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Primary Care Residency Initiative

Addressing Substance Use in Primary Care Through SBIRT Jim Winkle, MPH Oregon Health and Science University Dept. of Family Medicine. Primary Care Residency Initiative. Website. www.sbirtoregon.org. Clark. 68yo male, never married, retired accountant Known x 10years

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Primary Care Residency Initiative

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  1. Addressing Substance Use in Primary Care Through SBIRT • Jim Winkle, MPH • Oregon Health and Science University • Dept. of Family Medicine Primary Care Residency Initiative

  2. Website www.sbirtoregon.org

  3. Clark • 68yo male, never married, retired accountant • Known x 10years • Hx HTN and mild DM2 since 1999, not obese • Presents twice a year for DM/HTN f/u, usually no medical complaints

  4. Hi Clark. How’s the beach retirement going? What do you do with your time up there?

  5. I usually hit golf balls on the beach in the morning and spend a couple hours playing pool at the bar before I go home for dinner.

  6. That sounds great. Do you drink much when you’re playing pool at the bar?

  7. I might have a few beers.

  8. Interesting! In an average week, how many beers would you guess you might drink?

  9. Hmmm . . . 1, 2, 3, 4 . . .

  10. Oh, around 70.

  11. Wow. Clark doesn’t seem to think this is a big deal. Is it? And what can I do about it in our 15 minute diabetes f/u visit?

  12. SBIRT Referral to Treatment Screening Brief Intervention • An evidence-based method to intervene in unhealthy alcohol and drug use, but underemployed in medical settings.

  13. Our project • OHSU project • SAMHSA grant in 2008 • Implemented SBIRT in seven clinics over three years • Trained over 400 residents, faculty, and staff • Designed training tools and screening forms widely adopted around the country

  14. Clinics in our project Our project

  15. Why SBIRT? Why implement SBIRT? • High prevalence of unhealthy alcohol and drug use • Significant morbidity, mortality, and cost • Screening instruments work • Brief interventions effective, inexpensive, and acceptable

  16. Why SBIRT? SBIRT Business as usual VS. Routine and universal screening Inconsistent and selective assessment Validated screening tools Non‐systematized narrative questions Alcohol use seen as a continuum Alcohol use seen as dichotomous Evidence-based, patient-centered change talk Ineffective, directive style of communication Transition between primary care and treatment Discoordinate/unclear referrals and follow up

  17. Why SBIRT? • Update on SBIRT • Oregon Medicaid performance measure • Affordable Care Act requires coverage for two brief interventions towards alcohol use. • Joint commission: Alcohol SBIRTplus drug treatment. • Trauma centers mandated for alcohol SBI at different levels

  18. Unhealthy alcohol use Unhealthy alcohol use among PC patients Unhealthy use: 22% Low risk or abstention: 78% NIAAA. Manwell, 1998

  19. Unhealthy alcohol use Stratified prevalence of alcohol use among PC patients 5% Dependent 8% Harmful 9% Risky Low risk: 38% Abstain: 40% Manwell, et. al, 1998

  20. Zones of use Risky zone • • Risky drinking likely leads to new health problems or makes existing ones worse • This zone defined by quantity alone • Any illicit drug use is risky IV III Risky II I

  21. Zones of use The Harmful zone • Repeated negative consequences • Failure to fulfill major obligations • Use continues despite persistent problems • Associated with “alcohol abuse” IV Harmful III II I Donovan, et al. 2006

  22. Zones of use The Dependent zone • Patient’s life orbits around use • Distress or disability • Tolerance and withdrawal • Use in larger amounts or longer period than intended • Persistent desire to quit (or failed efforts) Dependent IV III II I Donovan, et al. 2006

  23. Unhealthy alcohol use • Unhealthy alcohol use associated with: • Chronic liver disease & cirrhosis • Eight specific cancers • Heart disease • Pancreatitis • Stroke • Injuries • Pneumonia • Seizures • Gastritis/PUD • Alcoholic Cardiomyopathy • Interacts with many medications • Exacerbates numerous chronic medical conditions (HTN, DM, PUD, etc.) MMWR Weekly, 2004, Naimi, 2002

  24. unhealthy alcohol use • Risks of unhealthy drinking, cont.

