Transcript Development of Screening and Brief Intervention Procedures

Screening and Brief Intervention
for Substance Abuse: Overview of
Practical and Conceptual Issues
Thomas Babor, PhD, MPH
Objectives
• Discuss SBIRT programs in relation to a
public health approach to substance abuse
• Describe progress made in the past two
decades in the development of concepts,
screening tools, intervention techniques, and
implementation for SBIRT
• Discuss implications for traffic safety
Basic Elements of SBIRT
• Screening—How, Who, and When?
• Treatment matching linked to screening results
• Brief intervention
• Brief treatment
• Referral to standardized assessment and more
intensive treatment
• Continued monitoring
Conceptual Overview of SBIRT
Screening, Brief Intervention, and Referral to Treatment
No/Low Risk
Negative Screen
Raise the Issue
Conduct Screening
High-Risk or
Risky
Substance Use
Positive
Screen
Brief
Intervention
Brief Treatment
Risk
Continues
Referral to
Treatment
Individual
screening scores
determined to
assess level of
risk
Risk Continues
Risk Continues
Specialist
Treatment
Motivational
Counseling
Risk Reduced
Follow-up
Risk Reduced
Follow-up
Risk
Reduced
Follow-up
Spurt – a sudden burst of energy or activity
A Brief History of SBIRT
• Phase I (1980’s) Development of screening tests
• Phase II (1985-current) Clinical trials of brief
intervention with risky drinkers and drug users
• Phase III (1990-current) Feasibility research on barriers
to implementation of SBIRT
• Phase IV (2000-current) Development and evaluation of
national plans for alcohol SBIRT program initiatives in
health care systems in both developed and developing
countries
Distinctions / Dichotomies
•
•
•
•
•
Treatment vs. prevention
Alcoholism vs. heavy drinking;
Addiction vs. recreational drug use
Disease conditions vs. risk factors
Individual vs. public health perspectives
Preconditions for a Public Health Approach
to Screening and Early Intervention
• Adequate definition of problem and
operational criteria for diagnosis
• Natural history of problem understood, as well
as risk factors and populations at risk
• Screening tests available: brief, easy to
administer, reliable, valid
• Effective intervention and treatment methods
available
Evaluating a SBIRT Program
Efficacy
Can it work?
Effectiveness
Does it work?
Availability and Reach
Is it reaching those who
need it?
Efficiency
Is it worth doing compared
to other uses of the same
resources?
Key Terms and Definitions
Dependence Syndrome
Harmful Use
Hazardous Use
A cluster of cognitive,
behavioral, and
physiological symptoms
A pattern of substance use
that has already caused
damage to health
A pattern of substance use
carrying with it a risk of
harmful consequences to
the user
The Drinkers’ Pyramid
Dependent Drinkers
At-Risk Drinkers
Responsible Drinkers
Abstainers
Illicit Drug Use Pyramid
Connecticut Adults Age 18 to 39
3%
(24,912)
Illicit drug abuse requiring
formal treatment
14%
(104,653)
Current illicit drug use
83%
(619,313)
No illicit drug use
Note: Figures based on Connecticut 1996 adult household telephone surveys
and 2000 US census of adults age 18 to 39.
Goals of Screening
• Identify both hazardous/harmful drinking or
drug use and those likely to be dependent
• Use as little patient/staff time as possible
• Create a professional, helping atmosphere
• Provide the patient information needed for an
appropriate intervention
Common Self-Report Screening
Assessments
• Alcohol
– AUDIT, CAGE, TWEAK, et. al.
• Drugs
– DAST
• Combined Substances (Tobacco, Alcohol,
Other Drugs)
– ASSIST, CAGE-AID, SASSI
A Short History of SBIRT: Phase II
Alcohol Brief Intervention Trials
• Malmo Study (1982)
• WHO AMETHYST Project (1985-1996).
• Other trials (Wallace et al., Fleming et al.)
• Meta-analyses and review papers
Sequence of Study and Procedures Associated with Each Condition
Screening
Recruitment
WHO Composite Interview Schedule
Stratified Random Assignment
GROUP I
Control group
GROUP II
Simple Advice
•Review interview results
•Explain Sensible Drinking
Leaflet (5 min)
GROUP III
Brief counselling
Review interview results
Explain Sensible Drinking leaflet
(5 min)
Introduce Problem Solving Manual
(15 min)
Mention Diary cards and identify a
helper
Mention six-month follow-up interview
Ask patient to fill out Health and Daily Living Questionnaires
Six month follow-up
Alcohol Brief Intervention Trials,
Results of Meta-analyses
• Brief interventions (BI) can reduce risky alcohol use
by about 20% for at least 12 months
• Approach is effective with younger and older adults,
men and women.
• Results mixed on longer-term health care utilization
and reduction of alcohol-related harm.
