SBIRT in medical settings Jim Winkle, MPH Dept.

SBIRT in medical settings Jim Winkle, MPH Dept.

SBIRT in medical settings Jim Winkle, MPH Dept. of Family Medicine Oregon Health and Science University Funded by the Substance Abuse and Mental Health Services Administration Website: Demonstration videos Screening forms Billing code information

Pocket cards and tools Interactive training curriculum Role play handouts and slides SBIRT Screenin g Brief Intervention Referral to

Treatment A public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at risk of developing these disorders. SAMHSA Terms SBIRT Adults Brief screen AUDIT Method DAST

Adolescents Pregnancy CRAFFT 5Ps Populations Common screening tools I. Why SBIRT? SBIRT vs. business as usual Policy update on SBIRT Oregon: Medicaid performance measure for primary care and ED

settings Affordable Care Act: reimbursement for brief interventions Joint commission: Alcohol SBI plus drug treatment. Trauma centers mandated for alcohol SBI Relevance to medical settings Significant prevalence of

unhealthy alcohol and drug use Substantial associated morbidity, mortality, and health care cost Valid screening instruments Interventions are effective, inexpensive, and feasible Zones of substance use IV Severe Harmful III

Risky II I Low risk Zone I: Low risk Defined by: No use, or Adult alcohol use within low-risk limits Low-risk limits do not apply to drug use

IV III II I Low risk Adult low-risk limits for alcohol use in the U.S Drinks per week Drinks per day 14 4

Ages >65 7 7 3 3 Pregnancy 0 0 Men Women Commonly recognized limits in U.S

Standard drink contains .6 oz of pure ethanol NIAAA Standard drink: .6 oz. of ethanol Beer Malt liquor Volume Standard drinks 12 oz

16 oz 22 oz 40 oz 12 oz 16 oz 22 oz 40 oz 1 1.3 2 3.3 1.5 2 2.5 4.5 NIAAA Standard drinks, cont. Wine

Liquor (80 proof) Volume Standard drinks 5 oz 1 750-mL bottle 5 1.5 liter bottle 9 5 liter box

30 1 mixed drink 1 1 pint (16 oz.) 11 One fifth (25 oz.) 17 1.75 liters (59 oz) 39 NIAAA Adolescent low-risk limit for alcohol use: 0 Even first use can result in

tragic consequences. Adolescence is a period of neurodevelopmental vulnerability Earlier use increases chance of later addiction. AAP, 2011 Zone II: Risky Defined by: Alcohol use that exceeds low-risk limits Any adolescent use

Any recreational drug use Not (yet) dealing with consequences of use IV III II I I Risky Zone III: Harmful Defined by: Repeated negative consequences from use

Failure to fulfill some major obligations Use continues despite persistent problems Likely correlates with mild or moderate SUD IV III II I I Harmful

Zone IV: Severe Defined by: Patients life orbits around use Distress or disability Tolerance and withdrawal Use in larger amounts or longer period than intended Likely correlates with moderate

or severe SUD IV Severe III II I I Alcohol use among adult pts Emergency Room Primary Care Severe 26 % 74% Low risk

or abstention Harmful Risky 5% 8% 9% 22% Low risk: 38% Abstention: 40% Ann Emerg Med, 2007. Manwell, et. al, 1998 Alcohol use among adolescents 100 % 90 80 70

60 50 40 30 20 10 0 8th grade 12th grade Had a drink, last 30 days Had a drink, last year Been drunk, last 30 days Been drunk, last year

Been drunk, ever Johnston et al, 2013 Drinking among pregnant women, 2011-12 SAMHSA, 2013 Morbidity of unhealthy adult alcohol use: Liver cancer and cirrhosis Alcoholic Cardiomyopathy

Mouth and throat cancer Injuries Hypertension Pneumonia Breast cancer Gastritis/PUD

Coronary heart disease Cerebrovascular disease Contraindicates many medications Pancreatitis Stroke

Exacerbates numerous chronic medical conditions NIAAA, 2003 Exam room sheet illustration Depression. Anxiety. Aggression. Cancer of the throat and mouth Frequent colds and infections, increased risk of pneumonia Liver damage Erectile dysfunction, birth defects, developmentally delayed or low birth weight babies. Dependence. Insomnia. Memory loss. Premature aging. Hypertension. Heart failure. Anemia. Blood clotting. Breast cancer. Vitamin deficiency. Bleeding. Stomach inflammation.

