SBIRT Community Health Centers NACHC Conference February, 2010 Reed Forman, MSW SAMHSA

Drinkers’ Pyramid Dependent At-Risk Drinkers Low Risk Drinkers Abstainers AT RISK DRINKERS: targeted group, most likely to respond to intervention, and represents greatest savings in care use and prevention.

Problems of Alcohol Misuse Physical Problems Brain Damage Withdrawal Fits Peripheral Neuritis Musculoskeletal System Heart Hypertension Peptic Ulcers Cirrhosis, Hepatitis Pancreatitis Skin Diseases Endocrine, Sexual Problems Obesity Malnutrition Dental Problems Avitaminosis Cancers Immune Suppression Blood and Bleeding Disorders Trauma Foetal Damage Public Order and Public Amenities Public Drunkenness Noise, Hooliganism and Public Disorder Psychological Problems Dementia Impairment of Impulse Control Depression Jealousy Alcohol Dependence DTs Alcoholic Hallucinosis Marital Problems Physical Abuse Sexual Abuse Psychological Stress Marital Breakdown Impact on Children School Failure Neurotic and Behavioral Disorder Delinquency Homelessness Vagrancy and the problems of Skid Row Intersection with Drug Problems Two-way Switch From Alcohol to Illicit Drugs Iatrogenic Benzodiazepam Problems Crime and Public Safety Issues Drunk Driving, Assault and Acquisitive Crime Lifestyle Issues Diet, Exercise, Smoking The Drinker ALCOHOL MISUSE People on whom the drinking impacts

SBIRT Components SCREENING: SCREENING: Universal – Upstream Public Health Approach Universal – Upstream Public Health Approach Validated tools: AUDIT, DAST, ASSIST, (prescreen large populations) Validated tools: AUDIT, DAST, ASSIST, (prescreen large populations) BRIEF INTERVENTION: BRIEF INTERVENTION: Score Risky: 1-5 sessions, non-judgmental interaction, teachable moment Score Risky: 1-5 sessions, non-judgmental interaction, teachable moment BRIEF THERAPY: BRIEF THERAPY: Score Hazardous/Abuse: 5-12 sessions, CBT/MI oriented Score Hazardous/Abuse: 5-12 sessions, CBT/MI oriented Assessment, education, problem solving, coping mechanisms, social sup. Assessment, education, problem solving, coping mechanisms, social sup. REFERRAL TO TREATMENT: REFERRAL TO TREATMENT: Score Abuse/Dependence: refer to specialty treatment system Score Abuse/Dependence: refer to specialty treatment system Develop formal linkages with local specialty providers Develop formal linkages with local specialty providers Critical aspect for successful SBIRT program Critical aspect for successful SBIRT program

SBIRT Core Components Screen Identification of substance related problems Brief Intervention Raises awareness of risks and motivates client toward acknowledgement Referral to Tx Referral of those with more serious addictions Brief Treatment Cognitive behavioral work with clients who acknowledge risks and are seeking help

SCREENING TOOLS: AUDIT ALCOHOL USE DISORDERS IDENTIFICATION TEST ALCOHOL USE DISORDERS IDENTIFICATION TEST 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 6 or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 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? 7. How often during the last year have you had a feeling of guild or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before you had been drinking? 9. Have you or someone else been injured as a result of your drinking? 10. Has a relative or friend, or doctor or other health worker been concerned about your drinking or suggested you cut down?

Washington State Screening, Brief Intervention, Referral and Treatment (WASBIRT) Program Client Flow Diagram WASBIRT Program in Hospital Emergency Departments & other Hospital Depts.  Chemical Dependency Professional (CDP) screen patients for substance use, abuse or CD issues  Use the AUDIT and DAST 10 screening tools  Determine initial course of action: screen & feedback; brief intervention (BI) or BI + a referral  Enter screening data (AUDIT, DAST) & demographics into Research & Data Analysis (RDA) dataset WASBIRT Brief Intervention & Referral Process  CDP gives patient a Brief Intervention (BI)  This service is 100% WASBIRT funded  CDP completes Max four sessions in ED or clinic  Data on BI services entered in RDA data set  If screen scores are moderate, then give BI & collect demographics & 30-day use  If screen scores are high, then give a BI + referral to BT & collect full GPRA Patient arrives at Hospital Patient Hospital Emergency Department plus other Depts. CDP screener Brief Therapy WASBIRT Brief Therapy Process  Patients go to a chemical dependency treatment agency for Brief Therapy (BT)  This service is 100% WASBIRT funded  Program consists of 5 to 12 sessions & usually includes an assessment to see if CD tx is needed  Data on BT reported to TARGET2000 using Client Support Activities using Contract Type and Support Activity codes  Report GPRA tx services data & discharge status data to RDA WASBIRT Chemical Dependency Treatment Program  Patient referred for regular CD Tx  Service may or may not be funded by WASBIRT  Client enters contracted CD Tx agency  Program is an existing CD tx program  Data is reported to TARGET2000 like any other CD tx client using Contract Type and County Special Project codes  Report GPRA tx services & discharge status data to RDA CD Treatment Collect demographic data Give feedback Screening Scores? Low Moderate or High Brief Intervention DSHS|RDA November 15, 2005 SBIRT: Example of Patient Logic Model/Flow Diagram

SBIRT Process OUTCOME MEASURES: the effectiveness of the SBIRT program is determined by reporting on social/behavioral changes occurring between intake and follow up. OUTCOME MEASURES: the effectiveness of the SBIRT program is determined by reporting on social/behavioral changes occurring between intake and follow up. INTAKE: universal pre/screen: GPRA INTAKE: universal pre/screen: GPRA FOLLOW UP: 6 months, GPRA FOLLOW UP: 6 months, GPRA OUTCOMES: health, employment, criminal justice, stable housing, abstinence, social connectedness. OUTCOMES: health, employment, criminal justice, stable housing, abstinence, social connectedness.

