Illustration of Statewide Adoption of NQF Standards: Identification of Substance Use Conditions

1. Illustration of Statewide Adoption of NQF Standards: Identification of Substance Use Conditions Rachel Gonzales, Ph.D. Thomas E. Freese, Ph.D. UCLA ISAP Substance Abuse Research Consortium 2009 Meeting Series

2. Presentation Objectives • Provide you with an overview of the NQF Domain I: Identification of Substance Use in relation to: • What we know? • California’s Response • History of SBIRT development • Current efforts • The future

3. What do we know?

4. Screening & Case Finding Evaluation process allows for determining whether an individual is at risk for or has an alcohol or drug problem Assessment & Diagnosis In-depth clinical process to determine the specific tx needs of the individual when “screening” identifies risk for an alcohol or drug problem NQF: Identification Domain

5. Identification of Substance Useis a Public Health Priority…

6. In Treatment ~1.8 million Abuse/Dependence ~22.3 million Misuse of Illicit Drugs ~ 19.9 million Misuse of alcohol ~ 126.8 million Challenges • Striking disconnect between the proportions of individuals reporting misuse of substances or diagnosed with substance abuse/dependence and those receiving treatment • Little attention has been paid to the latter “risk groups” (Klitzner et al., 1992; Fleming, 2002)

7. Targeting Latter Risk Groups AOD risk settings….

8. AOD Risk Settings • Health (including mental) Care • Primary care • Emergency Rooms/Trauma Centers [40% of visits are injury-related and 50% of them are alcohol-related (Nilsen et al., 2008)] • Educational institutions • Criminal justice settings • Others… • Dental offices

9. Research of Identification in Health Care Settings • CASA Health care study: included 650 primary care physicians with over 500 patients in tx for chronic diseases: • Findings: • LESS than 1/3 of PCP’s Screen for Substance Use • ~50% of patients said “PCP asked nothing of AOD use” • 10% said “PCP asked, but did nothing” Missed Opportunity: National Survey of Primary Care Physicians and Patients, the National Center on Addiction and Substance Abuse (CASA) @ Columbia University, NY 2000

10. Research of Identification in Health Care Settings • Results from a member survey of American Association for the Surgery of Trauma: • Majority (~50%) screen LESS than 25% of their patients • Issues: • >80 % no trainingin AOD screening • 75% not familiarwith standard screening instruments Arch. Surg. Vol 134, May 1999

11. A Public Health Early Intervention Solution:Screening, Brief Intervention & Referral to Treatment - SBIRT Identify patients who may not perceive a need for behavior change Focus on at-risk vs. dependent individuals Why SBIRT? Approaches are deemed an evidence based practice Approaches are clinically effective and cost-efficient

12. SBIRT Approaches: Definitions Screening: assesses the severity of substance use & identifies the appropriate response Brief Intervention: focuses on increasing insight & awareness regarding substance use and motivation toward behavioral change: Give feedback about screening results, inform patient about consuming substances, advise on and assess readiness to change, establish goals and strategies for change, and follow-up

13. SBIRT Approaches: Definitions Brief Treatment: consists of a limited number of highly focused and structured clinical sessions with the purpose of eliminating hazardous and/or harmful substance use -- usually increased intensity and shorter duration than traditional treatment Referral to Treatment: provides those identified as needing more extensive treatment with increased access to specialty treatment

14. SBIRT Approach Framework:Response Depends on Score* Screening Score Positive Screen Negative Screen Positive Reinforcement Moderate Use Moderate/High Use Abuse/Dependence Brief Intervention Brief Treatment Referral to Treatment *Severity & Consequences of use

15. Overall SBIRT Goals • Increases access to care for persons with or at-risk for substance use disorders • Improves linkages between at-risk & AOD settings • Fosters a continuum of care: integrates prevention, intervention, and treatment services Takes advantage of the “intervention moment…”

16. The Good News…It Works!

17. It Works! • Well supported in health care settings • Major impact on reducing morbidity & mortality • Saves $: each dollar spent on SBIRT saves 4 dollars in other health-related costs • So… • SBIRT required for certification of all Level I & II Trauma Centers • U.S. Preventive Services Task Force recommendsroutine SBIRT in primary care settings Babor & Kadden, 2005; Gentilello et al, 2005

18. Examples of Reductions in Morbidity & Mortality

19. Research To date: Mostly Alcohol Evidence for illicit drugs sparse…but promising Burke et al. 2003: Meta-analysis Bernstein et al. 2005: Randomized Controlled Trial WHO study 2008: Randomized Controlled Trial in multiple sites internationally Madras et al. 2009: SAMHSA program evaluation at multiple sites (intake vs 6 mo follow-up) Overall Findings: SBIRT efforts related to positive outcomes(abstinence, increased health, social, legal, economic, and vocational outcomes)

20. California Response How has California been responsive to initiatives that use ‘screening & case finding’ techniques to identify individuals with substance use disorders?