Diarrhea. Malnutrition. Inflammation of the pancreas. Impaired sensation leading to falls. Painful nerves. Numb, tingling toes. Failure to fulfill obligations at work, school, or home. Car accidents. Legal problems. Prevalence of psychiatric disorders in people with alcohol abuse and dependence Abuse Dependence 1year rate (%) Odds ratio

1year rate (%) Odds ratio Mood disorders 12.3 1.1 29.2 3.6 Major depressive disorder 11.3 1.1

27.9 3.9 Bipolar disorder 29.1 1.7 36.9 2.6 Generalized Anxiety Disorder 1.4 0.4 11.6

4.6 PTSD 5.6 1.5 7.7 2.2 Comorbid Disorder NIAAA, 2002 Risks of adolescent alcohol and marijuana use Brain damage Pregnancy

Injuries STDs School Failure Later addiction Violence Stunted growth and fertility Arrests, Incarceration Suicide Sexual assaults NIDA, Office of the Surgeon General, NPR, CSAM, Hendershot et al, IBT GWU, 2007 - 2014

Leading Causes of mortality, ages 10-24 Motor vehicle crashes 30% Other unintentional injuries 16% Homicides 16% Suicides 12% Total 74%

All are associated with alcohol and drug use Eaton et al., 2010 Percent experiencing dependence in lifetime, based on age of first use, U.S. 100% 90 Alcohol 80 Marijuana 70 60 50 40

30 20 10 0 13 14 15 16 17 Age started using 18 19 20

21+ Hingson et al 2006, SAMHSA 2010 Risks of drinking or using drugs while pregnant Fetal alcohol spectrum disorders Birth defects Low birth weight Miscarriage Premature birth Future child development and behavior problems March of Dimes 2012 Past month drug use among adults 40 35 Percent

30 25 20 15 10 5 0 Age NIDA, 2014 Past year drug use among adolescents Salvia Ritalin Cocaine OxyContin MDMA Hallucinogens Cough medicine

Tranquilizers Vicodin Inhalants Synthetic marijuana Adderall Marijuana 0 % 8th grade 12th grade 5 10 15 20 25 30

35 40 NIDA, 2014 Drug use during pregnancy Around 5% Low-income and/or urban populations as high as 1530% Marijuana most common, followed by cocaine and opioids SAMHSA, 2014; Schempf and Strobino, 2008 Morbidity of adult illicit drug use Overdose

Hepatitis Psychotic symptoms Prenatal exposure: Low birth weight and diminished child development Addiction

Motor vehicle crashes Cardiac arrest STDs, HIV Co-morbidity with mental disorders Respiratory illness NIDA, 2012 - 2014 Interventions in medical settings

Positive reinforcement Brief intervention Referral to specialized treatment Brief treatment SAMHSA, 2013 Interventions and zones Severe Harmful

Risky IV III II I Referral to specialized treatment Brief intervention/referral Brief intervention Positive reinforcement Missed opportunities in health settings Percent of adults ever discussing alcohol use with a health professional: 16% of U.S. adults overall

17% of current drinkers 25% of binge drinkers 35% of those who binge drink 10 times in the past month CDC, 2014 Missed opportunities, cont. Study: Most adult patients (68-98%) with moderate or severe alcohol use disorders are not detected by physicians. Contributing factors:

Screening tools not used universally Assuming Caucasian, female, and higher SES pts less likely to have unhealthy alcohol use. Friedmann et al., 2000; Yersin et al., 1995; Wilson et al., 2002. Missed opportunities with adolescent pts 2343% of Peds and 14 27% of FPs routinely ask adolescent pts about alcohol use Less often with younger

pts 11-14 years old Screening quality varies Accuracy of clinical impressions of teen substance use 14-18 year old patients Sensitivity Specificity (CI) (CI) .63 .81

(.58-.69) (.76-.85) 109 medical providers Any use Adolescent Diagnostic Interview used as gold standard Any problem .14 1.0

