1. Substance Abuse Disorders in Primary Care Improving Evidence Based Practice David W. Oslin, MD University of Pennsylvania, School of Medicine And Philadelphia, VAMC Hazelden Research Co-Chair on Late Life Addictions

2. Which Hat? Geriatrics Primary Care Addictions

3. Introduction  Alcohol use and abuse costs the nation $150 Billion / annum  Alcohol use and abuse is common in primary care practices  Very little research has focused on illicit substance use disorders in the context of primary care

4. 90-Day Prevalence in Primary Care (n=21,282 patients in 88 primary care clinician offices) Manwell, et al. Journal of Addictive Diseases. 1997;17:67-81. Low-risk Drinkers 38% Abstainers 40% At-risk Drinkers 9% Problem Drinkers 8% Alcohol Dependent 5%

5. The Bad News  Individuals with alcohol disorders or problem drinking who seek help  ECA: 11% specialty mental health/addictive services; 8% voluntary support network  NLAES: 10%  RAS: 7%-10%  Rates of Early Drop-out from Alcoholism Treatment (less than four sessions) range from 44 - 75%

6. Breaking down the Problem  Identification  Assessment  Initial Intervention  Referral and Follow-up

7. How is Identification Accomplished?  Systems  VA, Kaiser, Group Health  Individual Practitioners  State, City, other agencies

8. Examples: Screening Instruments  Michigan Alcoholism Screening Test (MAST)  Health Screening Survey (including other health behaviors, e.g. nutrition, exercise, smoking, depressed feelings)  CAGE (Cut down, Annoyed by others, feel Guilty, need ‘Eye-opener’)  AUDIT-C/AUDIT

9. Identify What?  Abstinence  Moderate Drinking  At – risk drinking  Problem drinking / alcohol abuse  Alcohol Dependence

10. VA Experience  Prior to 2003 – CAGE  11/03 AUDIT-C  2781 screens in those that drink over a 4 month period  32.6% positive

11. The First Challenge  Assessing individuals to understand what level of care is needed

12. BEHAVIORAL HEALTH LAB

13. Research to Practice: Behavioral Health Laboratory  BHL is designed to provide clinical services to support providers in Primary Care and Behavioral Health  It is intended to be analogous to Clinical Chemistry or Radiology Laboratories  The BHL is an automated telephone assessment, triage, and monitoring service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.  The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

14. How it works at the PVAMC  Mechanisms for requesting an assessment  Screening  Referral  Disease management  The BHL receives a printed consult request.  The BHL reports findings, provides interpretation, and recommendations.  Where appropriate, BHL staff facilitate referral or the appropriate level of intervention.

15. What does the Service Provide?  Assessment of major illnesses – depression, anxiety, substance use  Screening for other domains – cognition, smoking, psychosis, mania  Initial Treatment recommendations  Patient engagement  Monitoring of initial treatment for depression – adherence, adverse effects, symptoms

16. BHL Flow Annual ScreeningDirect consultNew treatment for depression Consult request Full Assessment Referral to ARU Recommendations to PCP and Patient At-Risk DrinkerReferral to Specific Research No Treatment Recommended Brief Intervention Watchful Waiting – 8 weeks Referral Management

17. Referrals

18. 5 Month Referral Success TotalReferred for Depression Referred for Alcohol Referred for Depression & Alcohol p value Sample sizeN=605N=472N=75N=58 Percentage of total cases100.078.012.49.6 Completed Interviews (% within category) 74.075.264.077.60.263 Age >65 (% )20.823.316.06.90.008

19. Characteristics of Patients Referred for Depression Referred for Alcohol Depression & Alcohol p value N=355N=48N=45 Age (% > 65)21.414.68.9.091 Race (% White)45.927.126.7.004 MDD45.025.655.8.014 Alcohol dependence7.139.651.1.000 Anxiety disorder (Panic or PTSD)21.56.331.1.010 Psychosis13.610.426.7.044 Mania7.92.117.8.020 High Risk Suicide14.511.620.9.439 In MH/SA care (last 12 months)27.314.622.2.379 On antidepressant38.123.3.036

