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Primary Care Residency Initiative. Case example. Clark Smith’s semi-annual office visit. 68yo male, never married, retired accountant Known x 10years Hx HTN and mild DM2 since 1999, not obese Moved to Long Beach, WA 5 years ago

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Primary Care

Residency Initiative


Case example

Clark Smith’s semi-annual

office visit

  • 68yo male, never married, retired accountant

  • Known x 10years

  • Hx HTN and mild DM2 since 1999, not obese

  • Moved to Long Beach, WA 5 years ago

  • Now presents twice annually for DM/HTN f/u, usually no medical complaints


Case example

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


Case example

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.


Case example

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


Case example

I might have a few beers.


Case example

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


Case example

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


Case example

Oh, around 70.


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?


Intro to SBIRT it?

SBIRT:


Intro to SBIRT it?

  • The SBIRT method

Brief

intervention

Full screen

Annual screen

+

+

+

Brief

intervention + referral


Intro to SBIRT it?

Criteria for a good

screening procedure


Annual screen it?

Alcohol misuse among PC patients

Misuse

22%

Low risk or

abstention 78%

National Institute on Alcohol Abuse and Alcoholism


Intro to SBIRT it?

Stratified prevalence of alcohol use

among PC patients

5%

Dependent

8%

Harmful

9%

Risky

Low risk: 38%

Abstain: 40%

Manwell, Journal of Addictive Disease, 1998


Intro to SBIRT it?

Characteristics of

the Risky zone

  • At-risk for future consequences

    • • Large body of evidence that shows drinking at this level will lead to health problems or make existing problems worse

    • Pts can fall into this category based on quantity alone

    • Any illicit drug use puts pt at risk for legal or employment problems

IV

III

Risky

II

I


Intro to SBIRT it?

Characteristics of

the Harmful zone

  • Repeated negative consequences:

    • • Distress or disability

    • • Failure to fulfill major role obligations at work, school, or home

    • • Physical hazards, legal problems

    • • Use continues despite persistent problems

    • Characteristics correlate with criteria for DSM-IV diagnosis of alcohol abuse

IV

Harmful

III

II

I


Intro to SBIRT it?

Characteristics of

the Dependent zone

  • Patient’s life orbits around use:

    • • Use leads to distress or disability

    • • Tolerance and withdrawal

    • • Use in larger amounts or longer period than intended

    • • Persistent desire to quit (or failed efforts)

    • • Great deal of time spent using or obtaining substance

    • • Characteristics resemble criteria for DSM-IV diagnosis for dependence

Dependent

IV

III

II

I


Impact of alcohol it? misuse

  • Alcohol misuse associated with:

  • Chronic liver disease & cirrhosis

  • Eight specific cancers

  • Heart disease

  • Pancreatitis

  • Stroke

  • Injuries

  • Pneumonia

  • Seizures

  • Gastritis/PUD

  • Alcoholic Cardiomyopathy

  • Interacting with many medications

  • Exacerbating numerous chronic medical conditions (HTN, DM, PUD, etc.)

  • MMWR Weekly, 2004, Naimi, 2002


    Impact of alcohol it? misuse

    • Alcohol: Psychiatric co-morbidity

    Odds of co-occurrence of Current (12-month)

    NIAAA, 2004.


    Impact of alcohol it? misuse

    Alcohol impacts society

    • HOMELESSNESS

    • Vagrancy and the problems of Skid Row

    • IMPACT ON CHILDREN

    • School Failure

    • Neurotic and Behavioral Disorder

    • Delinquency

    • PUBLIC ORDER AND

    • AMENITIES

    • Public Drunkenness

    • Noise, Hooliganism

    • Public Disorder

    Alcohol

    misuse

    • MARITAL PROBLEMS

    • Physical Abuse

    • Sexual Abuse

    • Psychological Stress

    • Marital Breakdown

    • CRIME & PUBLIC SAFETY

    • Drunk Driving,

    • Assault and

    • Acquisitive Crime

    LIFESTYLE ISSUES

    Diet, Exercise, Smoking

    Center for Substance Abuse Treatment


    Impact of alcohol it? misuse

    The 10 Leading Risk Factors for Disease In Developed Countries

    Percent of disability-adjusted life years

    The World Health Report 2002


    Impact of alcohol it? misuse

    • Public spending on substance use

    NY TIMES May, 2009:

    • Government spending related to smoking and the abuse of alcohol and illegal drugs reached $468 billion in 2005, accounting for more than one-tenth of combined federal, state and local expenditures for all purposes.

