1. Substance Use Disorders, Primary Care, Screening and Brief Intervention Norman Wetterau, MD, FASAM President: New York Society of Addiction Medicine

2. Health Care Reform Better Health Less cost

3. Alcohol brief screening and interventions AT SIX MONTHS, MEN DOWN FROM 21.3 TO 14.4 DRINKS A WEEK, WOMEN FROM 14.8 TO 8.4 HEALTH CARE UTILIZATION: 20% LESS ER VISITS 37% FEWER HOSPITAL DAYS CONTROL GROUP: 55% MORE CRASHES (31 VS. 20) 46% MORE ARRESTS (41 VS. 28) BENEFIT: MEDICAL $712 MINUS $166 COST= $546 SOCIETAL $7,985 PER PATIENT MINUS $205 COST LONG TERM EFFICACY AND BENEFIT - COST ANALYSIS MICHAEL FLEMING ET AL. ALCOHOL CLIN. EXP RES. VOL 26 NO 1 PP 36-43

4. US Preventive Task Force: SBIRT Score of 9 out of 10 for cost effectiveness and usefulness Only Immunizations, and discussing aspirin and tobacco received 10 Paps: 7 breast cancer 6 diabetes 2 Solberg et al American J of Prev. Med.34: 143-152

5. NCQA requirements for certification as a medical home To be certified as a medical home NCQA will require screening for alcohol and other substance use and an attempt to address the issue and treat or refer. Much Federal Money to implement SBIRT programs in Ers, Hospitals, Practices and residencies

7. OUTLINE 1. What is screening and brief intervention about? 2. Who does it? How is it done? 3. Screening: single question or AUDIT 4. Assess: Audit or abuse, dependency questions 5.Advise and Assist 6 Follow-up 7. Our role

8. What is SBIRT We ask questions to determine if people are nondrinkers, safe drinkers, at risk drinkers, harmful drinkers or dependent drinkers For those who are at risk, we provide a brief intervention For those whose drinking is harmful or dependant, we still do a brief intervention but may also refer the patient for further treatment.

9. Safe Drinking Men: 14 standard drinks a week, no more than 4 on one occasion Women and men over age 64: 7 drinks a week, no more than 3 on one occasion

10. Demand Treatment!- The Risk Paradigm A shift toward earlier detection, brief intervention, and strategic follow up …..

11. Initial Screening Questions Do you sometimes drink beer, wine or other alcoholic drinks? How many times in the last year have you had (Men 5, woman 4) or more drinks? Or Give them the first 3 questions of the audit (positive score woman 4, men 8) Or give them the whole audit

12. For positive screens Access using the audit or abuse, dependency questions If at risk, provide a brief intervention If harmful or dependent, consider referral Follow-up Consider offering medications

13. WHO DOES THIS? Initial screen: anyone –Ask or hand out audits to everyone –Can be part of other questions that are asked of all patients Rest of process: physician, assistant, booklet or online. It is very helpful if the physician is involved in some part of this.

15. Rethinking Drinking On one page they list the pros and cons Ready or not: keep track, notice how drinking affects you, make or remake a list of pros and cons about drinking Ask for support from your doctors, a friend or someone else you trust

16. strategies for cutting down Keep track Count and measure Set goals Pace and space Include food Find alternatives Avoid triggers Plan to handle urges Known your no

17. Planning for change From rethinking drinking List goals Timing: I will start on Reasons: My most important reasons to make these changes Strategies People who can help Signs of Success

18. Approach & Purpose: Alcohol Screening and Brief Intervention STEP 1-ASK ABOUT ALCOHOL USE & Safe Drinking…………… Safe Drinking: Men: 14 drinks/week no more than 4 on one occasion Women: 7 drinks/week no more than 3 on one occasion

19. Alcohol Screening and Brief Intervention Ask about alcohol and Drug Use Specific Screening Questions How many drinks do you consume in an average week? What is the most drinks you have had on one occasion in the past month? Has alcohol ever caused any problems for you? Do you use any drugs other than those prescribed by a physician? If they drink over the safe amount we give patient the Audit.

20. Demand Treatment!- The Risk Paradigm A shift toward earlier detection, brief intervention, and strategic follow up …..

21. Approach & Purpose STEP 2: ASSESS FOR ALCOHOL RELATED PROBLEMS 1.At Risk Drinking….More than safe amount but no problem yet…. 2.Harmful Drinking….. 3.Dependence….