• Results consistent across providers
(professional/nonprofessional), settings (PHC, ED,
Trauma, hospitals), and cultural groups
Subsequent Brief Intervention Trials
and Other SBIRT Research
• Brief intervention trials with at-risk drug users
• Combined health behavior risk factor brief
intervention research
• Brief treatment trials with substance users
• Motivational Enhancement Therapy (NIAAAfunded Project MATCH)
• Brief Marijuana Treatment (SAMHSA-CSATfunded MTP study)
MTP
Marijuana Treatment Project
A Multi-site Study of the Effectiveness
of Brief Treatment for Cannabis Dependence
A Cooperative Agreement
funded by
SAMHSA-CSAT
Study Design
Recrutiment of 450 chronic
marijuana users through
advertising and referral
Screening for Eligibility
Enrollment
and
Informed Consent
Baseline Assessment
Random Assignment
Delayed
Treatment Control
(DTC)
Brief
Treatment
(BT)
Follow-up Evaluation
4, 9, and 15 months
Extended
Treatment
(ET)
Outcomes: Baseline, 4, 9 & 15-months
% of Days Smoked Marijuana
100
% Days of Marijuana Use
90
80
70
60
50
40
30
20
10
0
Baseline
4 Months
Delayed Treatment
9 Months
2-Session Treatment
9-Session Treatment
15 Months
A Short History of SBIRT:
Time for Implementation Efforts
• Brief interventions and brief treatments are effective
with smokers, drinkers and results are promising with
marijuana users.
• SBIRT poised for implementation
• Two decades of clinical research, program development
• Effective screening tests, brief intervention and brief
treatment protocols available
• Training programs developed
• There is general agreement on the need to “broaden
the base” of treatment (expand treatment and early
intervention services to less severe cases and
populations at risk)
SBIRT Implementation Trials –
• R.A. Senft et al., primary care, 1997
• Prescription for Health Initiative, RWJ/AHRQ
(2002 – present)
• Vital Signs, UConn, dental clinics (2002–2004)
• Cutting Back, RWJ, 2002-2005
What is being learned from
implementation research?
• It can be done, but it’s not easy
• Staff participation in planning is critical
• Training does change beliefs and builds
capacities; practice reinforces change
• Many factors contribute to success & problems
• Outcomes may be somewhat less than in
tightly managed trials
• Costs are low compared to many services
Phase IV: The Future Has Arrived
USA Policy Implications
•
•
•
•
Expert committee reports
Standards and practices
National alcohol screening day
SBIRT National demonstration program
US Preventative Services Task Force Recommends that Primary
Care Clinicians Screen and Counsel Adults to Prevent Misuse of
Alcohol
AHRQ, April, 2004
• Primary care clinicians should screen all adults and pregnant
women for alcohol misuse and refer them for counseling if
necessary
• Women who drink more than 7 drinks per week or more than 3
drinks per occasion and men who drink more than 14 drinks
per week or more than 4 drinks per occasion are considered to
be risky or hazardous drinkers
• The term alcohol misuse includes risky drinking as well as
harmful drinking
• Effective counseling sessions for risky drinkers should include
advice to reduce current drinking; feedback about current
drinking patterns; explicit goal-setting, usually for moderation;
assistance in achieving the goal; and followup through
telephone calls, repeat visits, and repeat monitoring.
Standards and Practices
• Insurance policy legislation can restrict or
facilitate SBIRT
• American College of Surgeons, Committee on
Trauma, recommends new standards requiring
Level 1 and level 2 trauma centers to "include
identification and intervention for problem
drinkers."
National Alcohol Screening Day
• The largest and most visible SBIRT activity in
the USA
• Established in 1999
• Three objectives:
– Administer free and anonymous alcohol screening
in an accessible setting
– Provide referrals for treatment
– Provide public education about the impact of
alcohol on health
World Health Report 2002
• Burden due to
major risks
• Cost-effectiveness
of relevant
interventions
• Policy implications
Leading 12 selected risk factors
as causes of disease burden
High Mortality
Developing
Countries
1
2
3
4
5
6
7
8
9
10
11
12
= Major NCD risk factors
Low Mortality
Developed
Developing Countries
Countries
Underweight
Unsafe sex
Unsafe water
Indoor smoke
Zinc deficiency
Iron deficiency
Vitamin A deficiency
Blood pressure
Tobacco
Cholesterol
Alcohol
Low fruit & veg intake
Alcohol
Blood pressure
Tobacco
Underweight
Body mass index
Cholesterol
Low fruit & veg intake
Indoor smoke - solid fuels
Iron deficiency
Unsafe water
Unsafe sex
Lead exposure
Tobacco
Blood pressure
Alcohol
Cholesterol
Body mass index
Low fruit & veg. intake
Physical inactivity
Illicit drugs
Unsafe sex
Iron deficiency
Lead exposure
Childhood sexual abuse
Cost Effectiveness of Brief Intervention
with Risky Drinkers
From: Chisholm, D., Rehm, J., Van Ommeren, M. & Monteiro, M. (2004) Reducing the global burden of hazardous
alcohol use: A comparative cost-effectiveness Analysis. Journal of the Studies on Alcohol 65:782-793.
Implications and Applications of
SBIRT for DUI Countermeasures
• Driver education programs – early intervention
• DUI specific SBI, e.g., screening items,
intervention techniques
• Referral to alcohol assessment
• Referral to treatment
POLICY AND CLINICAL
IMPLICATIONS
• A successful example of translational research
• Meets requirements of a public health approach to secondary
prevention, but needs to focus on high risk groups in high
volume settings for maximum effect
• Consistent with IOM vision of “Broadening the Base” of
treatment, and SAMSHA/CSAT Access To Recovery Initiative
• Could serve as a major feeder to treatment system, AND an
additional secondary prevention component
• Alcohol SBI as a Trojan Horse to drug SBI
• Direct and indirect applications to drink-driving
countermeasures