Teaching Medical Learners about Substance Abuse ......An evidence-based intervention based on...
Transcript of Teaching Medical Learners about Substance Abuse ......An evidence-based intervention based on...
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Teaching Medical Learners about Substance Abuse
Screening, Brief Intervention, and Referral to Treatment
J.Aaron Johnson, PhD
Associate Professor
Institute of Public & Preventive Health
Augusta University
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Training Grant
• Georgia Regents University Interprofessional
Substance Abuse Training (GRISAT)
– Funded by Substance Abuse and Mental Health
Services Administration (SAMHSA) – Sept 2015
– SBIRT Training grant program started in 2008
– 60+ Training grants funded in 3rd round
– 13 more funded in 2016
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Participating Augusta University programs
• Psychology Masters Program
• Psychology Postdocs, Interns, Fellows
• Psychiatry Residency
• Advanced Practice Nursing Programs
• Family Medicine Residency
• Medical Students (throughout curriculum)
• Recently added the Physician Assistant Program
• Possible future additions - Emergency Medicine and Internal Medicine residencies
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Aims• To integrate existing SBIRT curriculum into the didactic
and clinical practice experiences of participating programs
• To train students in each of these programs the skills needed to provide SBIRT services to patients
• To implement SBIRT in one or more clinical training sites utilized by each of the participating programs
• To ensure the successful continuation of SBIRT by promoting its use in clinical practices throughout the state
– inter-professional regional trainings
– online continuing education opportunities
– ongoing advocacy at the state and local level
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Why is this important?
• Alcohol and drug misuse are common
• Alcohol and drug misuse are serious
• Alcohol and drug misuse are expensive
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Alcohol and drug misuse are common
Alcohol use:
Accounts for 4% of the global burden of disease.
Is 8th among global risk factors for death.
In the U.S. it is the 3rd leading cause of death and disability.
For those age 15 – 59 it is the leading cause of death and disability.
Cancer accounts for 21.6% of all alcohol attributable deaths.
Source: WHO (2011)
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Low Risk Alcohol Use
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Source: NIAAA (2013) http://rethinkingdrinking.niaaa.nih.gov/isyourdrinkingpatternrisky/whatslowriskdrinking.asp
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Current Binge and Heavy Alcohol Use:Persons Aged Twelve or over by age group 2012
Source: National Survey on Drug Use and Health 2012
SECSAT – APRN © 2014 9
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US Drug Use Prevalence 2012
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
10.00%
Illicit drug use Marijuana cocaine hallucinogens psychotheraputics
Source: National Survey on Drug Use and Health (2013)
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National Overdose DeathsNumber of Deaths from Prescription Opioid Pain Relievers
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000 Total Female Male
Source: National Center for Health Statistics, CDC Wonder
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National Overdose DeathsNumber of Deaths from Heroin
0
2,000
4,000
6,000
8,000
10,000
12,000 Total Female Male
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Alcohol and drug misuse are serious
Increased risk for—
Injury/trauma
Criminal justice involvement
Social problems (date rape, DUI, STIs, unintended pregnancies)
Mental health consequences (e.g., anxiety, depression)
Increased absenteeism and accidents in the workplaceSource: US DHHS, Healthy People 2020 (2013). http://healthypeople.gov/2020/lhi/substanceabuse.aspx
> 65 diseases/conditions associated with or caused by harmful use of alcohol. (Warren & Murray, 2013)
More than 100,000 deaths/year attributable to alcohol/drug misuse.
Source: WHO (2011)
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Medical and
Psychiatric
Harm of
High-Risk
Drinking
Source Babor, Thomas F., Higgins-Biddle, John C., Saunders, John B., and Monteiro, Maristela G (2nd edition; June 2006)., ‘The Alcohol Use Disorders Identification Test: Guidelines for use in primary care’,
WHO, Management of substance abuse: Alcohol
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The Evidence Indicates That Moderate-Risk Account for More Problems than High-Risk Drinkers
SECSAT – APRN © 2014 15
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Alcohol and drug misuse are expensive
Economic cost alcohol and drug misuse in US estimate at $373 Billion annually.
Less than 5% of cost related to Prevention and Treatment.
Majority of costs are societal burden (lost productivity, crime, destruction of property, etc.)
Source: US DOJ (2011) Economic Impact of Illicit Drug Use on American Society;
NIAAA (2000) 10th Special Report to US Congress on Alcohol and Health
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Historic Response to Substance Use
• Previously, substance use intervention and treatment focused primarily on substance abuse universal prevention strategies and on specialized treatment services for those who met the abuse and dependence criteria.
• There was a significant gap in service systems for at-risk populations.
