 
Hospitalizations and ED visits
Deaths 
Arrests

$3 to $4 reductions in healthcare costs per $1 spent National Commission on Prevention Priorities:  4th most effective and cost-effective preventive service

SLIDE 48

Drug Interventions - Effectiveness

Zgierska A, Amaza IP , Brown RL, Mundt M, Fleming MF. Unhealthy drug use: How to screen, when to intervene. Journal of Family Practice 2014; 63:524-540. Review of prior studies: Randomized controlled trials General healthcare settings Population-wide screening

5 studies

SLIDE 49

Drug Interventions

Bernstein et al 

Screened 23,699 adults in urgent care, women's health

and homeless clinics with the DAST 

Randomized 1,175 patients to single BI session vs. brochure 
Conducted follow-up at 6 months

49 Bernstein et al, Drug & Alcohol Dependence, 2005 P r o p o r t i o n A b s t i n e n t p-value Brochure Brief Intervention Cocaine 17% 22% 0.045 Heroin 31% 40% 0.050

SLIDE 50

Drug Interventions

Zahradnik et al 

Screened 6,000 internal medicine, surgical or GYN inpatients 
Randomized 126 patients with prescription drug misuse or

dependence to a 2-session intervention vs. a brochure

50 Zahradnik et al, Addiction, 2009;  Otto et al, Drug & Alcohol Dependence, 2009 Proportion with ≥25% Reduction Brochure Brief Intervention p-value 3 months 30% 52% 0.017 12 months 49% 50% 0.833

SLIDE 51

Drug Interventions

Humeniuk et al 

Screened primary care patients in Australia, Brazil, India & USA 
Randomized 731 marijuana, cocaine, amphetamine and opioid

users at moderate risk, according to the ASSIST, to brief   intervention vs. usual care

51 Humeniuk et al, Addiction, 2012 0% 10% 20% 30% Australia Brazil India USA 20% 10% 9% 2% 11% 24% 25% 17%

Brief Intervention Usual care

Decline in ASSIST Scores - 3 Months

SLIDE 52

Drug Interventions

Saitz et al 

Screened 1,504 primary care patients at an inner city hospital 
Randomized 528 patients to control, brief intervention (10 to 15

minutes) and modified motivational intervention (30 to 45 minutes)

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4 8 12 16

Control BI MMI

14.1 14.2 13.8 13.8 15.1 14.3

Baseline 6 months Days of Use of Primary Drug in Past 30 Days

Saitz et al, JAMA, 2014

SLIDE 53

Drug Interventions

Roy-Byrne et al 

Screened 10,337 patients

at 7 Washington State   safety-net clinics 

Randomized 868 patients to 
Face-to-face BI + phone F/U 
Usual care + brochure

53 Roy-Byrne et al, JAMA, 2014

SLIDE 54

Another negative study …

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SLIDE 55

Kaner et al

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29 primary care practices in England 

urban, suburban, rural 
socioeconomically diverse communities - affluent to impoverished 
culturally diverse patients

Eligible patients 

New or seeking help for mental health, GI, hypertension or minor injury 
Positive alcohol screen 
Ages 18+ 
Live within 20 miles of practice 
Not seeking help for drinking

SLIDE 56 56

Cluster RCT with randomization by clinic

Intervention Components Group  1 Group  2 Group  3 16-page educational brochure

✓ ✓ ✓

5 minutes of brief advice

✓ ✓

Appointment for 20-minute  modified MI session

✓ Interventionists: Physicians and nurses (95%) Primary outcome: Proportion with AUDIT scores < 8 Analysis: Intention-to-treat

Kaner et al

SLIDE 57 57 Presenting patients: 3,562 Eligible for screen: 2,991 (84%) Hazardous or harmful drinkers: 900 (30%) Consented to participate: 754 (84%) Brochure only + Brief advice + Brief counseling Randomization 251 251 254 Received brochure 251 (100%) 251 (100%) 254 (100%) Received brief advice – 250 (99%) 250 (99%) Received brief counseling – – 143 (57%) 6-month follow-up 212 (85%) 215 (86%) 205 (81%) 12-month follow-up 197 (79%) 209 (83%) 211 (83%)

Kaner et al

SLIDE 58

Proportion With AUDIT < 8

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Brochure + Advice + Counseling

0% 10% 20% 30% 40%

Baseline 6 months 12 months

Odds  Ratio 95% 

C. I.

p-  value 0.85 0.52 - 1.39 0.51 0.91 0.53 - 1.56 0.73 0.78 0.48 - 1.25 0.30 0.99 0.60 - 1.60 0.96

SLIDE 59

The Fallout …

“Alcohol screening and intervention did not decrease the percentage of patients drinking to excess”

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“SBIRT is dead in the water.”

