APNC Fall Conference 2012

1. SBIRT : Strategies for Implementation APNC Fall Conference 2012 Carolina Beach, NC October 17, 2012 John Femino, MD, FASAM, MRO Medical Consultant, Dominion Diagnostics Medical Director, Meadows Edge Recovery Center NE Regional Director, American Society of Addiction Medicine Sponsored by: Dominion Diagnostics

2. Treatment Gap: Hidden and Underserved It has been known for many years that the "treatment gap" is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2007, 23.2 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 3.9 million received treatment at a specialty substance abuse facility. • NIDA. Principles of Drug Addiction Treatment: A Research Based Guide; http://www.drugabuse.gov/PODAT/faqs2.html#faq7 , accessed : December 9, 2010.

3. Reasons for Screening • High prevalence in population • 10-20% of outpatient PCP patient settings • 20-40% of inpatient hospital settings • Leading cause of morbidity/mortality • Most problems are behavioral • Most problems are hidden • Provider underestimation of prevalence • Lower PCP referral rate to substance abuse and mental health programs • <5% of SA referrals come from health providers

4. Early Symptoms of Substance Abuse • Primarily behavioral • Usually hidden unless specifically asked for • Requires careful history taking • Few physical findings • Most routine hematology and chemistry tests are normal • Laboratory tests of most value for improved diagnosis are drug and alcohol testing

5. The Hidden Problem and Solution • Rhode Island ranks #1 in the nation for last 7 years for underage drinking and fatal auto accidents • <5% of substance abuse treatment referrals come from physicians • Screening for behavioral problems (alcohol and drug use, anxiety, depression and eating disorder) in a primary care office is effective for identification and referral into behavioral health treatment • Screening and brief intervention (SBI) are recommended for well child and routine medical visits by multiple professional national associations and governmental agencies • Total cost of untreated behavioral health problems exceed that of direct treatment costs • SBI is cost effective and saves $2 to $7 for each $1 spent • Despite cost effectiveness and benefits, SBI is underutilized with multiple barriers for implementation within PCP and Pediatricians practices

6. NON-PROBUSE AT-RISKUSE ABST ABUSE DEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, physical dependence - - - + -/+ - + + + + - - + ++ + +

7. General Hospital Intervention Program • Physician leadership • Administrative support • Self help groups on location • On site treatment resources • Employee policy and EAP services • Screening of admissions • Staff integrated within hospital systems • Employee education – awareness week • Ongoing medical / professional education • Recovering staff as advisory group

8. Definition: SBIRT SBIRT = integration of systematic screening for early intervention and treatment • For patients with or at high risk for substance use and mental health disorders • Multiple health care settings • Before more severe consequences occur

9. SBIRT : Core Components • Screening: Questions to identify problems • Brief Intervention: Education and feedback about risk status • Brief Treatment: Discussion of need for change • Referral: Referral to substance abuse and mental health therapist/program for specialized evaluation and treatment

10. Why Care About Mild-Moderate Cases? SBIRT SBIRT Primary Prevention Brief Intervention Specialized Treatment Referral Challenges Dependence Problem users - Abuse Infrequent use Drug Involvement Abstinence Adapted from Broadening the Base of Alcohol Treatment (IOM)

11. Effective Identification of Substance Use Disorders • Always screen for disorders • Recognize prevalence of problems • Look for associated conditions / problems • Take personal and family history • Corroborate results • Have non-judgmental attitude • Drop stereotypes • Motivational counseling + brief intervention

12. Who Should Be Screened? • All patients • Positive family history of abuse/addiction • With risk factors (including ADD) • Associated problems • Accidents - overdoses • Emotional and behavioral problems – • Anxiety, depression, eating disorders and substance abuse • Family problems • Kids already in trouble • Juvenile justice systems • Identified in schools – SAP • Oppositional and problem kids • Special education – ADD • Involved in drug culture • School drop outs • Child welfare involvement

13. SCPI – Goal & Mission • Assist and support medical community • Education and information about substance abuse and behavioral health problems • Early Identification of behavioral health problems through screening and brief intervention • Assessment, treatment recommendations and intervention • Referral to behavioral health specialists • Monitor compliance with behavioral health treatments

14. Goals of Behavioral Health Screening Project • Develop pilot project in pediatrician and primary care physicians offices in South County to implement screening and brief intervention (SBI) • Develop screening tool for substance abuse, depression, anxiety and eating disorder • Train staff on screening and brief intervention • Implement screening protocol at selected practices • New or established patients for annual well child visits • Collect prevalence data • Conduct key informant interviews to determine implementation issues and barriers towards expansion of program to all pediatricians and PCP’s in Rhode Island • Document impact of SBI on rates of identification and referral • Monitor patient compliance with referral recommendations

