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NASHP Annual Conference Blazing New Trails: Shifting the Focus on Alcohol and Drugs Barbara Cimaglio Sally Fogerty, BSN, M.Ed. John C. Higgins-Biddle, Ph.D. October 15, 2007

Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Authors: Barbara Cimaglio, Sally Fogerty, BSN, M.Ed., John C. Higgins-Biddle, Ph.D.

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Page 1: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

NASHP Annual Conference

Blazing New Trails:Shifting the Focus on Alcohol

and Drugs

Barbara CimaglioSally Fogerty, BSN, M.Ed.

John C. Higgins-Biddle, Ph.D.October 15, 2007

Page 2: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 2

Main Topics

What’s the Problem?

What is Screening, Brief Intervention, and Referral to Treatment?

What is the Federal Government Doing?

What States Can Do?

Page 3: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 3

Alcohol and Drugs . . .

Kill over 85,000 Americans per year; third leading cause of death

Cost over $250 billion in lost productivity, health costs, legal and justice issues

Are perceived to be moral problems, legal problems, social problems, a failure of individual responsibility

Page 4: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 4

Alcohol and Drugs . . .

Cause/exacerbate many medical, mental, social and family problems

Their use is often unidentified by doctors Diagnose & treatment of many diseases &

disorders often neglect their use This applies to many levels of use besides

alcoholism and drug dependence Understanding requires new perspective

Page 5: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 5

How we address other issues

Are you a better driver than a typical 16 year-old male?

Have you had an auto crash? Does your state require seatbelt use? Who has more heart attacks: People diagnosed

with heart disease; those without heart disease? So what?

Page 6: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 6

The Preventive Paradox

Large group (LG) with small problems vs. small group (SG) with big problems

Good drivers (LG) have more accidents than high-risk drivers (SG)—hence seatbelts for all

Patients without a diagnosis of heart disease (LG) have more heart attacks than those with a diagnosis (SG) —hence screen all for cholesterol

Page 7: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 7

Types of Alcohol/Drug Risk

Dependence—a cluster of behavioral, cognitive, and physiological phenomena that may develop after repeated use

Harmful Use—consumption causing physical, mental, or social harm

Hazardous Use—consumption causing elevated risk without presence of physical or mental harm (yet)

Page 8: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 8

Who Causes the Harm?

Small group with Dependence experience & cause the most harm

But there are far more Hazardous and Harmful users

So Hazardous & Harmful drinkers cause at least half of alcohol/drug harm

Two ways—high-level regular use and occasions of intoxication lead to work, health, social, legal problems

Page 9: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 9

What we don’t see can hurt!

Page 10: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 10

Biggest Drug Issue: Alcohol

Despite publicity, illicit drugs are a small part of America’s problems

Alcohol misuse dwarfs the problems of illicit drugs

Misuse occurs in all age, racial, and social groups, and in both genders

But the biggest problem is not alcoholism

Page 11: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 11

The Drinkers’ Pyramid

Dependent Drinkers

Harmful/Hazardous Drinkers

Responsible Drinkers

Abstainers

Page 12: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 12

Treatment alone won’t work

For 50 years USA has had the world’s best treatment system but always 5% dependent

87% of people who need TX don’t want it We typically wait 20 years—until dependence-

to help people who drink too much For every dependent patient who quits or dies,

a harmful user becomes dependent Meanwhile harmful users produce ½ our harm

while we could help many in 5 minutes

Page 13: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 13

Summary of the Problem

25% use too much at least once/year 5% are dependent; 20% are not Reducing problems requires finding and

helping both groups So how can we find them and help the

hazardous, harmful, and dependent—each of whom needs somewhat different kinds of help?

Page 14: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 14

We need a new focus

Alcohol & drug treatment are not provided where most people regularly go

To find a health problem among all Americans we must go to general medical settings

So to find people who misuse alcohol & drugs we must enlist medical services

This is requiring a new focus & approach

Page 15: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 15

SBIRT Provides a Way

Screening identifies degree of risk and likelihood of a condition

Brief Intervention helps patients reduce hazardous and harmful use

Referral sends dependent patients to specialized Treatment

Page 16: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 16

Screening for Drugs/Alcohol

25 years of research in medical sites Where people go with health issues and

expect to be asked questions Self-report screening is quick, accurate, and

inexpensive Can be done via paper, oral, computer Good screens distinguish risk levels But do patients get upset?

