SCREENING, BRIEF INTERVENTION & REFERRAL TO TREATMENT (SBIRT) IN THE HOSPITAL EMERGENCY DEPARTMENT June 23, 2015 HOUSEKEEPING ITEMS Please enter your AUDIO PIN To communicate with speakers, please use the “chat” function; Ask questions at any time. Webcast will be recorded. 2 TODAY’S AGENDA SBIRT in the Emergency Department Jim Winkle,MPH Dept. of Family Medicine OHSU Hospital Case Studies • Mercy Medical Center-Todd Luther • Willamette Valley Medical Center-Carolyn Lash 3 SBIRT in the Emergency Department Jim Winkle, MPH OREGON Website: sbirtoregon.org • Demonstration videos • Screening forms • Billing code information • Pocket cards and tools • Interactive training curriculum • Role play handouts and slides SBIRT Brief Referral to Screening Intervention Treatment “A public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at risk of developing these disorders.” SAMHSA SBIRT vs. business as usual SBIRT implemented No SBIRT • Routine and universal screening, • Inconsistent and selective regardless of medical complaint screening • Non‐systematized narrative • Validated, standardized screening tools questions • Alcohol use seen as a continuum • Alcohol use seen as dichotomous • Evidence-based, patient-centered • Ineffective, directive style of change talk communication • Ongoing transition between primary • Discoordinate/unclear referrals care and treatment and follow up Relevance to medical settings • Significant prevalence of unhealthy alcohol and drug use • Substantial associated morbidity, mortality, and health care cost • Valid screening instruments • Interventions are effective, inexpensive, and feasible Zones of substance use IV Dependent III Harmful II Risky I Low risk Zone I: Low risk Defined by: IV • No use, or III II • Adult alcohol use within low-risk limits I Low risk Low-risk limits do not apply to drug use Adult low-risk limits for alcohol use in the U.S Drinks Drinks per per • Commonly week day recognized limits Men 14 4 in U.S Women 7 3 • Standard drink Ages >65 7 3 contains .6 oz of Pregnancy 0 0 pure ethanol NIAAA Adolescent low-risk limit for alcohol use: 0 • Even first use can result in tragic consequences. • Adolescence is a period of neurodevelopmental vulnerability • Earlier use increases chance of later addiction. AAP, 2011 Zone II: Risky Defined by: IV • Alcohol use that exceeds low-risk limits III II Risky • Any adolescent use • Any recreational drug use I Not (yet) dealing with I consequences of use Zone III: Harmful Defined by: • Repeated negative IV consequences from use III Harmful II • Failure to fulfill some major obligations • Use continues despite I I persistent problems Likely correlates with mild or moderate SUD Zone IV: Dependent Defined by: IV Dependent • Patient’s life orbits around use III • Distress or disability II • Tolerance and withdrawal • Use in larger amounts or I I longer period than intended Likely correlates with moderate or severe SUD Alcohol use among adult pts Emergency Room Primary Care Dependent 5% 26% Harmful 8% 22% Risky 9% 74% Low risk Low risk: 38% or abstention Abstention: 40% Ann Emerg Med, 2007. Manwell, et. al, 1998 Alcohol use among adolescents 100 % 90 8th grade 80 12th grade 70 60 50 40 30 20 10 0 Had a drink, Had a drink, Been drunk, Been drunk, Been drunk, last 30 days last year last 30 days last year ever Johnston et al, 2013 Drinking among pregnant women SAMHSA, 2013 Morbidity of unhealthy adult alcohol use: • Liver cancer and cirrhosis • Alcoholic Cardiomyopathy • Mouth and throat cancer • Injuries • Hypertension • Pneumonia • Breast cancer • Gastritis/PUD • Coronary heart disease • Contraindicates many medications • Cerebrovascular disease • Exacerbates numerous • Pancreatitis chronic medical conditions • Stroke NIAAA, 2003 Exam room sheet illustration Depression. Anxiety. Aggression. Dependence. Insomnia. Memory loss. Premature aging. Cancer of the throat and mouth Hypertension. Heart failure. Anemia. Frequent colds and infections, Blood clotting. Breast cancer. increased risk of pneumonia Vitamin deficiency. Bleeding. Liver damage Stomach inflammation. Diarrhea. Malnutrition. Erectile dysfunction, birth defects, developmentally delayed or low birth Inflammation of the pancreas. weight babies. Impaired sensation leading to falls. Painful nerves. Numb, tingling toes. Failure to fulfill obligations at work, school, or home. Car accidents. Legal problems. Risks of adolescent alcohol and marijuana use • Brain damage • Pregnancy • Injuries • STDs • School Failure • Later addiction • Violence • Stunted growth and fertility • Arrests, Incarceration • Suicide • Sexual assaults NIDA, Office of the Surgeon General, NPR, CSAM, Hendershot et al, IBT GWU, 2007 - 2014 Leading Causes of mortality, ages 10-24 Motor