e-mail: [email protected] May 2008 The Scope of the Problem and the Case for Screening, Brief Intervention, Objectives and Referral to Treatment After reading this issue, the Lee Kim Erickson, MD clinician should be able to: azardous alcohol use and alcohol astounding numbers that we need to • Identify the scope of the problem to implement abuse and dependence are more address. prevalent in the United States screening, brief intervention, H This is undeniably a massive public health and referral for treatment than most conditions routinely screened • Review the history of and for and treated by physicians, yet doctors problem, yet doctors rarely screen for it or integrate the Screening, usually fail to identify and treat problem give advice to their patients about alcohol Brief Intervention, Referral use. In 1997, 10 states collected data and Treatment Program into alcohol use. The impact of this failure on society is enormous. Alcohol consump- on health interventions for smoking and their practice drinking. Only 23 percent of binge drinkers • Develop a protocol to tion is the third most common actual effectively screen patients 1 received advice about alcohol; two million cause of death in the United States. 9 for alcohol use and to Alcohol is a factor in 60 to70 percent of opportunities to intervene were lost. Inad- perform a comprehensive equate training and pessimism about the risk assessment homicides, 40 to 50 percent of fatal motor vehicle accidents, 60 percent of fatal burn effectiveness of intervention make many • Formulate strategies to physicians reluctant to screen for alcohol effectively communicate injuries and drownings, and 40 percent of concern about alcohol use 2 problems; physicians also feel constrained fatal falls. The National Institute on Alco- 10 or abuse without judging hol Abuse and Alcoholism conservatively by time and reimbursement pressures. patient behavior • Identify links with estimates economic costs in excess of Most physicians are familiar with the 3 appropriate treatment $184 billion a year. late-stage sequelae of alcoholism. Acute resources Hazardous alcohol use and abuse cuts hepatitis, pancreatitis, gastritis and • Examine the rationale bleeding ulcers, cirrhosis and liver failure, and evidence to support a wide swath through all age groups. pharmacotherapy’s to treat On any average day in the past year, cardiomyopathy and heart failure, acute alcohol problems in the 8,000 children ages 12 to 17 had their withdrawal and delirium tremens are primary care setting first drink.4 Approximately 47 percent of sadly common place on inpatient medical people who begin drinking before the age wards. Health care providers are used Faculty information can be to seeing only these sickest of patients, found on page 2. All faculty of 14 become dependent later in life, com- have stated they have no pared with 9 percent who begin drinking and therefore understandably do not conflict of interest to disclose. after the legal age of 21.5 Nearly 18 per believe that intervention and treatment cent of eighth graders and 41.2 percent work because they have little experience Activity Development Team of tenth graders have been drunk at least with the patients who get better. Yet data – Barbara A. Layne, RN, has on treatment for alcohol dependence returned her disclosure form once.6 In 2001 alone, 2.8 million 18-24 stating that she has no relevant year old college students reported driving shows success rates well above popular financial relationships to under the influence; 696,000 reported perception: decreases in alcohol use of disclose. being assaulted by a fellow student under 60 percent, decreases in criminal activity the influence, and 97,000 were victims of of 50 percent, and increased employment alcohol-related sexual assault.7 And while rates of 40 percent. It is estimated that every dollar spent on treatment saves us the prevalence of problem alcohol use 11 in the elderly is debated, it is clear that $12 in crime and health care costs. In there are serious concerns about alcohol comparison, consider our success rates use in older patients who are already at at managing hypertension—less than one increased risk for falls and hip fractures, third of patients with high blood pressure automobile accidents, and multiple are adequately treated and controlled. Copyright © 2008 medication interactions.8 These are all Pennsylvania Medical Society continued on page 2 2 The Scope of the Problem and ized controlled trial of 774 problem change. And for patients identified as drinkers, those who received brief having more severe alcohol problems, the Case for Screening, Brief interventions had significant reductions Referral to treatment is most appropriate. Intervention, and Referral to in seven-day alcohol use and episodes As of August 2007, the SBIRT program Treatment of binge drinking, as well as significantly fewer hospital admissions and emer- had screened 536,000 individuals and continued from page 1 gency room visits. The positive effect of had been implemented in multiple trauma the brief intervention was sustained at 48 centers/emergency rooms, community Alcohol abuse and dependence is more months and provided an estimated sav- clinics, federally qualified health centers, prevalent than hypertension and re- ings of $43 in future health care costs for and school clinics and primary care prac- sponds to treatment at higher rates. 