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Shifting the Paradigm
From detection of
alcohol use disorders
to identification of
health risk.
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What is SBIRT?
• Screening quickly assesses the severity of
substance use
• Brief Intervention focuses on increasing
motivation toward behavioral change.
• Referral to Treatment provides referral to those
identified as needing more extensive treatment
An evidence-based intervention based on “motivational interviewing” strategies
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Basis for Implementation of SBIRT into Healthcare settings
• Most people who misuse alcohol do not seek treatment at addiction treatment programs
• Most people who misuse alcohol do require care for other health issues
– Alcohol-related health issues may be chronic or acute
• When properly implemented in healthcare settings, SBIRT identifies both abuse/dependence (4-5% of population) and at-risk use (occasional binge drinking or high levels of daily drinking) (20-25% of population)
• At-risk users respond best to SBIRT services
– Can prevent future long-term health consequences
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Example of an SBIRT intervention
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https://www.youtube.com/watch?v=ONPlsxurIJg
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Brief Intervention Works!
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• Strongest evidence in Primary Care Settings
• SBIRT meta-analyses & reviews:
– More than 34 randomized controlled trials
– Focused primarily on at risk and problem drinkers
– Result in 10-30% reduction in alcohol consumption at
12 months
Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005;Kaner et al, 2007; Sullivan et al. 2011
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Other Benefits of BI in At-Risk Drinkers –
Healthcare and Societal Costs
Decreases risk of major trauma, ER visits, recurrent
hospitalization, and future DUI’s
Gentilello et al, 1999; Fleming et al, 2002; Schermer et al,
2006
http://healthwise-everythinghealth.blogspot.com/2010/04/surprises-about-emergency-room-use.html
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US Preventive Services Task Force: SBIRT
Recommended for All Adult PC Patients
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• Class B recommendation
– Flu shots
– Cholesterol screening
– SBIRT
• “…good evidence that screening in primary care can accurately
identify patients whose levels of alcohol consumption…place
them at risk for increased morbidity and mortality”
• “…good evidence that brief behavioral counseling
interventions…produce small to moderate reductions in alcohol
consumption”
http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm; USPSTF, 2004
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Most Useful Preventive ServicesRanking Service
1 Aspirin (Men 40+; Women 50+)
2 Childhood immunizations
3 Smoking cessation
4 Alcohol Screening & intervention
5 Colorectal cancer screening & treatment
6 Hypertension screening & treatment
7 Influenza Vaccination
9 Cervical cancer screening
10 Cholesterol screening (men 35+: women 45+)
12 Breast cancer screening
18 Depression screening
21 Osteoporosis screening
23 Diabetes screening - adults
Maciosek MV et al. Am J Prev Med. 2006;31(1):52-61.Solberg LI et al., Am J Prev Med. 2008;34(2):143-152
For rankings: 1=highest
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SBIRT is endorsed by Important Payers
and Policymakers
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Where are medical students learning SBIRT?
• Year 1 students
– Didactic training in Physical Diagnosis using online video modules
– Live Brief Intervention practice with standardized patient exhibiting at-risk drinking
– PBL case with patient exhibiting possibly dependent drinking
• Year 2 students
– Brief intervention refresher using computer-based simulated patient
– PBL case – patient with cirrhosis
• Year 3 students
– Clinical practice in clerkship rotations
– Module on prescribing/monitoring chronic pain patients
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What we’ve learned from years of teaching SBIRT
• One time didactic training is necessary but not sufficient for learning SBIRT
– Students need opportunity to develop skills through simulated patients as well as clinical practice
– As preceptors and group facilitators your assistance is critical
• Some students will, understandably, express ambivalence
– Most common reasons for ambivalence
• Their own alcohol use behavior
• Concern about time (common in residents)
• Cost
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Resident Binge Drinking
26.5
35.7
49.7
17.6
0
10
20
30
40
50
60
Past 12 months Past month
All adults
Adults 26-35
Residents
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Comparing female residents and APRN students
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Addressing the issue of time
• Every BI doesn’t have to be perfect
• Think of it as “planting a seed” by raising awareness
• https://adept.missouri.edu/Resources.aspx
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Coding & Billing
• SBIRT services are reimbursable
• Though not all codes are billable in all states
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www.millenniumhcs.com
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http://sbirt.samhsa.gov/coding.htm
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What can we do?
• Be supportive of our efforts – encourage development of
these skills in students across the health professions
• Be familiar with SBIRT – if precepting or leading PBL group
know the terminology, know what a good BI should look
like
• Complete an online training – abbreviated and free CME
• Attend an in-person training – full-day for CME credit
• Join the team – the more the merrier
• Implement SBIRT in your clinical setting – We’ll be glad to
help
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Questions