(.10-.20) (.99-1.0) Any disorder .10 (.04-.17) 1.0 (.99-1.0) Dependence 0.0 1.0 Wilson et al., 2004 Perceived barriers to addressing alcohol use with patients

Belief that patients lie Time constraints Fear of questioning patients integrity Fear of frightening/angering patient Uncertainty about treatment

Personally uncomfortable with subject May encourage patient to see other MD Belief that Insurance doesnt reimburse PCP time CASA: 2000 SBI towards adult alcohol use More than 34 randomized controlled trials Focused primarily on at-risk and

problem drinkers Result: 13-34% reduction in alcohol consumption at 12 months Whitlock et al, 2004; Bertholet et al, 2005; Jonas, et al, 2012; ODonnell, et al, 2014; Kaner, et al 2009; Kaner, et al, 2007 USPSTF on alcohol SBI Class For both alcohol screening and brief intervention rating

Adults and pregnant women Insufficient evidence for adolescents B USPSTF, 2004 and 2013 Suitable methods of identification and readily learned brief intervention techniques with good evidence of efficacy are now available. The committee recommends broad deployment of identification and brief intervention. Institute of Medicine, 1990 Broadening the Base of Treatment for Alcohol Problems

SBI alcohol cost effectiveness 12-month study with 17 primary care practices Brief physician advice for problem drinking resulted in cost-savings of $523 per patient from reduced utilization of EDs and hospital Fleming, et al, 2000 Washington state SBIRT ER project

Two-year study in ER depts. Medicaid savings from pts receiving BI: $185-192 per member per month Due to less inpatient hospitalizations from ER admissions Estee, et al, 2008 Survey on adult patient attitudes Agree/Strongly Agree As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.

92% If my doctor asked me how much alcohol I drink, I would give an honest answer. 99% If my drinking is affecting my health, my doctor should advise me to cut down on alcohol. 96% Disagree/Strongly Disagree I would be annoyed if my doctor asked me how much alcohol I drink. 86% I would be embarrassed if my doctor asked me how much alcohol I drink. 78%

Miller, et al. 2006 Teen pts very likely to be honest on substance use screening form Paper Computer Doctor who pt does know Nurse who pt does know Doctor who pt

does not know All pts 95% 91% 90% 89% 84% 84% Pts with problem use 96%

92% 91% 90% 84% 85% Pts with SUD 91% 89% 83% 83% 80%

79% N=2133 Nurse who pt does not know Knight et al 2007 Performing preventative services in primary care To fully satisfy the USPSTF recommendations, 7.4 hours per working day is needed for the provision of preventive services. - Primary Care: Is There Enough Time for Prevention? American

Journal of Public Health Yarnall KS, et al. 2003 Alcohol SBI ranks high Nine highest-scoring preventative Score services 25 recommended preventative services Ranked on health impact and cost effectiveness Only 3 score higher than alcohol SBI

Aspirin chemoprophylaxis Childhood immunization series Tobacco-use screening and brief intervention 10 Alcohol screening and brief intervention Colorectal cancer screening Hypertension screening Influenza immunization Pneumococcal immunization Vision screeningadults 8 Maciosek, et al. 2006 II. Screening

Basic SBIRT workflow in primary care Exam room Waiting room Adult brief screen Reception CRAFFT AUDIT / DAST Medical assistant Exam room Brief intervention or

Referral to treatment Clinician Basic SBIRT workflows ED Bedside Triage room Adult brief screen Nurse CRAFFT AUDIT / DAST Nurse or Social worker Bedside

Brief intervention or Referral to treatment Social worker Video demonstration: Primary care workflow with behavioral health specialist Adult screening forms Brief screen AUDIT DAST Adult brief screen One alcohol question One drug question Single alcohol question Single item question recommended by the NIAAA Sens: 82% Spec: 79% for risky alcohol use McNeely , et al. 2015 Single drug question

Sens: 93% Spec: 94% for past year, self-reported drug use. McNeely , et al. 2015 Full screens AUDIT DAST SBI in the ED Typically delivered verbally by behavioral health specialist When theres a break in the action - waiting for x-rays,

labs or ready for discharge Best case scenario: warm handoff Pts may be more receptive to BHS than medical clinician and answer more honestly than in triage Warm handoff principles Direct introduction BI and/or RT delivered immediately