22. Approach & Purpose STEP 2: ASSESS FOR ALCOHOL RELATED PROBLEMS: Use Audit Plus: Medical Problems such as……… Depression, hypertension, sexual problems, trauma, sleep disorders Behavioral Problems such as……. Work, family, school, accidents

23. BIG THREE Smoking Drinking Obesity Anxiety Depression Drinking

24. Approach & Purpose STEP 2: ASSESS FOR ALCOHOL RELATED PROBLEMS : AUDIT Positives on 1-3 (quality questions) - AT RISK Score of 15-20 can be harmful or dependent Any drinking that causes problems is HARMFUL Positives of 4-6 or score over 20 suggest ALCOHOL DEPENDENCE

25. Demand Treatment!- The Drinkers ’ Pyramid SAFE DRINKING: MEN 2 DRINKS A DAY, 4 ON ONE OCCASION WOMEN 1 DRINK A DAY, 3 ON ONE OCCASION

26. STEP 3: ADVISE, ARRANGE, ASSIST State your concerns Give clear advice to cut down or abstain Agree on a specific plan of action

27. SOLICIT THEIR RESPONSE Do the WHO guidelines seem low to you? Are there changes you might make that could reduce your risk of alcohol related problems? How hard would that be? OFFER SUGGESTIONS TO ACCOMPLISH THEIR GOALS

28. OFFER CHOICES I could order tests but there is a good chance that if you reduce your alcohol intake, the symptoms would go away. We can prescribe life long medication, but it might not be necessary if you are able to reduce you alcohol use. I would like to prescribe this medication but I cannot unless you are able to stop drinking

29. EXPLORING PROS AND CONS WHAT DO YOU LIKE ABOUT DRINKING? Acknowledge what they said WHAT DO YOU LIKE LESS ABOUT DRINKING? IS THERE ANYTHING ELSE? SUMMARIZE: on the one hand you said... but then you said …Where does this leave you?

30. Who should be strongly advised to abstain rather than just cut back? 1. Those who have failed before to cut back and to remain cut back 2. Those who are pregnant, hypertensive or have abnormal liver function 3. Those taking medicine that should not be taken with alcohol 4. Those who are depressed 5. Those who might be depressed

31. Who should be referred? 1. Those with alcohol dependence 2. Those who try to cut down or quit and are unable to follow through 3. Those who have multiple alcohol related problems who are unable to stop drinking 4. Patients who have been prescribed medication for anxiety or depression, have been advised to stop drinking, and are unable to do so.

32. Example 1. If patient presents with a problem that has some relationship to alcohol, you could deal with it quickly. The patient will likely be more responsive right then. “…. your blood pressure is high today. I noted on your screen that you drink 20 or so drinks a week. Although one drink a day might help the heart, 20 a week can contribute to high blood pressure and harm the hear ……. Would you be able to cut back or possibly abstain from alcohol until we sort this problem out?….” PRACTICAL CONCERNS: TIME AND YOUR STYLE

33. Example 2. “….. I can see that your anxiety (or depression) is a real problem. Do you ever have a drink to calm you down or make your feel better? …….. Alcohol may make you feel better for a short while, but it actually increases depression and anxiety levels. I would like to help you with your problem, but would like to ask you to stop all alcohol use for a while. Is this something you could do?…. If the person has a significant problem or high audit score you might say,… “In addition to some counseling around your problems, I could give you someone to work with you in trying to cut down or stop drinking…..” PRACTICAL CONCERNS: TIME AND YOUR STYLE

34. Example 3... If the person is simply at risk, you can provide some advice in just a few minutes, and if necessary, give them some material and let them know you could talk to them later about this if they wish; If you have 5 minutes, you can do a brief intervention and have them come back later PRACTICAL CONCERNS: TIME AND YOUR STYLE

35. Specific Protocol THE AUDIT –1. WHERE WILL THEY BE KEPT? –2. WHO WILL GIVE THEM TO THE AT RISK PATIENT?

36. Specific Protocol: Specific Questions on Logistics Who will you screen? Will this be in a questionnaire format or will the questions be asked in an interview? Who will do the screening? (e.g. nurse, physician) What specific questions will you ask? If drinking is above safe limits, what will you do next? Where will materials be kept?

37. BILLING 214: 1 new complicated problem or 3 chronic problems Update at least one element of past history Review of at least 2 systems USE WRITTEN SCREEN AS YOUR DOCUMENTATION OF PAST HISTORY IF SCREEN IS POSITIVE, YOU HAVE A NEW PROBLEM AND A 214 ON FOLLOWUP, USE ALCOHOL ABUSE AS ONE OF THREE CHRONIC CONDITIONS YOU ADDRESS.