Screening and Brief Intervention E-Learning Module Draft

1. Screening and Brief Intervention E-Learning Module Draft

2. Module I:Overview • Alcohol use and health in NYC • What is SBIRT? • Core components of SBIRT testing • Reimbursement

3. Excess alcohol consumption is the third leading “actual” cause of death Actual Causes of Death, United States, 2000 Source: Mokdad AH, Marks JS, Stroup DF, Geberding JL, JAMA 2004;291:1238-1245

4. Nationwide, alcohol kills more than twice as many people as illicit drugs Source: McGinnis JM and Foege WH. Proc Ass Am Physicians 1999;111:109-118

5. Drinking patterns vary by neighborhood in NYC Estimated prevalence of Binge Drinking Estimated prevalence of Heavy Drinking

6. 1 in 10 of all hospitalizations in NYC are alcohol-related Any Alcohol Alcohol Dependence Alcohol Abuse Source: NYS DOH SPARCS, 2006

7. Alcohol-related ED visits are increasing in NYC Source: NYC DOHMH Syndromic

8. Among underage drinkers, alcohol-related ED visits have nearly doubled Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2008 (11/2009 update).

9. Alcohol-related ED visits are more common in particular neighborhoods

10. What is Screening Brief Intervention & Referral to Treatment (SBIRT)? An Evidence-based Model Program : - Identifying persons at ALL levels of alcohol and drug use through to dependence - Providing brief intervention to patients who are misusing alcohol and other drugs • Assessing patients who may be using alcohol and/or drugs to determine if they would be eligible for treatment • Referring patients who are probably alcohol and/or other drug dependent to addiction treatment. SBIRT is a Paradigm Shift from the traditional model of service provision to one that is more expansive, focusing on the “at-risk” individual for prevention and early intervention.

11. Substance use occurs along a continuum - SBIRT is grounded in this perspective

12. Core components of SBIRTSource: SAMSHA/CSAT, 2005

13. Overall, what do we hopeSBIRT will do? • Improve public health • Increase clinical knowledge • Decrease stigma • Prevent alcohol-related violence and interpersonal abuse • Reduce high risk behaviors • Prevent alcohol dependence

14. Benefits analysis(more than just cost-effectiveness) • SBIRT Effectiveness Reduce unhealthy drinking Reduce alcohol-related consequences • Morbidity & Mortality • Trauma (MVCs) • Lost wages • QoL (pt, family, society) • ED visits • Cost and burden to society

15. Are there codes that can be used for reimbursement? In January 2008, the AMA introduced new health care codes for substance abuse screening and brief intervention. Healthcare professionals now have four different codes that can be used in 2008 for screening and brief intervention (SBI). Two of the codes are for privately insured patients (99408 and 99409), and two for Medicare patients (G0396 and G0397). Fees are based on length of activity (15 -30 minutes; more than 30 minutes). The definitions of the Healthcare Common Procedure Coding System (HCPCS) codes focus on "assessment" instead of "screening." These codes, again, will only be used for people age 65 and above. The G-code definitions are "Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, ASSIST, DAST) and brief intervention, 15-30 minutes" for G0396, and "Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and intervention, greater than 30 minutes" for G0397. Note that Medicare calls the 15-30 minute intervention "brief," but does not use that same denomination for the longer intervention. The G codes also are defined as "assessment" instead of "screening". Medicare will instruct its carriers to pay for G0396 and G0397 "only when considered reasonable and necessary." For patients not covered by Medicare -in other words, patients under age 65 -the only codes healthcare professionals can now use are the Healthcare Common Procedure Coding System (CPT) codes. In some areas of New York State, private payers have already started to use these codes. But Medicare made it much easier for them to do so by publishing the RVUs (relative value units) for the CPT codes. These RVUs, when multiplied by the conversion factor, give the dollar amount payable per code. Since most payers rely on the Medicare fee schedule, at least as a jumping off point to set their own fees, the publishing of RVUs makes it much more likely that non-Medicare patients will get these services as well. Medicaid coding is in place, but requires each individual state Medicaid authority to "turn on" the codes. New York State had done so in January 2010 for Primary Care and Emergency Department settings. Source: http://www.oasas.state.ny.us/Admed/FYII sbirt. cfm