20. Does the BHL change practice?  25% reduction in the number of patient not screened for depression  10% increase in the screen positive rate for depression  Significant increase in the identification of patients with suicidal ideation  Possible improvement in EPRP measures for depression

21. Engagement in Care OverallRequired an appointment Requested an appointment p value Patients needing an appointment (% of total # of assessments) N=254 (44.3%) N=200 (35.0%) N=54 (9.3%) Patients refusing appointment12.5% Proportion seen in MH/SA care within 3 months of the BHL assessment N=119 (55.0%) N=92 (52.6%) N=27 (50.0%) 0.741 Proportion seen in primary care within 3 months of BHL assessment N=117 (51.1%) N=87 (49.7%) N=30 (55.6%) 0.453

22. Conclusions  BHL is a flexible, evidence based program  Fills gaps in the VHA system  Provides valid information and documentation  Acceptable to veterans  Valued by provider  Can function at low cost across diverse settings  Useful for outreach  Can provide coordination as well as assessment  Disease Management  Referral Management  Valuable as a tool for improving system performance

23. But?  The number of patients referred doesn’t match those assessed.

24. Referrals for depression 3008 already in MH/SA care 17,543 Patients Screened 1232 positive screens (7%) 740 Patients referred to the BHL (60%) 104 Unable to contact (14.1%) 56 Refused 7.6%) 580 Completed Assessment

25. Referrals for Alcohol Misuse In MH/SA care not an option 2781 patients who drank screened 906 positive screens (32.6%) 118 Patients referred to the BHL (13%) 17 Unable to contact (14.4%) 7 Refused (5.9%) 94 Completed Assessment

26. What about the Instrument? Q#1: How often did you have a drink containing alcohol in the past year? Never (0 points) Monthly or less (1 point) Two to four times a month (2 points) Two to three times per week (3 points) Four or more times a week (4 points)

27. What about the Instrument? Q#2: How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 (0 points) 3 or 4 (1 point) 5 or 6 (2 points) 7 to 9 (3 points) 10 or more (4 points)

28. What about the Instrument? Q#3: How often did you have six or more drinks on one occasion in the past year? Never (0 points) Less than monthly (1 point) Monthly (2 points) Weekly (3 points) Daily or almost daily(4 points)

29. Is the Screener to “sensitive” 2 Drinks/day 3-4 Drinks/day with binges10+ Drinks/day

30. Does the Type of Provider Matter? OtherMD CRNP/PA Residents/ Fellows Choices: MD CRNP/PA Residents/ Fellows Other

31. Do Clinician Beliefs Matter? Low Referral Pattern (n=19) Moderate Referral Pattern (n=10) Age46.846.9 Gender (% female)7850 Provider type (%CRNP or PA) 6320

32. Do Clinician Beliefs Matter? Low Referral Pattern (n=19) Moderate Referral Pattern (n=10) Beneficial Drinking6.23.2 Inpatient - Yeah!7840 Outpatient - Yeah!6790

33. Starting a New Practice  Identify a thought leader / Champion  Define practice specific needs – screening, referral, resources  Define practice specific procedures  Announce the availability of the service  Face-to-face  Email  Letters / Brochures

34. Other Marketing Strategies  Business cards for patients  Business cards for providers  ELM interface  Listing of providers  Staff in practice / Screening of patients  877 number  Pens  Sticky pads  Business size card for computer  Monthly email reminders  Clinic feedback  In-service by staff on MH/SA topics  Website

35. A Platform for other activities  Telephone disease management for problem drinking  Supported by VA HSR&D  Developing watchful waiting strategies  Supported by Robert Wood Johnson Foundation  ExTENd – Use of naltrexone in managing alcohol dependence  Supported by NIAAA – R01  DIADS – depression of Alzheimer’s disease  Supported by NIMH R01  Family caregiver Support  Depression Treatment Monitoring  PTSD  Referral Management