21. Importance of SBIRT in California? • SBIRT is a system change that will move a core mission of ADP forward… …moving the AOD system to a comprehensive and integrated continuum of services system model Source: UCLA ISAP State Treatment Needs Assessment, 2001.

22. SBIRT in the AOD Service Delivery Continuum of Care Prevention Primary Secondary Tertiary Reducing the probability that a substance use problem develops Minimizing the severity of a substance use problem if it occurs Minimizing the disability caused by substance use problems Intervention/Treatment Intervention Recovery Support Continuing Care Care Management Screening/Assessment Brief Intervention or Referral to Treatment Screening/Assessment Brief Treatment Treatment

23. Brief History: SBIRT Efforts in CA • California was selected as 1 of 7 states to participate in a national SBIRT demonstration project funded by SAMHSA (5-year cooperative agreement) – called CASBIRT • CASBIRT initiative • Administered by CA ADP • Managed by San Diego County, Alcohol & Drug Services AND San Diego State University, Center on Alcohol and Other Drug Studies & Services

24. What is the CASBIRT Model? • SBIRT implemented in trauma, emergency (chest pain urgent care), & primary care settings throughout San Diego County • Patients 18+ are routinely screened by certified Health Educators during their visit using a standardized, scripted screening instrument • SBIRT service response made depending on score • CASBIRT staff: conduct evaluation by tracking patients deemed as “at-risk”, provide follow-up booster calls, and facilitate their participation in appropriate services

25. CASBIRT Effectiveness • To date, over 500,000 patients have received SBIRT services in SD county • Between 2005-06 alone, SBIRT performed with 125,000 patients • 48% of high risk clients completed at least one Brief Treatment session • 74% stopped or reduced their substance use • Current status: funding by San Diego county AOD agency supported CASBIRT services through June 2009 (now looking to other grant mechanisms)

26. SBIRT in Educational Settings • SAMHSA Cooperative Agreement to implement SBIRT in College setting: UCLA Access to Care Project (2006-2009) • 1st pick: Student Health Center (although not interested) • 2nd pick: Counseling & Psychological Services • Given the prevalence of co-occurring substance abuse/mental health disorders, counseling centers are good places for early intervention • Serves over 6,000 students a year Spear & Rawson

27. Access to Care Project Team • SBIRT Implementation: UCLA Counseling & Psychological Services center clinical staff (n=28): • Psychologists & LCSWs • Interns (social work, post-docs) • Project Liaison: ensure proper implementation by clinical staff • SBIRT Evaluation: UCLA ISAP team (Spear, Rawson, Ransom) Spear & Rawson

28. SBIRT Implementation in Access to Care Project Student completes pre-screen at routine intake* AUDIT-C plus 1 question on illicit drug use in past 30 days *performed at Kiosk If +, clinician conducts ASSIST in 1st therapy session as well asbrief intervention (if deemed appropriate) Clinician refers student toUCLA ISAP Evaluation Pre-screen score tabulated by Kiosk computer • Students given ASSIST are GPRA’ed at intake & 6-mo follow-up Spear & Rawson

29. Access to Care Results • As of Oct 2008: 6,786 students coming for initial appointments were pre-screened • 38% of students scored positive • Of those who scored positive 60% received the ASSIST screen & brief intervention (n=1,442) Spear & Rawson

30. GPRA Results (2007) Spear & Rawson

31. 85% of binge drinkers (n=425) received a brief intervention 46% of binge drinkers reported no binging at 6-mo follow up GPRA Results: Binge Drinking Spear & Rawson

32. GPRA Results: MJ Use • 37% (n=303) of students reported any marijuana use in past 30 days at intake • Of these students, 87% (n=264) received a brief intervention • Half (53%) of marijuana users reported no use at 6-month follow up Spear & Rawson

33. Lessons learned: SBIRT in Educational Mental Health Settings • Has made mental health staff more aware of substance use issues among students • Offers mental health staff a more systematic approach for identification (less of a “judgment call”) • Allows college students to: • express concerns about their substance use • “shift their thinking” about their use Spear & Rawson

34. Lessons learned: SBIRT in Educational Mental Health Settings • Implementation challenges • Interrupts routine clinical flow: difficulty dedicating 15-20 minutes of customary 50-minute routine intake session to SBIRT • Not enough time to do (and score) SBIRT in routine assessments (generally 30 minutes) • To address: UCLA ISAP team developed & pilot-tested a self-administered computer version ofASSIST (which is now used) • Briefer, efficient, feasible Spear, S.E., Tillman ,S., Moss, C., Gong-Guy, E., Ransom, L., Rawson, R. Another way of talking about substance abuse: Substance abuse screening and brief intervention in a mental health clinic. In press. Journal of Human Behavior in the Social Environment.