16. Screening and Brief InterventionDraft Module II SBIRT: The Components • Screening: Purpose of • Validated Screens: AUDIT/DAST-10/CRAFFT Scoring

17. 1. Purpose of Screening • Create a professional, helping atmosphere • Identify both hazardous/harmful drinking or drug use and those likely to be dependent • Use as little patient/staff time as possible in doing so • Provide information to patient(s) needed for choosing the appropriate intervention(s)

18. Screening Process • IS NOT a substitute for care of clients with a moderate to high level of abuse or dependence. • IS NOT a formal diagnosis of alcohol or drug dependence, but a reliable indicator of either the presence or absence of one. • IS an impartial tool used to engage and motivate clients who need specialized treatment to accept a referral for diagnostic evaluation and possible treatment.

19. What does “at-risk” mean for alcohol users? • National Institute on Alcohol Abuse and Alcoholism defines: - Men who drink more than 14 standard drinks per week or more than 4 drinks on occasion- Women who drink more than 7 standard drinks per week or more than 3 drinks on occasion

20. BUT I ONLY HAD ONE DRINK

21. Alcohol • Most people ask “What’s a Standard Drink?” 1 standard drink = 1 can of ordinary beer (e.g. 12 oz. at 5%) - OR - A single shot of spirits (whiskey, gin, vodka, etc.) (e.g. 1.5 oz. at 40%)

22. Alcohol (cont’d) A glass of wine or a small glass of sherry (e.g. 5 oz. at 12% or 3 oz. at 18%) - OR - A small glass of liqueur or aperitif (e.g. 2.4 oz. at 25%) *How much is Too Much? The most important thing is the amount of pure alcohol in a drink. These drinks, in normal measures, each contain roughly the same amount of pure alcohol. Think of each one as a standard drink.

23. Problem & Dependent Drinkers • Problem drinkers are persons who drink above NIAAA limits and also have one or more alcohol-related problems or adverse events • Dependent drinkers are persons who are unable to control their alcohol use, have experienced one or more adverse consequences of alcohol use, and have evidence of tolerance or withdrawal

24. Drinking Pyramid

25. Negative Effects of Alcohol

26. Effects of High-Risk Drinking • Vitamin deficiency, Bleeding, Vomiting, Diarrhea, Malnutrition • Trembling hands, Tingling fingers, Numbness, Painful Nerves. • Severe inflammation of the stomach and/or Ulcers • Inflammation of the pancreas. • Impaired sensation leading to falls. • Men: Impaired sexual performance Women: Risk of giving birth to deformed, developmentally disabled or low birth weight babies. • Numb, Painful nerves. • Physiological dependence.

27. Interviewing Styles • Approaches to screening: Motivational vs Confrontational

28. Effect of High-Risk Drinking • Psychological & Behavioral Concerns - Aggressive, Irrational behavior, Arguments, Violence, Depression, Nervousness, Substance Dependence, Memory Loss • Physiological Concerns - Premature aging, Drinker’s nose, Frequent colds, Reduced resistance to infection, Increased risk of pneumonia - Weakness of heart muscle. Heart failure, Anemia, Impaired blood clotting. Breast Cancer - Liver Damage - Dependence

29. Confrontational: - emphasis on acceptance of self as having problem; acceptance of diagnosis essential for change - emphasis on personality pathology which reduces personal choice, judgment and control Motivational: - less emphasis on labels; acceptance of labels unnecessary for change - emphasis on personal choice and responsibility for deciding future behavior Motivationalvs. ConfrontationalApproach

30. Confrontational

31. Confrontational: - present evidence of problems to convince patient to accept diagnosis - resistance is “denial” a trait requiring confrontation Motivational: - counselor conducts objective evaluation, but focuses on eliciting patient’s own concerns - resistance is an interpersonal behavior pattern influenced by counselor’s behavior Motivational vs. Confrontational Approach

32. Motivational

33. Confrontational: - resistance met with argumentation and correction - goals and strategies for change are prescribed for the patient since patient is seen as incapable of making sound decisions Motivational: - resistance is met with reflection - goals and strategies for change are negotiated between the patient and counselor; collaboration is vital Motivational vs. Confrontational Approach

34. 2.Validated Screens • Alcohol Use Disorders Identification Test (AUDIT) • Drug Abuse Screening Test (DAST) • Car, Relax, Alone, Family Friends, Forget, Trouble (CRAFFT for Adolescents)

35. Validated Screens 1. The AUDIT:Standardized, validated instrument • AUDIT is the acronym for Alcohol Use Disorders Identification Test • Developed in 1993 from a six-country World Health Organization (WHO) collaborative project as a screen for hazardous and harmful alcohol consumption. • It consists of 10 brief questions that effectively demonstrate levels of drinking behavior that become a springboard for intervention.