  25. unhealthy alcohol use • Alcohol: Psychiatric co-morbidity • Odds of co-occurrence of Current (12-month) Grant., et al, 2004

  26. Prevention • Public spending on substance use NY Times 2009: • Government spending related to substance use reached $468 billion in 2005. • Most spending went toward direct health care costs or law enforcement, including incarceration. • Just over 2% of the total went to prevention, treatment and addiction research.

  27. Evidence behind SBIRT Evaluations of SBIRT Meta-analyses & reviews: • More than 34 randomized controlled trials • Focused primarily on at-risk and problem drinkers • Result: 13-34% reductionin alcohol consumption at 12 months Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

  28. Evidence behind SBIRT • USPSTF on SBI • For both alcohol screening and brief intervention • Adults and pregnant women • Insufficient evidence for adolescents Class B rating USPSTF, 2004 and 2013

  29. Evidence behind SBIRT Other health behaviors • Meta-analysis: • Growing evidence that MI technique effective towards diet and exercise Burke, et al, 2003

  30. Evidence behind SBIRT SBIRT effectiveness • Fewer hospitalizations & ER visits • Cost savings: Fleming, et al, 2002

  31. Evidence behind SBIRT Washington state SBIRT ER project • 2003-2008 study implementing SBIRT 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

  32. Evidence behind SBIRT “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 (23 years ago!) “Broadening the Base of Treatment for Alcohol Problems”

  33. Missed opportunities in primary care Missed opportunities • Most patients (68-98%) with alcohol abuse or dependence are not detected by physicians • Physicians are less likely to detect alcohol problems: • When screening tools are not used universally • In patients who they do not expect to have alcohol problems: whites, women, higher SES Friedmann et al., 2000; Yersin et al., 1995; Wilson et al., 2002.

  34. Hypothetical Patient – Physician survey Missed opportunities “A patient is a married, 38-year-old male/female with recurrent abdominal pains. He/she has intermittently elevated blood pressure, and gastritis visible on gastroscopy, as well as waking up frequently at night and irritability. He/she also reports normal libido, and no previous psychiatric history. Based on this information alone, what are the top five diagnoses that come to mind?” - Survey of a nationally representative sample of 648 primary care physicians CASA: Missed Opportunity, 2000

  35. Hypothetical patient: Top 5 physician diagnoses Missed opportunities CASA, 2000

  36. Overcoming barriers Clinician barriers to discussing alcohol with patients CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000

  37. Overcoming barriers Survey on patient attitudes Miller, et al. 2006

  38. Prevention and primary care Overcoming barriers “To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 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

  39. Only 3 preventative services rank higher than alcohol SBIRT Overcoming barriers 25 recommended services ranked on health impact and cost effectiveness Maciosek, et al. 2006

  40. Overcoming barriers SBIRT is reimbursable Full screen only Brief intervention only Full screen plus Brief intervention

  41. Clinic workflow • Clinic workflow Full screen Brief Intervention or BI plus referral Annual screen + +

  42. Clinic workflow • SBIRT clinic workflow example http://www.youtube.com/watch?v=YM0G6bfBjUc

  43. Annual screen Annual screen • Quick screen of all patients >18 • One alcohol question Unhealthy • One drug question Low-risk or abstention

  44. Annual screen: alcohol Annual screen: Alcohol • Single item question recommended by the NIAAA • Sens: 82% Spec: 79% for risky alcohol use Smith, et al. 2009

  45. Annual screen: alcohol Rates of positive responses to single alcohol question • 4 OHSU clinics, during 2011

  46. Annual screen: alcohol Standard drinks NIAAA

  47. Annual screen: alcohol Standard drinks, cont.

  48. Annual screen: alcohol Clark’s annual alcohol screen: positive

  49. Annual screen: drugs Annual screen: drugs • Sens: 93% Spec: 94% for self-reported current drug use. Smith, et al. 2010

  50. Annual screen: drugs Rates of positive responses to single drug question • 4 OHSU clinics, during 2011

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