vehicle crashes 30% Other unintentional injuries 16% All are associated Homicides 16% with alcohol Suicides 12% and drug use Total 74% Eaton et al., 2010 Percent experiencing dependence in lifetime, based on age of first use, U.S. 100% 90 Alcohol 80 70 Marijuana 60 50 40 30 20 10 0 ≤13 14 15 16 17 18 19 20 21+ Age started using Hingson et al 2006, SAMHSA 2010 Risks of drinking while pregnant Bailey, et al, 2008 Past month drug use among adults 40 35 30 25 20 Percent 15 10 5 0 Age NIDA, 2014 Past year drug use among adolescents Salvia Ritalin 8th grade Cocaine OxyContin 12th grade MDMA Hallucinogens Cough medicine Tranquilizers Vicodin Inhalants Synthetic marijuana Adderall Marijuana 0 % 5 10 15 20 25 30 35 40 NIDA, 2014 Drug use during pregnancy SAMHSA, 2014 Morbidity of adult illicit drug use • Overdose • Hepatitis • Psychotic symptoms • Prenatal exposure: Low • Cardiac arrest birth weight and diminished child • STDs, HIV development • Co-morbidity with mental • Addiction disorders • Motor vehicle crashes • Respiratory illness NIDA, 2012 - 2014 Interventions in medical settings • Positive reinforcement • Brief intervention • Referral to specialized treatment • Brief treatment SAMHSA, 2013 Interventions and zones Dependent IV Referral to specialized treatment Harmful III Brief intervention/referral Risky II Brief intervention I Positive reinforcement Washington state SBIRT ER project Estee, et al, 2008 Alcohol SBI ranks high Nine highest-scoring preventative Score services • 25 recommended • Aspirin chemoprophylaxis preventative • Childhood immunization services series 10 • Tobacco-use screening and • Ranked on health brief intervention impact and cost • Alcohol screening and brief effectiveness intervention • Colorectal cancer screening • Only 3 score higher • Hypertension screening 8 than alcohol SBI • Influenza immunization • Pneumococcal immunization • Vision screening—adults Maciosek, et al. 2006 Common SBIRT clinic workflows Adolescent Brief full screen + intervention or Adult Adult Referral to brief screen + full screen + treatment Adult screening forms www.sbirtoregon.org Adult brief screen One alcohol question One drug question www.sbirtoregon.org Single alcohol question • Single item question recommended by the NIAAA • Sens: 82% Spec: 79% for risky alcohol use Smith, et al. 2009 Single drug question • Sens: 93% Spec: 94% for self-reported current drug use. Smith, et al. 2010 Full screens AUDIT DAST Administering the full screen • Typically delivered verbally by behavioral health specialist • When there’s a “break in the action” - waiting for x-rays, labs, or ready for discharge • Best case scenario: warm handoff • Pts may be more receptive to BHS than medical clinician and answer more honestly than in triage AUDIT • Alcohol Use Disorders Identification Test • Created by WHO, accurate across many cultures/nations • 10 questions - multiple choice • Addresses alcohol only WHO, 2001 Scoring the AUDIT • Each question has five answer choices • Answers correlate with points, totaled for score AUDIT zones and scores Dependent IV Women and Men: 20+ Harmful III Women: 13-19 Men: 15-19 Risky II Women: 4-12 Men: 5-14 I Johnson, et al., 2013 Circling the zone of use AUDIT zones and interventions Dependent IV Referral Harmful III Brief intervention/referral Risky II Brief intervention I No intervention Full screen: DAST • Drug Abuse Screening Test • DAST-10 version • Validated for adults • Cut-off score of 3 has high validity for drug abuse Skinner, 1982. Yudko 2007. Scoring the DAST • Each question has yes or no answer • Yes answers get one point Scoring the DAST DAST zones and scores Dependent IV 6+ Harmful III 3 - 5 Risky II 1 - 2 I Adolescent full screen Front Back CRAFFT www.sbirtoregon.org CRAFFT • Car Relax Alone Forget Friends Trouble • Designed for adolescents • Validated, developmentally appropriate, easy-to use • Less than a minute to complete when self-administered Validation of the CRAFFT • General adolescent outpatients, ages 12-18 • Spanish-speaking teens (CARLOS) • Native American teens Acceptable and feasible with 9-12 year olds Mitchell et al, 2014; Harris et al, 2015; Levy et al, 2004; Cummins et al 2003; Gomez, 2011 Interpreting the CRAFFT Score Risk Recommended action “No” to 3 opening No risk Positive reinforcement questions Discuss alternatives to riding with “Yes” to car question Riding risk impaired drivers CRAFFT score = 0 Brief advice Medium risk CRAFFT score = 1 Brief intervention Consider referral for further CRAFFT score ≥ 2 High risk assessment (delivered through brief intervention) 5Ps screening tool • Designed for pregnant women • Asks about use by Parents, her Peers, her Partner, in her Past, and during her Pregnancy • Also screens for tobacco,