36. Using the AUDIT • Review Questions • Tips for Administering the Questions • Scoring • Interpretation and Recommendations

37. NOTE: Place graphic version of AUDIT C/10 with scoring instructions (PDF version). In place of the 2 following AUDIT slides

38. AUDIT: 10 Questions • How often do you have a drink containing alcohol? • How many drinks containing alcohol do you have on a typical day when you are drinking? • How often do you have 6 or more drinks on one occasion? • How often during the last year have you found that you were not able to stop drinking once you had started? • How often during the last year have you failed to do what was normally expected of you because of drinking?

39. AUDIT: 10 Questions (cont’d) • How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? • How often during the last year have you had a feeling of guilt of remorse after drinking? • How often during the last year have you been unable to remember what happened the night before because of your drinking? • Have you or someone else been injured because of your drinking? • Has a relative, friend, doctor, or other health care provider been concerned about your drinking or suggested you cut down?

40. Key Terms and Definitions for AUDIT

41. Domains and Item Content of Audit

42. Interpretation of AUDIT ScoreZoneDegree of Problems 0-7 I No Problems at this time 8-15 II Hazardous & Harmful Alcohol Use 16-19 III High Level of Alcohol Problems and Possible Dependence 20-40 IV Possible Alcohol Dependence

43. Questionnaire - Takes less time - Easy to administer - Suitable for computer administration and scoring - May produce more accurate answers Interview - Allows clarification of ambiguous answers - Can be administered to patients with poor reading skills - Allows seamless feedback to patient and initiation of brief advice Advantages of Different Approaches to AUDIT, DAST and CRAFFT Administration

44. Introducing the AUDIT “Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Because alcohol use can affect many areas of health (and may interfere with certain medications and treatment), it is important for us to know how much you usually drink and whether you have experienced any problems with your drinking. Please try to be as honest and as accurate as you can be.”

45. Considering the Patient • The interviewer is friendly and non-threatening; • The patient is not intoxicated or in need of emergency care at the time; • The purpose of the screening should be clearly stated in terms of its relevance to the patient’s health status;

46. Considering the Patient • The patient must understand that for the information shared to be of value the questions require truthful and accurate responses; and • Assurance is given that the patient’s responses will remain confidential.

47. Match AUDIT Score with type of response or intervention • Types of Brief Intervention: • Alcohol Education • Simple Advice • Simple Advice plus Brief Counseling and Continued Monitoring • Referral to Specialist for Diagnostic Evaluation and Treatment

48. Matching Risk Levels and Interventions Based on AUDIT Scores

49. 2.Validated Screens 2. Drug Abuse Screening Test (DAST) • Yudko E; Lozhkina O; Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment 32(2): 189-198, 2007. (24 refs.) • This article reviews the reliability and the validity of the (10-, 20-, and 28-item) Drug Abuse Screening Test (DAST). The reliability and the validity of the adolescent version of the DAST are also reviewed. An extensive literature review was conducted using the Medline and Psychinfo databases from the years 1982 to 2005. All articles that addressed the reliability and the validity of the DAST were examined. Publications in which the DAST was used as a screening tool but had no data on its psychometric properties were not included. Descriptive information about each version of the test, as well as discussion of the empirical literature that has explored measures of the reliability and the validity of the DAST, has been included. The DAST tended to have moderate to high levels of test-retest, inter-item, and item-total reliabilities. The DAST also tended to have moderate to high levels of validity, sensitivity, and specificity. In general, all versions of the DAST yield satisfactory measures of reliability and validity for use as clinical or research tools. Furthermore, these tests are easy to administer and have been used in a variety of populations.

50. NOTE: Place graphic version of DAST 10 with scoring instructions (PDF version). Eliminate next two DAST slides