Colleague or someone who specializes in Avoid counseling label California Mental Health Services Authority, 2007 AUDIT Alcohol Use Disorders Identification Test Created by WHO, accurate across many cultures/nations

10 questions - multiple choice Addresses alcohol only WHO, 2001 Scoring the AUDIT Each question has five answer choices Answers correlate with points, totaled for score AUDIT zones and scores Severe Harmful Risky IV

III II Women and Men: 20+ Women: 13-19 Men: 15-19 Women: 4-12 Men: 5-14 I Johnson, et al., 2013 Circling the zone of use AUDIT zones and interventions Severe Harmful Risky IV III II

I Referral Brief intervention/referral Brief intervention No intervention Case study: Clark 68yo male, never married, retired, lives alone Mild hypertension and diabetes since 1999, not obese Presents twice a year for follow up, usually no medical complaints Latest visit: discloses drinking 10 beers a night at local bar Exercise

Take a minute to fill out an AUDIT, circling what you think might be Clarks responses. Clarks AUDIT answers: Questions 0 1. How often do you have a drink containing alcohol? Never 2. How many drinks do you have on a typical day when drinking? 1 or 2 3. How often do you have six or more drinks on one occasion? Never 4. How often during the last year have you found that you were not able to stop drinking once you had started?

1 2 3 4 or more Monthly 2-4 times 2-3 times 4 times a or less a month a week week 3 or 4 5 or 6 7 to 9 10 or more

Less than Monthly monthly Weekly Daily or almost daily Never Less than Monthly monthly Weekly Daily or almost daily 5. How often during the last year have you failed to do what was

normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than Monthly monthly Weekly

Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than Monthly monthly Weekly Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Clarks AUDIT score: 15 Full screen: DAST Drug Abuse Screening Test DAST-10 version

Validated for adults Cut-off score of 3 has high validity for drug abuse Skinner, 1982. Yudko 2007. Scoring the DAST Each question has yes or no answer Yes answers get one point Scoring the DAST

Questions added to the DAST Types of drugs used Frequency of use Injection drug use Status of drug treatment DAST zones and scores

Severe Harmful Risky IV III II I 6+ 3-5 1-2 DAST Risky zone Brief advice can substitute for brief intervention when pt reports: No daily use of any substance

No weekly use of opioids, cocaine, or meth No injection drug use in the past 3 months. Not currently in Drug Abuse Treatment. Case study: Stacey 30yo female, single, works at restaurant, lives with housemate Takes Aderall for ADHD since 2013 Presents every few months

for in-person follow up, usually no medical complaints. Uses a bump of cocaine most weekends Exercise Take a minute to fill out a DAST, circling what you think might be Staceys responses. x x Staceys possible DAST score x x DAST zones and

interventions Severe Harmful Risky IV III II I Referral Brief intervention/Brief treatment Brief intervention No intervention Brief interventions & drug use JAMA editorial:

Rigorous studies show null effect for BIs towards adult drug use in medical settings Exploring drug use with patients should remain a priority Research needed on SBIRT towards adolescents Hingson, et al, 2014 Adolescent full screen Front CRAFFT Back

PHQ-9 Modified for Teens PHQ-2 Oregon consent and confidentiality laws for teens Pts 15 can consent to medical services. (ORS 109.640) Oregon law does not give minors a right to confidentiality or parents a right to disclosure. Providers are encouraged to use their best clinical judgment over whether to disclose (ORS 109.650) OHA, 2012 When parents ask to review their minors records

Things to consider: Review your confidentiality policy with parents. Discuss the benefits of maintaining confidentiality Assure parents that their teen has been screened How does your clinic handle disclosure? CRAFFT screening tool Car Relax Alone Forget Friends Trouble Validated for: Adolescent patients, ages 12-17 Spanish-speaking and Native American teens Can be self-administered or clinician-administered Mitchell et al, 2014; Harris et al,

2015. Cummins et al 2003; Gomez, Interpreting the CRAFFT Score No to 3 opening questions Yes to car question CRAFFT score = 0 CRAFFT score = 1 CRAFFT score 2 Risk Recommended action No risk Positive reinforcement Riding risk