Page 17: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 17

Patient Comfort

0102030405060708090

100

Very

Comfortable

Very

Uncomfortable

Diet/Exercise

Smoking

Drinking

Page 18: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 18

Patient Sense of Importance

0102030405060708090

100

Very

Important

Very

Unimportant

Diet/Exercise

Smoking

Drinking

Page 19: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 19

Goals of Screening

• Identify both hazardous/harmful use and those likely to be dependent

• Create a professional, helping atmosphere• Gain the patient information needed for an

appropriate intervention• Use as little patient/staff time as possible

Page 20: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 20

Who and When to Screen?

Not knowing who drinks or uses drugs, we must screen everyone who is able yearly

Rough estimates of excessive use by setting: Primary Care—10-25% Ob-Gyn—10-20% Emergency—20-40% Trauma—40-60%

Should become as common as blood pressure Can be done by existing or special personnel

Page 21: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 21

Brief Intervention

Structured brief advice/counseling Builds upon screening info Non-judgmental, interactive, empathic Aims: to reduce or stop use; or to refer patient

to specialized treatment Cognitive info and motivation to change Differing protocols, similar results

Page 22: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 22

Elements of an Intervention

1. Feedback from screening on risks

2. Advice to reduce use & risk

3. Negotiation of patient acceptance of responsibility & choice of a goal

4. Information on limits and “how to”

5. Encouragement/Motivation

Page 23: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 23

Referral To Treatment

• Screening can supply a likelihood of dependence

• Those who are dependent may benefit from a brief intervention but probably need motivation for traditional treatment

Early identification may get more patients to treatment earlier; thus increasing effectiveness of therapy, decreasing costs

Page 24: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 24

Research Findings

Since 1980, 50+ different clinical trials—One 3-5 min. to multiple 15-30 min. sessions

Most studies show positive results of decreasing use among many (not all) patients

Effective with all ages, races, genders, ethnics Some benefit from follow-up session; least

effective with most severe cases Low cost: One study--<$1 screen; <$4 doc BI Supports a preventive public health service

Page 25: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 25

Policy Actions to Date

USPSTF rates evidence for alcohol SBI with Cholesterol Screening and Flu Shots for Elderly

Most physician societies have endorsed it Am. College of Surgeons Com. on Trauma

requires it in Level I centers; other levels to follow

Federal govt. agencies now acting

Page 26: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 26

How to pay for SBIRT

CMS issued new Medicaid codes for SBIRT H0049 for Screening H0050 for Brief Intervention

Must be adopted within state plans AMA will announce in November two CPT codes

for SBIRT to be used for private insurance and Medicare beginning Jan. 08

Page 27: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 27

Federal Agency Actions

NIAAA supported research; NIDA beginning VA initiated program; IHS starting in trauma NHTSA supporting dissemination; CDC supports

emergency/trauma dissemination White House ONDCP supporting budgets and

implementation SAMHSA providing large state & university

grants; more on the way

Page 28: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 28

SAMHSA SBIRT Initiative

Largest Federal program 11 state/tribal coop. agreements ave. >$2 mil.

per year for 5 years; 12 campus grants ave. $1.3 mil. over 3 years Over 500,000 patients screened since 2004 Programs in large urban hospitals to small rural

clinics More grants to come; plus residency training Stay informed at:

http://sbirt.samhsa.gov/index.htm

Page 29: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

Massachusetts Implementation of SBIRT into Primary Care

Sally Fogerty, BSN, M.Ed.Director, Bureau of Family and Community Health

Page 30: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

30

Four Models

MASBIRT – Implementation in one large Boston medical center. Implementation on medical inpatient floors, in one ED and several outpatient clinics.

3 Mass colleges are completing the final year of their SAMHSA college SBIRT grants

Twelve Emergency Departments around the state Community Health Centers – adolescents and women of

child-bearing age integration into regular care

Page 31: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

31

4 Key Components All Models Screening Brief Intervention Referral to Assessment and/or Treatment

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MASBIRT Massachusetts is one of 10 states and one tribal

council awarded this SAMHSA funded 5 year grant

Clinical service that utilizes specially trained Health Promotion Advocates to universally screen and help patients with risky or unhealthy tobacco, drug and alcohol use through brief intervention counseling and facilitated referrals to assessments and specialty addiction treatment.

Screening in hospital inpatient, emergency department, and rolling out to 4-5 outpatient clinics

Page 33: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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MASBIRT

3 CHCs will be added in FY08 Staffing resources –

Health Promotion Advocates work with hospital social workers, some clinical staff in clinics – medical assistants, nurses and physicians.