16 every dollar spent.15 tices. More about the SBIRT program can be found at http://sbirt.samhsa.gov In the last decade, research has been In response to this overwhelming and many useful screening and inter- focusing on earlier intervention and evidence, the Substance Abuse and vention tools are available through the prevention of alcohol problems. Many Mental Health Services Administration Pennsylvania SBIRT project site at http:// studies on brief interventions for haz- (SAMHSA) launched the Screening, Brief www.ireta.org/sbirt/clinical_tools.htm. ardous alcohol use have repeatedly Intervention, and Referral to Treatment The SBIRT approach to problem drinking demonstrated immediate decreases in (SBIRT) initiative, an implementation grant is a simple, concrete way to incorporate alcohol consumption and alcohol related program to translate the research into screening for and intervention of one morbidity and mortality.12,13 In one practice. SBIRT represents a paradigm of our biggest public health issues into trauma center, brief interventions for shift in health care’s approach to alcohol routine medical care. It is long overdue. hazardous alcohol use decreased use and abuse and targets the hazard- What can you do to help? alcohol consumption at 12 months ous and problem drinker in an effort by 21.6 drinks per week, compared to intervene earlier and prevent further Screen patients universally for alcohol, to an increase of 2.3 drinks per week morbidity, mortality, and progression even if they present with other addictive in the control group receiving no to end-stage alcoholism. Screening disorders, i.e., opiate dependence, etc. advice. There was also a 47 percent quickly assesses the level of alcohol use reduction in injuries requiring a visit to and identifies the appropriate level of an emergency room or trauma center.14 References are available at intervention. Brief intervention focuses on And it appears that the decreases in www.pamedsoc.org/counterdetails increasing awareness regarding alcohol morbidity and mortality may hold longer or by calling (800) 228-7823, use and motivation toward behavioral than six to 12 months. In one random- extension 7806. Faculty and all others who have the ability to control the content of continuing medical education activities sponsored by the Pennsylvania Medical Society are expected to disclose to the audience whether they do or do not have any real or apparent conflict(s) of interest or other relationships related to the content of their presentation(s). Lee Kim Erickson, MD is Medical Director for Quality at President of Allegheny County Medical Society and West Penn Hospital, Forbes Regional Campus, Monroeville, President-Elect of the Pennsylvania Society of Addiction Pa. She is a resident faculty member of West Penn Family Medicine. Medicine Residency Program in Pittsburgh, Pa. and director of the SBIRT Program. She is board certified in Bradley J. Miller, DO, FAAFP is Director of the Family Medicine. Dr. Erickson is a member of the American Osteopathic Medical Education and Director of the Academy of Family Physicians, Pennsylvania Academy of Williamsport Hospital and Medical Center Osteopathic Family Physicians, and the Society of Teachers of Family Family Medicine Residency Program. He is a member of the Medicine. Screening Brief Intervention Referral and Treatment (SBIRT) Rural Subcommittee for the Pa Department of Health, Adam J. Gordon, MD, MPH, FACP, FASM is Assistant Bureau of Drug and Alcohol Programs. Professor of Medicine, Division of General Internal Medicine, and Core Faculty of the Center for Health Equity Research Dr. Miller is board certified in Family Medicine by both the and Promotion, among other appointments. He is a staff American Board of Family Medicine and the American physician with the Veterans Administration (VA) Pittsburgh Osteopathic Board of Family Physicians. He is a member of Health System, and Director, Substance Abuse Detection many professional organizations including the Pennsylvania and Early Intervention Program of the Veterans Affairs, Medical Society, Lycoming County Medical Society,