Discuss alternatives to riding with impaired drivers Medium risk High risk Brief advice Brief intervention Consider referral for further assessment (delivered through brief intervention) Levy and Kokotailo, 2001 Validity study of CRAFFT score 2 Sens Spec

PPV NPV Any problem use or SUD .79 .97 .84 .95 Mild SUD .91 .93 .64

.99 Moderate severe SUD .88 .87 .32 .99 N=525, ages 12-17 45% male, mostly African American

Setting: CHC in Baltimore Knight et al 2002 CRAFFT score: Car question Yes to the CAR question Teens should not drive even after a single drink often teens dont notice the early effects of alcohol Discuss safer alternatives Ask teen to take home the Contract For Life to discuss with parent(s) or adult. Offer to facilitate conversation. SADD, 2001 CRAFFT scores across sites CRAFFT score/ Specific question

All (n=213 3) Peds Adoles. Rural School clinic HMO Clinic Fam Prc clinic (n=747) (n=483) (n=499) (n=282) (n=122) 0 65% 78%

69% 58% 52% 42% 1 20% 15% 17% 26% 24% 28%

2 15% 7% 14% 16% 24% 30% Car 24% 15% 20%

29% 37% 46% Relax 10% 6% 8% 16% 14% 17% Alone

8% 4% 8% 8% 14% 12% Forget 10% 7% 10% 9%

14% 20% Friends/Family 7% 4% 8% 8% 9% 16% Trouble 7%

3% 7% 7% 14% 12% 12-18 year old pts presenting over 2 years in New England Knight et al 2007 5Ps screening tool Designed for pregnant women Asks about use by Parents, her Peers, her Partner, in her Past, and during her Pregnancy Also screens for tobacco, emotional health, and

intimate partner violence. Administered through interview Other validated tools: TWEAK and T-ACE (alcohol only) 5Ps screening tool Non-confrontational questions elicit genuine responses YES answers suggest need for a more complete assessment and possible treatment for substance abuse. Advise the client that the responses she provides are confidential. Other screening tools CAGE: poor sensitivity for risky drinking ASSIST: validated only as an administered survey, takes more time to

complete, but covers alcohol as well as drug use. MAST: poor sensitivity for risky drinking, 24 questions, outdated terminology towards substance use Incentive measure screening codes Service Full screen only Payer Medicaid & Commercial Medicare Code

Description CPT 99420 Administration and interpretation of a full screen. plus Z13.89 or Z13.9 G0442 Screening for alcohol misuse in adults once per year. 99420 must be used with one of two ICD-10 codes for inclusion in the CCO measure. Z13.89 may be used as a standalone code OHA, 2014

SBI billing codes in Oregon Service Full screen plus brief intervention Payer Code Med & Com. CPT 99408 Medicare G0396 Med & Com.

CPT 99409 Medicare G0397 No diagnosis codes necessary Use modifier 25 Description 15-30 minutes spent administrating and interpreting a full screen, plus performing a brief intervention. Same as above, only 30 minutes. Documentation supporting screening with

adult pts (CPT 99420) The patient completed a AUDIT alcohol screening tool today and the total score placed the patient into the Low risk zone of use. We did not discuss this further because the patient's low risk did not warrant further discussion. Documentation supporting screening with adolescent pts (CPT 99420) The patient completed a CRAFFT alcohol and drug screening tool today and the results indicate the patient has abstained from using alcohol or drugs in the last 12 months. In discussing this issue, I educated the patient about risks associated with adolescent substance use and gave positive reinforcement for continuing to abstain from using alcohol or drugs or ride in a car with an impaired driver. Documentation supporting