Top Substances Used Substance % Used Alcohol70.3% Marijuana25.2% Cocaine12.3% Heroin4.8% Methamphetamine4.1%

GPRA Data Intake Performance Combined State SBIRT intakes: Combined State SBIRT intakes: Over 1 million screened.  103% of GPRA target goal for intakes Combined College SBI intakes: Combined College SBI intakes:  9,029 individuals (as of 10/29/08)  100.4% of GPRA target goal for intakes.

Change in Behavioral Risk Behavioral Risks IntakeFollow-upChange Abstinence from drugs/alcohol 15.1%40.2%166.2% No drug/alcohol related health or behavioral consequences 49.4%83.4%68.8% Employed or attending school 37.5%45.0%20.0% Injected illegal drugs 3.5%1.7%-51.9% Had unprotected sexual contact with intoxicated person 28.5%13.2%-53.8%

SAMHSA SBIRT 2003: Awarded 7 State/Tribal Entities. 2003: Awarded 7 State/Tribal Entities. 2005: Awarded 12 College/University awards to combat college aged drinking. Set in health centers, student service organizations, Greek system. 2005: Awarded 12 College/University awards to combat college aged drinking. Set in health centers, student service organizations, Greek system. 2006: Awarded 4 State grants 2006: Awarded 4 State grants 2008: 2008: 4 State/Tribal Entity grants. 4 State/Tribal Entity grants. 11 Medical Residency SBIRT Training grants. 11 Medical Residency SBIRT Training grants. 2009: Awarded 6 additional Medical Residency grants. 2009: Awarded 6 additional Medical Residency grants.

SAMHSA SBIRT 2004 – 2009: 2004 – 2009: Served 943,568 clients Served 943,568 clients 82% received screening only 82% received screening only 14% received Brief Interventions (BI) 14% received Brief Interventions (BI) 2% received Brief Treatment (BT) 2% received Brief Treatment (BT) 2% received Referral to Specialty Treatment (RT) 2% received Referral to Specialty Treatment (RT) Top 5 Substances Used (reported at intake for clients receiving either BI, BT or RT): Top 5 Substances Used (reported at intake for clients receiving either BI, BT or RT): Alcohol 13% Alcohol 13% Marijuana/Hashish 5% Marijuana/Hashish 5% Cocaine/Crack 1% Cocaine/Crack 1% Heroin 1% Heroin 1% Methamphetamine 1% Methamphetamine 1%

SAMHSA SBIRT National Outcome Measures (NOMS): National Outcome Measures (NOMS): Abstinence increased (no substance use in last 30 days): Abstinence increased (no substance use in last 30 days): 144% for BI;359% for BT; 389% for RT 144% for BI;359% for BT; 389% for RT Criminal Justice (reported no arrests last 30 days): Criminal Justice (reported no arrests last 30 days): 2% for BT and 65% for RT 2% for BT and 65% for RT Social Connectedness (with family, community last 30): Social Connectedness (with family, community last 30): Increased 5% for RT Increased 5% for RT Social Consequences (no health problems due to substance abuse in last 30 days): Social Consequences (no health problems due to substance abuse in last 30 days): Increased 37% for BT; 75% for RT Increased 37% for BT; 75% for RT

State SBIRT Locations West Virginia Georgia Missouri SAMHSA State SBIRT Grant Sites (all cohorts) Learning Cluster Sites

Medical Residency Programs Washington DC Howard Univ. Connecticut Yale 17 Sites Total Albany Medical Center U. Maryland Children's Hospital U. Pittsburgh Mercer Un. Kettering Indiana Un. Access Chicago Un. Missouri U. TX. Health Sciences Baylor Oregon Health Sciences UCSF UCSF Gen Natividad MC

SAMHSA SBIRT and Community Health Centers The SAMHSA SBIRT 2003 – 2008 The SAMHSA SBIRT 2003 – 2008 Settings: Settings: Emergency Departments Emergency Departments Inpatient/Outpatient Inpatient/Outpatient Trauma Centers Trauma Centers CHCs/FQHCs CHCs/FQHCs Rural: New Mexico Rural: New Mexico Urban: Illinois, Massachusetts Urban: Illinois, Massachusetts

SBIRT Health Center Sites New Mexico Illinois W. Va. Predominantly Health Clinic Oriented

SBIRT Resource: CSAT SBIRT Website Information regarding the Information regarding the SBIRT Initiative, core clinical SBIRT Initiative, core clinical components, and screening components, and screening instruments, and how to instruments, and how to establish an SBIRT program. establish an SBIRT program. Online resources (e.g., Online resources (e.g., training guides) links to training guides) links to curricula, organizations, curricula, organizations, publications, and publications, and references. references. SAMHSA/CSAT specific SAMHSA/CSAT specific information, such as SBIRT information, such as SBIRT Cooperative Agreements, Cooperative Agreements, grantee profiles, key CSAT grantee profiles, key CSAT SBIRT staff, meetings, SBIRT staff, meetings, training opportunities, and training opportunities, and news. news.