Mark Willenbring, MD Addiction Psychiatrist, Allina Health Former Director, Division of Treatment  and Recovery Research, NIAAA

SLIDE 60

Why might the Kaner study be negative?

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2. “Only 57% of patients in the brief lifestyle counselling group actually

received the intervention, which could have reduced its potential impact.”

3. “It is possible that the lack of intervention differences may have been due

to unsuccessful implementation of the brief intervention protocols by the primary care clinicians.” 

Training: epidemiology, standard drinks, demonstrations of screening

and intervention, role plays, assurance of competence via skills checklist 

Fidelity: “The issue of intervention fidelity will be explored in an in-depth

qualitative (interview based) process study with clinicians from this trial,  which occurred after patient follow-up was completed.”

1. “Recruiting individuals into the study might reduce their drinking.”

SLIDE 61 61

Not a study of effectiveness of alcohol screening and intervention A study of effectiveness of training primary care physicians and nurses to deliver alcohol screening and intervention, where patients with risky or problem drinking are invited back for one intervention session

Kaner et al: The Bottom Line

SLIDE 62 62

Characteristics of Subjects in Recent Drug Intervention Trials

Saitz 

Age: 41 ± 12 years (mean ± standard deviation) 
Never married: 62% 
Medicaid or Medicare: 81% 
Mood disorder: 46% 
Self-help group participation in past 3 months: 18% 
Residential addiction treatment in past 3 months: 8%

Roy-Byrne 

Age: 48 ± 11 years (mean ± standard deviation) 
19% married 
9% employed, 64% disabled 
56% have diagnosed mental illness 
30% homeless for ≥1 night during the past 90 days 
30% DAST score of ≥7

Brief drug interventions appear ineffective for urban populations with high rates of 

poverty 
social instability 
disability 
mental health disorders 
drug dependence

They may be effective for

ther general healthcare

populations.

SLIDE 63 63

WIPHL’s Experience

15% decline in marijuana use  among 100+ patients 

Pre-intervention - health educator

interview in clinical settings 

Post-intervention - researcher

interview not shared with  clinicians, in which patients   reported higher lifetime  substance use

SLIDE 64

Binge Drinking and Drug Use are  Major Problems for Employers

64

US Binge Drinkers - 2010

Employed 

75%

SAMHSA, National Survey on Drug Use and Health, 2010

US Adult Drug Users - 2010

Employed  Full Time

48%

Employed  Part Time

18%

Out of  Labor Force 

21%

Unemployed 

13%

Employed 

66%

SLIDE 65

Alcohol Screening and Intervention:  Cost Savings

Fleming et al, 2000 (Project TrEAT):  $523 reduction in healthcare costs over the next year for $205 spent per primary care patient receiving an intervention Estee et al, 2010 (WASBIRT):  $4,392 net reduction in healthcare costs over the next year per disabled Medicaid patient receiving SBIRT in Washington State EDs Paltzer et al, 2015 (WIPHL):  $546 net reduction in healthcare costs over the next 2 years per Medicaid patient screened in Wisconsin primary care settings

SLIDE 66

Rankings of USPSTF  Preventive Services

66

Search: National Commission on Prevention Priorities

Which services would best … prevent disease, injury and death reduce healthcare costs?

1 Aspirin prophylaxis 2 Childhood immunizations 3 Tobacco screening & intervention 4 Alcohol screening & intervention

Alcohol screening & intervention  is ranked higher than: Blood pressure screening Cholesterol screening Diabetes screening Osteoporosis screening Cancer screenings Adult immunizations

R O I w i t h i n o n e y e a r !

SLIDE 67 67

6.0 5.5 5.0 4.5 4.0 Mean Drinks per Drinking Day Brief Advice  (4.7 ± 2.2 min) Motivational  intervention  (22.5 ± 10.4 min) Motivational  intervention  (22.5 ± 10.4 min)  plus booster  (28.0 ± 10.4 min) Base-  line 3 mo. 6 mo. 12 mo.

Field, Annals of Surgery, 2013

How should interventions be delivered?

Inpatients  with Alcohol  Related  Trauma

SLIDE 68

Outline

The problem SBIRT - an overview Screening Brief assessment

68

Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 69

Referral to Treatment - Alcohol

Meta-analysis of 13 studies on receipt of alcohol services after intervention: 

RCTs in medical settings 
Non-treatment seeking patients with unhealthy drinking 
Linkage to alcohol services 
English language

9 studies in US, others in Australia, France, Germany, Poland Settings: Hospitals, emergency departments, outpatient clinics Results: No effectiveness for … 

All patients
High-severity patients

69

Glass, Addiction, 2015

SLIDE 70 70

WIPHL’s Experience

Of about 1,500 substance-dependent  patients identified in general healthcare  settings by screening and the ASSIST completed an assessment or initial treatment session at a treatment program, despite availability of funding for patients who couldn’t afford treatment

n l y 1 0 %

SLIDE 71

Outline

The problem SBIRT - an overview Screening Brief assessment

71

Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 72

Brief Treatment

A few to several sessions intended to motivate, implement and sustain change Blurs with brief intervention plus follow-up For patients with moderate disorder For patients severe disorder who cannot or will not

btain treatment

Ideally delivered in general healthcare settings

SLIDE 73 73

“Less than a third of all people with alcohol problems receive treatment

f any kind, and less than

10 percent are prescribed medications.”