SBI with adults (CPT 99408) The pt was given a AUDIT screening form today. The total score placed the pt into the Risky zone of use. In discussing this issue, my medical advice was that the patient cut back to no more than 14 drinks per week or 4 per day. The pts readiness to change was 6 on a scale of 0 - 10. We explored why it was not a lower number and discussed the patients own motivation for change. The patient agreed to cut back and to make a follow up appointment in 8 weeks. Total clinic time administering and interpreting the screening form, plus performing a face-to-face brief intervention with the patient was greater than 15 minutes. Documentation supporting SBI with adolescent pts (CPT 99408) The patient completed a CRAFFT alcohol and drug screening tool today and the results indicate used alcohol or drugs with experiencing at least one related problem. In discussing this issue, I educated the patient about risks associated with adolescent substance use and recommended the patient abstain from using alcohol or drugs or ride in a car with an

impaired driver. The pts readiness to change was 3 on a scale of 0 - 10. We explored why it was not a lower number and discussed the patients own motivation for change. Total clinic time administering and interpreting the screening form, plus performing a face-to-face brief intervention with the patient was greater than 15 minutes. Who can independently bill for SBI Oregon Medicaid: Medicare:

Physicians Physician Assistants Nurse Practitioners Licensed Clinical Psychologists Licensed Clinical Social Workers Physicians (MD, DO only) Physician Assistants Nurse Practitioners Licensed Clinical Psychologists Licensed Clinical Social Workers Clinical Nurse Specialists

Certified Nurse Midwives OHA, 2014 Incident-to billing Any clinic employee under supervision can bill for SBI Examples: CADCs, Health Educators, Registered Nurses, Clinical Nurse Specialist, Students or Graduates entering medical profession, Community

Health Workers Some limitations apply OHA, 2014 SBIRT CCO measure Numerator: Denominator: SBIRT billing codes Medicaid visits of patients age 12 and older Perfect implementation: ~22% (based on prevalence stats.) OHA Benchmark: 12% OHA Improvement target: Reduction in the gap between previous years performance and benchmark by at least 3 percentage points. SBIRT ED measure

Screening rate: Brief intervention rate: # patients screened # patients receiving brief intervention # visits age 12+ # patients who score positive on full screen Hospitals must report both rates, and achieve either a benchmark or improvement target on the screening rate. OHA Benchmark: Brief Screen: 67.8% Full Screen: 12.0% OHA Improvement target: Reduction in the gap between previous years performance and benchmark by at least 3 percentage points.

Keys to implementing a sustainable SBIRT workflow Secure buy-in from leadership Identify workflow Train all staff involved Identify champions Optimize EMR

Employ tools III. Brief intervention Communication styles during the patient visit Directing Following Guiding Rollnick and Miller, 2008 How do you approach conversations about behavior change with your patients? Video demonstration: Directive style of communication towards

behavior change University of Florida, Psychiatry Dept. Directive communication towards behavior change Explaining why Telling how Emphasizing importance Persuading Rollnick and Miller, 2008

Common patient reactions to the Directive style Angry Agitated Oppositional Discounting Defensive Justifying Not understood Procrastinate Afraid Helpless, overwhelmed Ashamed Trapped Disengaged Not come back avoid Uncomfortable Not heard Rollnick and Miller, 2008

Characteristics of guiding communication Respect for autonomy, goals, values Readiness to change Ambivalence Patient is the expert

Empathy, non-judgment, respect Brief Interventions in medical settings Even 3 minutes can help Personal feedback may be active ingredient Can be performed by any trained clinic employee 2 hours of training can be

sufficient for providers to make difference Humeniuk et al, 2010. Cunningham et al, 2014. Whitlock et al, 2004. Motivational interviewing towards other health behaviors Meta studies: MI shows effects in improving health outcomes, including diet and exercise Burke, et al, 2003. Hettema et al, 2005 Steps of the brief intervention Raise subject

Provide feedbac k Enhance motivati on Negotiat e plan D`Onofrio, et al., 2005 Video demonstration: Brief intervention: Steve Steps of the brief intervention Raise subject

Screening forms act as conversation starters Ask permission Tell me about your substance alcohol/drug use Steps of the brief intervention Provide feedbac k State Zone of use Ask and explain connection between use and health

issue State low risk limits Give recommendation to reduce use or abstain Patient recommendations Zone of use Low risk Risky Harmful Severe Adult alcohol use

Adult drug use Adolescent use Positive reinforcement Reduce use Abstain Reduce use or Abstain Abstain Additional reasons to consider a referral - adults Prior history of substance use disorder Pregnancy Contraindicated medications Serious mental illness or

medical condition Additional reasons to consider a referral adolescents Patient 14 years old Daily or near daily use of any substance Alcohol-related blackout or substance use-related hospital visit Alcohol use with another sedative drug Steps of the brief intervention Enhance motivati on Ask and reflect about

perceived pros and cons of use Use the 0 10 scale Why not a lower number? Steps of the brief intervention Negotiat e plan If pt sounds ready, ask: What would that look like for you?