15. Provider Barriers to Screening • Time constraints – extend routine office visit • Money – how to reimburse for screening • Stigma-Fear of alienating patient or family • Hopelessness re: treatment effectiveness • Inadequate training on substance abuse • Inadequate dissemination of information about effectiveness of treatment and consequences of failure to treat • Lack of knowledge of local resources

16. Parental Barriers to Screening • Belief that use of drugs and alcohol = experimentation • Time constraints will interfere with well child visit • Stigma-Fear of labeling patient or family • Insurance labeling via Medical Information Bureau (MIB) create lifelong stigmatization and place in high risk category for life, disability or health insurance eligibility or premium ratings • Confidentiality and self incrimination issues • Lack of knowledge about effectiveness of treatment and consequences of failure to treat

17. Screening Instruments • Evidence for reliability and validity • Which population utilized? • Setting under which developed • Intended use of instrument • Ease and manner of use • Trained staff • Costs of materials to administer and score • Self administered, computer assisted • Subject self assessment vs. family evaluation • Substance abuse or general problems • Focused vs. multidimensional

18. Screening and Brief Intervention • Screen for hidden condition by use of standardization screening instrument • CAGE • MAST • DAST • AUDIT • CRAFFT • SCPI – RISAM • Any other instrument with documented validity and accepted through literature

19. CRAFFT(Riggs & Alario; Knight) Drivencarwhile intoxicated? Use torelax, feel better or fit in? Ever use while you arealone? Do any closefriendsuse? Do any closefamilymembers have problems from using? Ever gotten introublefrom using? 2+ endorsements

20. Medical v. Non-Medical Screening Issues • Knowledge of patient and family over time • Genetic and family history known to clinician • Screening questions compared to medical record • Past treatment or referral known • Problematic behaviors recognized or treated in past • Older sibs may have received treatment • Parent or grandparents may be in recovery • Snapshot vs. movie – context of screening in relation to knowledge of family • Hidden indicators of problems – missed appointment, lack of follow up of previous recommendations, high risk behaviors

21. Development of BHS Instrument • Need for one page with estimated testing time < 10 min • Self administered, assisted by staff is necessary • Combined mental health & substance abuse screening instrument • Multidimensional assessment scales • Depression • Anxiety • Eating disorder • Alcohol abuse • Drug Abuse • Associated conditions

24. BHS-Crafft, SA, Depression+Anxiety

25. BHS-Audit + Eating Disorder

26. Psychometric Valid v. Clinician Concern • Anxiety and depression scores developed from validated scales • Individual item severity vs. total score • Cutoff scores – sensitivity and specificity are established for non-medical and can be lowered for individual items or high risk patients i.e. – patient with family history of alcoholism/substance abuse who is actively using - ? Experimentation or early development of problems • Pattern analysis between scales • Substance abuse, affective and high risk behavior • Knowledge of genetic type of parental problem – ie early onset addiction in context of adolescent using and involved in other high risk and problematic behavior = problem until proven otherwise

27. Screening Score Interpretation • Set point of threshold = positive • Below cutoff = no problem • Above cutoff = problem or potential problem • Set point dependent upon selection biases • Lower cutoff = increase sensitivity, lower specificity (higher false positive rate) • Raise cutoff – decrease sensitivity & increase specificity (increase false negative rate)

28. Receiver Operating Characteristics: ROC • Set point of threshold of positive • Below cutoff = no problem • Above cutoff = problem or potential problem • Set point dependent upon selection biases • Lower cutoff = increase sensitivity, lower specificity • Raise cutoff – decrease sensitivity and increase specificity • Positive predictive value

29. Screening & Brief Intervention Procedure • Determine eligibility for screening • Identify primary prevention office visits • Provide screening instrument instructions prior to provider examination • Monitor or assist patient self administration • Review, score and interpret guestionnaire results • Discussion of test results with patient and family • Provide education and instruction by risk category • Hand out educational and interventional packages • Referral to behavioral health treatment provider

30. Screening Procedure • Determine eligibility for screening • Ask patient/parent to sign permission form • Hand out primary prevention educational packages • Provide screening instrument to patient • Two sites – attach to chart • One site – keep in exam room • Have physician score form in office • Physician discuss results with patient/parent • Education and referral

31. Onsite Education v. Return Visit • Primary prevention material to all patients • Package obtained from community TASC force • National Clearinghouse • Local resources • Insurers • Secondary prevention –targeted information • Optional and individualized • Read