35. Sustaining Implementation of SBIRT within College Campuses System-wide training across the State

36. 1st Training: March 2008 UCLA hosted and trained (1 day) 11 counseling centers on SBIRT & use of the ASSIST Spear & Rawson

37. Evaluation of 1st Training • Survey sent assessing implementation of the screening tool at their centers (n=11) • 7 centers responded: • 3 reported using the ASSIST • 4 reported not doing any screening, but indicated that they “intend to use” the ASSIST when they have more time and staff to develop a plan Spear & Rawson

38. 2nd Training: Oct 2008 • UCLA conducted day long SBIRT training with 7 additional colleges • Hosted at UCSF Spear & Rawson

39. Evaluation of 2nd Training • Survey sent related to implementation of screening tool • Only 2 implementing ASSIST • Barriers cited included: • Lack of time • Short staffed • Clinicians focused on other priorities • Limited resources • Need additional training • ASSIST doesn’t relate to students Spear & Rawson

40. Integrating SBIRT into California Trauma CentersTimeline: April 09-Nov 09 Under collaboration with ADP, UCLA is conducting large scale SBIRT training effort Series of day-long workshops on SBIRT with trauma centers, emergency departments & primary health care settings Trainings offered during Spring, Summer and Fall 2009 Participant Counties (n=9) Alameda Ventura Los Angeles Santa Clara Contra Costa Santa Barbara Fresno Solano Nevada Data collection: GPRA Freese & Rawson

41. Implementation by CASCs Homeless Healthcare LA Behavioral Healthcare Services Community Transition Unit Participants LA County Jail (Twin Towers) LA County Police Department (Parker Center) Evaluation: UCLA doing GPRA Integrating SBIRT in CA Criminal Justice Settings Rawson & Freese

42. Under a SAMHSA grant, ADP, LA County (DPH, ADPA) & UCLA are conducting a 2-year pilot demonstration project: Implementing SBIRT in 2 Community Transition Units Phase I: training staff on SBIRT & the ASSIST Phase II: Pre-screening all short-term stay detainees to identify AOD risk (low vs high) using AUDIT-C+ (3 etoh/2 drug) Phase III: ASSIST & BL GPRA Phase IV: Follow-Up (6-mo GPRA) Integrating SBIRT in CA Criminal Justice Settings Rawson & Freese

43. Criminal Justice SBIRT Flow Chart Twin Towers (n=5,000) GPRA 6-Month Follow-up Information and Referrals Provided Brief Intervention Referral if indicated Rawson & Freese

44. Under a SAMHSA initiative, UCLA partnered with California Rural Indian Health Board (CRIHB) to provide SBIRT training for tribal organizations Phase I: CRIHB identified specific tribal organizations and clinics interested in training (Oct 08 – Mar 09) N=24 Phase II: UCLA conducted SBIRT/ASSIST training with identified tribal organizations (2 large trainings: Apr 09 & Aug 09) Phase III: ASSIST implementation by tribal organizations Depending on tribal community desires: ASSIST will be conducted with paper and pencil, using a personal interview or via computers Phase IV: Evaluation of adoption in tribal communities (future) Integrating SBIRT in CA Tribal Settings Rawson, Freese, Dickerson

45. Professional Settings 8 Administration 7 Education 6 Addiction Counselor 5 Social Work/Human Services 2 Medicine 2 Psychology 1 Medicine-Primary Care 5 Other Agencies: 10 Gender: 20 Female; 5 Male Ethnicity/Race: 3 Hispanic/Latino 14 American Indian 6 White 3 Native Hawaiian/Pacific Islander 1 Asian Training Participants* *2nd Training evaluation in progress Rawson, Freese, Dickerson

46. Assessment & Diagnosis

47. What is Assessment/Diagnosis? Gathering information to: • Confirm the presence of an AOD problem • Identify the severity of the AOD problem & factors that affect AOD problems: • Social support networks • Employment • Health • Housing • Motivation to change • History of physical/sexual abuse • Mental illness status • Determine what services/treatment would be most effective

48. California Illustration II • Identification of Substance Use Disorders domain: Diagnosis and Assessment California initiatives that require or recommend the use of a standardized biopsychosocial tool(s) for diagnosing and assessing individuals with substance use disorders

49. Pilot Project Efforts Underway • UCLA-ADP COSSR Evaluation work • Alameda working on developing a framework to address this area • Issues: • Clarity on difference between assessment and diagnosis (where does placement fit in?) • Identification on specific instrument to use for each • Who should do the assessing & diagnosing? • Issues with staffing, training, conflicts of interest

50. Future Efforts • Continuing evaluation of current efforts • Establishing more funding to keep activities ongoing • Expanding partnerships into other diverse settings, i.e., EDD, dental offices, juvenile justice, high schools, etc. • White paper on SBIRT to disseminate CA experience