Re-state your recommendation Ask to schedule follow-up Reference sheets Adult Adolescent Pocket cards Adult Adolescent

Practice: Jill Groups of three: Physician Patient Observer Practice: Tom Groups of three: Physician Patient Observer Video demonstration: Brief intervention: Tom How ready are you to change your behavior? Brain Tumors And Cell Phone Use Found To Be Linked (Again) Hardell and Carlberg, 2014 Stages of change Relapse Precontemplation Contemplation

Maintenance Preparation Action IV. Referral to Treatment Treatment is underutilized 10.7% 14.0% (29,000 per year) (17,000 per year) Alcohol Oregonians age 12+ with abuse or dependence Illicit drugs

Same individuals who received treatment in last year SAMHSA, 2009 - 2013 DSM-5: new terminology Abuse, dependence or alcoholism are terms no longer used Official term: Substance Use Disorder A spectrum of 11 symptoms experienced in year Hasin, et al., 2013

11 SUD criteria Hasin, et al., 2013 Categories of substance use disorders 2-3 symptoms: mild 4-5 symptoms: moderate 6 or more symptoms: severe Hasin, et al., 2013

Substance use treatment Not everyone with substance use disorders needs the same treatment No need to wait until patients are ready to abstain and enter abstinence-based treatment before we treat substance use disorders. Brief treatment Some pts cannot or will not obtain conventional

specialized treatment BT can be performed in primary care or ED settings More numerous and comprehensive sessions than BIs Involves a combination of techniques SAMHSA Levels of treatment in specialty addiction clinics

Purpose: determine diagnosis and appropriate level of care: Level I: Outpatient treatment Level II: Intensive outpatient treatment Level III: Residential/inpatient treatment Level IV: Medically managed intensive inpatient treatment SAMHSA, 2006

Effective treatment options for AUDs: Counseling Medications Alcoholics Anonymous (AA) and other mutual help groups McCrady 2013; UK National Health Service, 2011; Veterans Administration, 2013. Counseling

One-on-one counseling or couples therapy Appropriate counseling reflects patients goals: Help patients assess their drinking and consider change, and support patients while they make changes. Help patients who want to abstain by teaching them skills to help prevent relapse. McCrady 2013; UK National Health Service, 2011; Veterans Administration, 2013; Magill & Ray, 2009 Support groups

Growing number of sober support options besides AA Peer support groups can improve treatment outcomes by helping pts develop relationships that support their drinking goals Participation in 12-step programs has been shown as effective as other proven treatments. Project MATCH, 1998 Video: Patient testimonials Types of adolescent treatment Outpatient:

Group Family Intensive outpatient Partial hospital program Inpatient/residential: Detoxification Acute residential treatment

Residential treatment Therapeutic boarding school AAP, 2011 Oregon laws towards minor consent and treatment Youth 14 years or older may initiate treatment without parental consent (ORS 109.6750) Providers are to involve the parents before end of treatment unless parents refuse or there are indications not to involve parents (ORS 109.6750) Providers may advise the parent /guardian of diagnosis of treatment of chemical dependency or mental disorder when

clinically appropriate and if condition has deteriorated (ORS 109.680) Confidentiality and the referral Consider: May be difficult for teen to manage treatment requirements without parent knowledge. Teens respond better to treatment when parents are involved. Insurance carrier may notify parent if insurance is under their name. Williams RJ, et al. 2000 Involving parents or trusted adults An adolescent who discloses heavy drug use may be

looking for help. Ask patient if parents or trusted adults are aware of drug use. If so, inviting parents into conversation may be easy. Special considerations when parents themselves use substances Involving parents in a referral Side with the teen when presenting information: Terra has been very honest with me and told me about her marijuana use. She has agreed to see a specialist to talk about this further. I will give you the referral information so that you can help coordinate.

Questions? Jim Winkle, MPH Dept. of Family Medicine Oregon Health and Science University [email protected]

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