Lost Opportunity? SBI for Substance Abuse In ERs and Trauma Centers

1. Lost Opportunity? SBI for Substance Abuse In ERs and Trauma Centers Academy Health Mady Chalk, Ph.D. Treatment Research Institute June, 2006

2. What’s the Problem? • Disasters such as Hurricane Katrina and the attacks of September 11 affect substance abuse treatment systems in several ways: • Increasing the intensity and need for intervention for those currently involved in treatment; • Increasing a return to treatment for those who previously received treatment services; • Increasing the use and misuse of alcohol, illicit drugs and prescription and nonprescription medications by those who may never have used or misused these substances previously.

3. What’s the Problem? • For Individuals Exposed to Trauma: • Four to five times greater risk of substance abuse • Tendency to “self-medicate” • Use of alcohol or drugs provides only temporary relief • Leads to lower functioning, poor decisions, behavioral dysfunction, and exaggerated anxiety and fears

4. What Seems To Be The Problem? • For Healthcare Settings To Provide SBI Following a Disaster or Traumatic Event: • Lack of reimbursement and codes • Reluctance of medical professionals to screen and provide a brief intervention • Where to refer (if needed) and how to track patients • Inhibitory effect of insurance statutes (UPPL) for SBI in emergency rooms and trauma centers

5. What Seems To Be The Problem? • For the Substance Abuse Treatment System: • Planning for Subacute, Acute and Chronic Reactions • On-Going Communication with Primary Care Centers, ERs, and Trauma Centers • Capacity To Provide Treatment on Demand for Newly Identified Individuals • Ability to Implement Specialized Outreach to Traumatized Individuals and Those in Recovery Who are Vulnerable to Relapse

6. What Do The Data Show From Previous Traumatic Events? • Five to Eight Weeks Post 9/11: • 30% reported an increase in substance use • 20% reported at least one additional drink per day • People who reported increases in use were more likely to be diagnosed in addition as having PTSD and depression (Vlahor, D., 2004; 2002)

7. What Do The Data Show From Previous Traumatic Events? • Post Oklahoma City Bombing: • 20% used alcohol to cope • 40% used increased medication to cope • Alcohol consumption 2.5 times greater in Oklahoma City than in control community (Smith et al., 1999) • Two years following, documented increases in the need for treatment services and elevated substance abuse (CASA, 2001)

8. What Do We Know About Costs? • Economic evaluation studies commonly convert outcomes in natural units (e.g., reduced hospitalizations) into dollars to show costs and benefits. • All studies to date demonstrate cost savings and cost offsets: • Project TREAT: Primary Care (Fleming, 2003) • Trauma Center (Gentillelo, et al. 2005) • Inpatient Med/Surg (Storer, 2003)

9. What Do Guidelines Say? • Clinical practice guidelines of the following professional medical societies recommend SBI for substance abuse: • Amer. Psychiatric Association • Amer. Academy Of Pediatrics • Amer. Academy Of Family Physicians • Amer. Academy Of Child and Adolescent Psychiatry • Amer. Society Of Addiction Medicine

10. What Do Payers Say? • Major payers have developed practice standards and specific recommendations to use SBI: • Magellan • United Healthcare • National Business Coalition on Health eValue8 RFI • National Business Group on Health • CMS

11. What Do Quality Improvement Groups Say About SBI ? • Washington Circle Group: Is creating quality measures for SBI to be used by health plans. • National Quality Forum: Has found SBI to be a proven category of evidence-based practice. • Forum on Performance Measurement for Mental Health and Substance Abuse: Is developing consumer surveys to assess experience of care for SBI.

12. And Underlying These Problems Are: • Discriminatory Health Insurance Coverage e.g., Coverage in ERs • Beliefs of Clinicians About Alcohol and Drug Use Following Trauma • Stigma • Unwillingness of Individuals to Identify Themselves Even Following Traumatic Events

13. So, What Really Is the Problem? • Care of Chronic Conditions (Disease Management): Where is substance abuse? • Care of High-Risk Medical Conditions Following Trauma: Where is substance abuse? • Preventable Admissions (i.e., identifying patients at risk for emergency admissions): Where is substance abuse?

14. Care of Chronic Conditions • Where are individuals with these conditions most likely to show up following a trauma? • What do clinicians know about how to treat substance use disorders as chronic conditions ? • What can we do to assist specialty, primary care, ERs, and trauma centers to communicate across settings? • Policy • Practice

15. Care of High-Risk Conditions Following Trauma • Assuring Identification • Capacity of Healthcare System to Provide Brief Intervention, Referral, and Connection with Specialty Treatment Programs • Capacity of the Healthcare or Specialty Treatment System to Provide Brief Therapy

16. Preventable Admissions • For individuals who are at risk for relapse, the availability of SBI in primary care settings can prevent ER admissions. • There are “teachable moments” following accidents and other traumas. • Trauma centers and ERS often miss these “moments.” • Use of SBI in these settings can often prevent admission to inpatient substance abuse treatment facilities.

17. In Summary • Discriminatory health insurance, stigma, lack of knowledge and skill, and difficulty linking systems of care have combined to create significant missed opportunities to identify and treat substance use disorders. • Focus needs to be on policy and practice initiatives in which substance use disorders are viewed as chronic diseases and as high-risk conditions holding the potential for preventable hospitalizations.