Standardized questionnaire. Automated patient screening using TLC (telephonic linked care) and a web-based link from EMR to questionnaire and back being developed

New level of treatment – brief treatment

Page 34: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

34

Massachusetts Colleges Purpose was to screen students and link with

services Wrapping up and evaluation just being

completed Three colleges involved:

Northeastern University, Boston University of Massachusetts, Amherst Bristol Community College, Fall River

Issue was campus vs. community services – how do you link and get students to utilize community services.

Page 35: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

35

Emergency Room Specially trained Health Promotion Advocates

are funded in emergency departments to screen for tobacco, drug and alcohol use, brief intervention counseling and facilitating referrals

12 emergency departments – at least one in each region of the state

800 people screened in August

Page 36: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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CHC Integration Model

Goal: integration into existing primary care services of on-going screening for Violence Tobacco use Substance use Behavioral health issues

Utilized a new procurement for services for women of reproductive age and adolescents which were previously funded as prenatal and adolescent health programs under MCH.

Page 37: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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Integration into CHC Primary Care Joint effort of two program areas: Bureau of

Substance Abuse Services and Bureau of Family and Community Health

Paradigm shift from how care currently delivered for women of reproductive age with focus on pre and intra conception and prenatal period.

Train existing providers to do screening and brief intervention

32 programs funded – 17 both adolescents and Women of Reproductive Age; 5 adolescents only and 10 women only.

Page 38: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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Process – CHC Integration Model Screening of all individuals at annual

visit/prenatal care visit Adult screening tools utilized CRAFFT for adolescents

Early identification of individuals at risk for problems or addiction Brief intervention if high-risk

If positive screen further assessment by professional, may or may not be on site, with additional training

Referral for treatment

Page 39: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 39

Process – CHC Integration Model Primary care site will follow-up to ascertain

individual goes for first appointment Collaboration between Primary Care and

Treatment providers.

Page 40: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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Implementation CHC Integration Model Identifying an SBIRT champion Regional trainings by substance abuse vendor

Basic Overview Interview skills Referrals

One-on-one at each site to develop plan to integrate into existing care

Page 41: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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Where are we – 1 year later CHC Integration Model 100% integrated tobacco 90+ integrated violence Substance abuse/behavior health

1/3 have integrated utilizing questionnaire 1/3 in process majority “tweaking” electronic

medical record to incorporate questions 1/3 still at early stage of implementation

Page 42: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

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CHC Integration Implementation Challenges Takes time – long learning curve Need to change “pattern” of how care delivered

– asking to do something new according to prescribed questions difficult

RFR spelled out expectations and requirements but needed to reinforce and reinforce.

If just setting up electronic medical record easier

Page 43: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

43

What have we learned?

Basic acceptance of Concept Development of HCSPCS codes for CMS billing

and CPT codes may promotes screening and brief intervention

Implementation in all sites requires change in process and is a challenge

Need to have a champion If provide “trained advocate” easier to begin

implementation and collect data but sustainability is questionable

Page 44: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 44

What Have We Learned

Need to have treatment/referral resources available and easy to access.

Need to have relationships between health care and substance abuse/behavioral health treatment providers.

Page 45: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 45

What States Can Do

Executive Organization Substance abuse agencies often do not relate to

general medicine. Coordinate across many agencies & budgets to reposition the focus & linkages

A public health issue affecting economic development, health, safety, & more (see below)

Establish relations with Level I trauma centers now developing programs & link treatment programs

Work with state medical society to develop programs, provide training, and TA

Page 46: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 46

What States Can Do

Economic Development/Labor Educate employers that hazardous/harmful users

cause lower productivity and higher health costs Encourage SBIRT coverage in all health plans

Health/Insurance Assure insurance reimburses cost for intoxicated

patients so health services can screen & get paid Include new HCPCS codes in state Medicaid plan Encourage state insurers/HMOs to cover new

CPT codes Get state-supported medical systems to include

SBIRT

Page 47: Blazing New Trails: Shifting the Focus on Alcohol and Drugs

© 2002-07 John C. Higgins-Biddle 47

What States Can Do

Administrative Services—Include SBIRT services in health plans for state employees

Higher Education—Implement SBIRT in campus health services

Veterans Affairs—Implement SBIRT Legislature—Require SBIRT inclusion in state

plans & set measurable goals and timelines Everywhere: Educate all in state leaders &

legislators about the real problem & SBIRT Stay informed at:

http://sbirt.samhsa.gov/index.htm