    • Most abuse-related spending went toward direct health care costs or for law enforcement expenses, including incarceration.

    • Just over 2% of the total went to prevention, treatment and addiction research.

    “This is such a stunning misallocation of resources,”

    • Joseph A. Califano Jr., Chairman

    • National Center on Addiction and Substance Abuse.


    Evidence behind SBIRT it?

    Evaluations of SBIRT

    Meta-analyses & reviews:

    • More than 34 randomized controlled trials

    • Focused primarily on at-risk and problem drinkers

    • Result: 10-30% reductionin alcohol consumption at 12 months

    Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005


    Evidence behind SBIRT it?

    • Effectiveness of SBIRT example:


    Evidence behind SBIRT it?

    SBIRT effectiveness

    • Fewer hospitalizations & ER visits

    • Cost savings:

    Fleming, et al, 2002


    Evidence behind SBIRT it?

    • USPSTF on SBIRT

    • For both alcohol screening and brief intervention

    • Same level of recommendation as flu shots and cholesterol screening

    Class

    B

    rating

    USPSTF, 2004


    Evidence behind SBIRT it?

    “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 (20 years ago!)

    “Broadening the Base of Treatment for Alcohol Problems”


    Missed opportunities in primary care

    Missed opportunities in primary care it?

    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

    Buchsbaum et al., 1992; Yersin et al., 1995; Wilson et al., 2002.


    Hypothetical patient physician survey
    Hypothetical Patient – Physician survey it?

    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


    Hypothetical patient top 5 physician diagnoses
    Hypothetical patient: it? Top 5 physician diagnoses

    Missed opportunities

    CASA, 2000


    Missed opportunities it?

    Clinician barriers to discussing alcohol with patients

    CASA: Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, April 2000


    Overcoming barriers it?

    Survey on patient attitudes

    Miller, PM, et al. Alcohol & Alcoholism; 2006


    Notes from a phone call: it?

    “Called pt to let her know that BH can give her information to help with counseling resources. Pt reported that she was very impressed by the diagram her provider showed her about the safe amount to drink, and after she got home she decided she needed to wean herself off the beer slowly. She reported she was drinking a 12 pack a night, now is down to 5 beers a night and plans to keep decreasing the amount. She also reported she has gotten involved in a community action effort and is stoked about it.”


    Prevention and primary care
    Prevention and primary care it?

    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, Pollak AI, et al.. 2003


    Sbirt and prevention
    SBIRT and prevention it?

    Overcoming barriers

    SBIRT ranks in the top 5 highest-ranking preventive services, based on effectiveness and clinic burden.

    • Current levels of SBIRT delivery, meanwhile, are the lowest of comparably ranked services.

    Leif, et al. 2008


    Overcoming barriers it?

    Medical home: SBIRT

    • Vital Signs Study:

      • Clinicians were 12x more likely to intervene if nurses screened for at-risk drinking as part of vital signs.

    • Healthy Habits Study:

      • Clinicians were 3x more likely to intervene with at-risk drinkers if given assessment results by the nurse.

    Seale et al., Subst Abus., 2005; Seale, et al., Fam. Prac., 2005


    Overcoming barriers it?

    SBIRT is reimbursable


    Clark tells me his drinking 70 beers a week isn’t causing him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.