SLIDE 74

SLIDE 75 75

SBIRT Overview

Screen Brief Assessment Abstinence 

r low risk

High risk or mild to  moderate disorder Dependence or  severe disorder Brief Intervention Referral to Treatment Follow-up and Support

(Brief Treatment)

SLIDE 76

SBIRT - Adjusting the Model

Screen Brief Assessment Abstinence 

r low risk

High risk or mild to  moderate disorder Dependence or  severe disorder Brief Intervention Referral to  Treatment Follow-up and Support On-site medication-  assisted therapy

SLIDE 77

Outline

The problem SBIRT - an overview Screening Brief assessment

77

Intervention Referral to treatment Brief treatment Implementation & spread

SLIDE 78

Few Americans Receive Evidence-Based SBIRT

CDC:  1 in 6 Americans talked about their drinking with their healthcare providers in 2011 National Survey on Drug Use and Health:  72% of Americans underwent alcohol screening in 2013  Most with risky/problem drinking got no intervention

78 http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html  Glass et al, Unpublished, 2015

SLIDE 79 79

Prevalence – US Adults

The Problem:  >40% of Deaths and Most Chronic Disease

CDC, Behavioral Risk Factor Surveillance System, 2013; SAMHSA, National Survey on Drug Use and Health, 2013

Prevalence

0% 20% 40% 60% 80% 100%

29% 7% 9% 25% 19%

Smoking Binge  drinking Drug  use Depression Obesity

SLIDE 80 $0B $50B $100B $150B $200B $250B $300B

Smoking Alcohol Drug Use Depression Obesity

$73B $52B $120B $166B $156B $147B $26B $11B $25B $133B Healthcare Productivity Justice, Social, Crashes http://www.cdc.gov/nchs/data/nhis/earlyrelease/200812_08.pdf; http://www.oas.samhsa.gov/NSDUH/2K6NSDUH/2K6results.cfm#Ch3; http:// www.cdc.gov/NCCDPHP/publications/aag/osh.htm; www.ensuringsolutions.org; http://www.drugabuse.gov/NIDA_notes/NNVol13N4/ Abusecosts.html; http://www.cdc.gov/Features/AlcoholConsumption/; http://archives.drugabuse.gov/about/welcome/aboutdrugabuse/magnitude/

$342B $503B $100B

$945B

$34B $61B $5B

Costs of Behavioral Risks and Disorders 

– United States –

SLIDE 81

Who SHOULD do SBIRT?

81

No direct comparison studies Reviews:

Healthcare providers may get

slightly better outcomes than   paraprofessionals

May be differences in case mix

SLIDE 82

Who SHOULD do SBIRT?

82

No direct comparison studies Reviews:

Healthcare providers may get

slightly better outcomes than   paraprofessionals

May be differences in case mix

MOOT  POINT

SLIDE 83

Primary Care Providers Don’t Have Time

address 3 clinical issues in  a typical visit must delegate all prevention  services to serve expanding  elderly and insured patients

Issues Extra Time Tobacco 6 30 min. Alcohol 6 30 min. Drugs 2 10 min. Obesity 8 40 min. Depression 2 10 min. Total 24 120 min. Extra Time Per Day Needed to  Address Positive Screens for  24 Patients at 5 Minutes Per Issue

Primary care providers ...

Altschuler, Annals of Family Medicine, 2012; Beasley, Annals of Family Medicine, 2004;  Bodenheimer, Health Affairs, 2010

SLIDE 84

Workflow in Healthcare Settings

In clinics:

Medical assistant reviews screen Health educator  sees patient  at that visit Patients complete screen while  waiting

In EDs & hospitals, health educators introduce themselves and deliver services

SLIDE 85

Three federally funded projects:

$14M since 2006
Helped 44 clinics deliver BSI
Screened >100,000 patients
Delivered >25,000 interventions

Wisconsin Department 

f Health Services

Results: Patient satisfaction: 4.3 to 4.9 of 5 points Binge  drinking

20%

Marijuana  use

15%

Depression  symptoms

55%

Wisconsin Initiative to  Promote Healthy Lifestyles

Brown, American Journal of Managed Care, 2014; Paltzer, unpublished

Best outcomes: Bachelor’s-level HEs Savings per Medicaid pt screened: $546/2 yrs

SLIDE 86

Spreading SBIRT: What Hasn’t Worked

SLIDE 87

Facilitators and Barriers to Spread

87

Possible Facilitators Barriers

Medicare and the ACA   → ↑reimbursement

Reimbursement for services by paraprofessionals is patchy. 
Reimbursement is inadequate incentive.