32. Training of Office Staff • Overview of SBI project • SCPI description and role in community • Review of screening instrument • Screening protocols – who does what when • Referral options • Data collection • Location of screening tool- notebook binder or chart • Consent form and confidentiality issues • Identify concerns and training needs • Training on Motivational Interviewing • Two hour introduction and one hour advanced skill training

33. Usual Patient – Physician Discussion • Physician Role • Most often pattern = Don’t Ask, Don’t Tell • Judgmental style of questioning – “Do you drink too much” • Focus on symptoms and not feelings and behaviors • Confrontational – Shame and Blame • Tell the patient – direct instruction vs. listening to conflict • Patient Role • Most patients are not resistant to honestly answering questions about feelings and behaviors • Fear of being rejected or change in physician behavior • Want to understand PCP role and relation to specialist

34. Five Principles of Motivational Interviewing • Express Empathy • Avoid Argumentation • Develop Discrepancy • Roll with Resistance • Support Self-efficacy (Miller and Rollnik)

35. Stages of Changes & SBIRT

36. Scoring & Intervention Recommendation

39. Preliminary Data (N=886) • Total Number of eligible patients • % refused to sign permission • % exceeded threshold (screened in) • One scale • Two scales • Three scales • Relationship between scales • Relationship between individual items (deferred)

40. Age Distribution : All Sites

41. Rate of Screening Positive by Test type % At Risk Screening Tests Sample size = 866 51% were age 15 or younger

42. Process Evaluation-Screening Procedure • Office manager / parent advocate • Acceptance of appointment for return office visit • Provide information / contact referral source • Contact with insurer – behavioral health authorization • Document availability and timing of referral appointment • Monitor referral compliance • Contact family to verify compliance with appointment • Ask family if insurance coverage problems • Ask family if treatment recommendations accepted • Time required for office staff to monitor compliance

44. Checklist and Qualitative Key Informant Interviews • Purpose – capture process of using BHS tool • Length of time to take • Need for parental assistance • Section for office staff, provider, and manager/researcher • Whether counseling was given for individual items • Need for follow up visit • Referral information • Follow up information

45. Confidentiality Wording • Lots of discussion re: wording of confidentiality • Need for absolute confidentiality = secret • Separate confidentiality of questionaire answers from recommendation for additional info/referral • Return visit = indirect acknowledgement of problems • Confidentiality of patient in revealing parental problems • Requesting additional forms and consent may create less interest in participating • Honesty of answers may be jeopardized if patient believes that parents will be told results of testing • Need for separation of BHS questionnaire from medical record • Progress note report of screen completed with suggested recommendations • Separate binder/chart of questionnaire • 42 CFR apply to assessment as distinct from treatment for a diagnosed problem • Need for report from behavioral health provider to be kept in separate section or along with other consultations

46. Process Evaluation: Treatment Comliance • Did patient/family return for office visit to discuss changes based upon SBI • Were educational materials helpful • Did referral source communicate with referring physician – telephone, report, interagency • Family satisfaction with referral • Identify barriers to follow up • Transportation • Lack of coverage and ability to pay for co-pay • Office hours • Treatment resistance

47. Time Necessary for Self Administration • Screening administration and scoring • Time to fill out screening instrument • Age, education, language, reading functions • < 10 minutes if patient is >15 years old • > 15 minutes if patient is <15 years old • Scoring of tests and documentation of screening results • Intervention & Referral to treatment • Interpretation and discussion of results • Low score - Informational and educational • Moderate - Instructional & Interventional • High - Referral to Behavior Health

48. Impressions of Staff in Utility of SBI • Two of these practices were considered the “gold standard” of community based pediatricians in awareness of and inclusion of behavioral health questions during their standard well child visit Despite this sensitivity and skills: • Use of standardized guestionnaire significantly increased pediatricians ability to conduct interview compared to unstructured clinical interview • “I’ve known this family for two generations and have taken care of this child since birth and asked behavioral health questions at each visit including today, and I was astonished to see how many positive items were noted on the scale compared to my clinical interview” • “The guestionnaire helps me during my interview – It warmed the patient up and helped me guide questions to the appropriate area” • “What I thought was experimentation, was NOT” • “I want to continue to use it, but we can’t afford to continue”

49. Pre-Post SBI Implementation Issues Pre Post

50. Most Effective Interventions • Training of office staff on SBI implementation and integration into medical office workflow • Provision of ongoing support to office staff • Provision of educational materials, collection of data and on-site collaboration with research and support staff • Focus group presentation and discussion • Review and feedback of study data • Analysis of scheduling and coding procedures • Impact of SBI implementation on office workflow • Costs of resources and time for SBI • Identification and quantification of implementation barriers