    Annual screen him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    • The SBIRT method

    Brief

    intervention

    Full screen

    Annual

    screen

    +

    +

    +

    Brief

    intervention + referral


    Annual screen him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Annual screen

    • Quick screen of all patients >18 years old:

    • Purpose: Identify pts who are likely misusing substances

    • One alcohol question

    Misuse

    • One drug question

    Healthy


    Annual screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Annual screen: Alcohol

    • Single item question recommended by the NIAAA

    • Sens: 82% Spec: 79% for risky alcohol use

    Smith, et al. 2009


    Annual screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Standard drinks

    National Institute on Alcohol Abuse and Alcoholism


    Annual screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Standard drinks, cont.


    Annual screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Clark’s annual alcohol screen: positive


    Annual screen: him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future. Drugs

    Annual screen: drugs

    • Sens: 93% Spec: 94% for self-reported current drug use.

    Smith, et al. 2010



    Full screen him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    • The SBIRT method

    Brief

    intervention

    Full screen

    Annual Screen

    +

    +

    +

    Brief

    intervention + referral


    Full screen him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Full screen

    The full screen stratifies patients into zones of misuse:

    Full screen for alcohol (AUDIT)

    Full screen for drugs (DAST)

    IV

    III

    II

    I

    • Zones act as a diagnostic aid and inform intervention


    Full screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Full screen: Alcohol

    • AUDIT(Alcohol Use Disorders Identification Test)

    • 10 questions - multiple choice

    • Addresses alcohol only

    • Created by WHO, accurate across many cultures/nations

    • Sens: 51% - 97% Spec: 78% - 96%

    Agency for Healthcare Research and Quality, 2004


    Full screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Scoring the AUDIT

    • Each question has five answer choices

    • Answers assigned points and totaled


    Full screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Circling the zone of use

    I II III IV

    0 8 16 20


    Scores and zones him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    AUDIT zones and scores

    IV

    20+

    Dependent

    16 - 19

    III

    Harmful

    8 - 15

    II

    Risky

    I

    0 - 7

    Low risk or

    Abstention


    Exercise

    Exercise: him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Take a minute to fill out an AUDIT, writing what you think might be Clark’s responses.

    Full screen: Alcohol


    Full screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Clark’s possible AUDIT answers:


    Full screen: Alcohol him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Clark’s AUDIT score: 15

    I II III IV

    0 8 16 20


    Clark example

    Clark example: him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    If SBIRT was in place during Clark’s visit:

    Annual screen would have identified Clark as likely misusing alcohol, rather than relying on a clinician interview.

    Full screen would have stratified Clark as a risky user (a clinician may have assumed Clark was dependent based on quantity alone).


    Full screen: Drugs him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Full screen: Drugs

    • DAST (Drug Abuse Screening Test)

    • Addresses drugs only

    • Validated for screening adults

    • Sens: 82-96% Spec: 81-91%

    Skinner, 1982. Agency for Healthcare Research and Quality, 2004


    Full screen: Drugs him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Percent of illicit drug users with

    dependence or abuse

    National Survey on Drug Use and Health, 2007


    Full screen: Drugs him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Scoring the DAST

    • Each question has yes or no answer

    • Answers assigned points and totaled


    Exercise1

    Exercise: him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Imagine a patient who smokes marijuana once a month, but no other drug use.

    Take a minute to fill out a DAST using what you think might be this patient’s responses.

    Full screen: Drugs


    Full screen: Drugs him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Imaginary patient’s DAST Score: 1

    I II III IV

    0 1 3 6


    Scores and zones him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Zones and scores

    IV

    AUDIT: 20+ DAST: 6+

    Dependent

    AUDIT: 16-19 DAST: 3-5

    III

    Harmful

    AUDIT: 8-15 DAST: 1-2

    II

    Risky

    I

    Low risk or

    Abstention


    Scores and zones him any problems right now, but this much beer sure sounds like it’s enough that it will hurt him at some point in the future.

    Zones and interventions

    IV

    Advise referral

    Dependent: 5%

    III

    Harmful: 8%

    Brief intervention

    II

    Risky: 9%

    I

    Low risk or abstention

    No intervention


    How can I best help Clark cut back or stop drinking so he won’t have health problems from this?


    To be continued. . . . . won’t have health problems from this?


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