Accountable care

rganizations (ACOs)
Most are busy establishing infrastructure and addressing

high-cost patients. 

Fee-for-service reimbursement will continue to dominate for

years. Patient-Centered Medical Homes (PCMHs)

PCMH recognition does not require delivery of SBIRT or

medication-assisted therapy for alcohol or opioid  dependence. Joint Commission quality metrics on SBIRT

Use of these quality metrics is optional.

Healthcare organizations are

verwhelmed with current

mandates for change Improvements in  behavioral healthcare must  compete with those mandates

SLIDE 88

The Quote Out of Context

88

“SBIRT is dead in the water.”

Mark Willenbring, MD Addiction Psychiatrist, Allina Health Former Director, Division of Treatment  and Recovery Research, NIAAA

SLIDE 89

The Full Quote

“SBIRT is dead in the water.”

Mark Willenbring, MD Addiction Psychiatrist, Allina Health Former Director, Division of Treatment  and Recovery Research, NIAAA

“Why SBIRT is Dead in the Water … Until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT [is] DOA …”

SLIDE 90 90

Current quality metrics can be met  without evidence-based service delivery

Completion of screening or brief validated  assessment questionnaires

3

Intervention delivery

3

Referral delivery

2

Pharmacotherapy recommendation

2

Follow-up contact

1

Treatment initiation and engagement

2

Drinking outcomes TOTAL

11 Brown & Smith, American Journal of Medical Quality, 2015

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Measures  indicate  whether  services are  delivered,  not how well

SLIDE 91 91

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 92 92

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+ Srecd = # of patients who received screening of those eligible Selig = # of patients eligible for screening Of patients who were eligible for screening, how many completed screening?

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 93 93

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+ Arecd = # of patients who received assessment S+ = # of patients with positive screens Of patients who were eligible for assessment because they screened positive, how many completed assessment?

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 94 94

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+ Irecd = # of patients who received an appropriate intervention   (including referral and pharmacotherapy) Of patients recognized with risky, problem or dependent drinking, how many received the appropriate intervention  (including referral and pharmacotherapy for dependence)? A+ = # of patients whose assessment was positive

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 95 95

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+ ∆Bactual = # of patients who manifested a certain level of  behavior change – eg, 20% reduction in risky drinking   days per month ∆Bexpected = # of patients expected to manifest that level of  behavior change based on prior research Of patients who received appropriate interventions,  how many manifested expected changes in drinking?

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 96 96

Q = Srecd Selig Arecd S+ x x ∆Bactual ∆Bexpected x

Screening Assessment Intervention Behavioral outcomes

Irecd A+

75% of eligible patients were screened
75% of patients with + screens completed brief assessments
75% of patients with + assessments received appropriate intervention
75% of patients who received appropriate intervention reduced their

risky drinking as expected

Q = .75 x

.75

=

.32

x

.75

x

.75

Population-Level Quality Measure for SBIRT

Brown & Smith, American Journal of Medical Quality, 2015

SLIDE 97 97

Payer withholds 2% of all revenue through each year True-up at end of year is based on quality metric  performance on SBIRT and other behavioral services:

Pay-for-Performance Program

Modeled after Medicare’s End Stage Renal Disease Quality Incentive Program

Performance At end of year,  payer pays… Net Poor Nothing Loss of 2% of revenue Fair 1% of revenue Loss of 1% of revenue Good 2% of revenue Break even Very good 3% of revenue Gain of 1% of revenue Excellent 4% of revenue Gain of 2% revenue}

4%  swing  in  margin

SLIDE 98

Summary

SBIRT clearly works for unhealthy drinking. SBIRT substantially reduces healthcare costs for unhealthy drinkers. SBIRT does not work for complex, disadvantaged, urban drug users. SBIRT might work for other drug users. More research is coming soon. The SBIRT model should expand to include pharmacotherapy and behavioral treatment for dependent patients in general healthcare settings. Strategies to implement SBIRT must take into account other behavioral healthcare needs in primary care/general healthcare settings. Strategies to spread SBIRT and similar services for other behavioral risks and disorders must go beyond fee-for-service reimbursement.

SLIDE 99

A Look at the Evidence  – and Gaps to Address

SBIRT:

wellsys.biz

Richard L. Brown, MD, MPH

Director of WIPHL  Professor of Family Medicine & Community Health School of Medicine and Public Health  University of Wisconsin CEO and Chief Medical Officer, Wellsys LLC

SBIRT:

MOOT POINT

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SBIRT:

MOOT  POINT