Transcript Gonzales and Freese_FINAL

Illustration of Statewide
Adoption of NQF Standards:
Identification of Substance Use
Conditions
Rachel Gonzales, Ph.D.
Thomas E. Freese, Ph.D.
UCLA ISAP
Substance Abuse Research Consortium
2009 Meeting Series
Presentation Objectives
Provide you with an overview of the NQF
Domain I: Identification of Substance Use
in relation to:
– What we know?
– California’s Response
History of SBIRT development
Current efforts
The future
What do we know?
NQF: Identification Domain
Screening & Case Finding
– Evaluation process allows for
determining whether an individual is
at risk for or has an alcohol or drug
problem
Assessment & Diagnosis
– In-depth clinical process to determine
the specific tx needs of the individual
when “screening” identifies risk for an
alcohol or drug problem
Identification of Substance Use
is a
Public Health Priority…
Challenges
Striking disconnect between the proportions of individuals
reporting misuse of substances or diagnosed with substance
abuse/dependence and those receiving treatment
In Treatment ~1.8 million
Abuse/Dependence ~22.3 million
Misuse of Illicit Drugs ~ 19.9 million
Misuse of alcohol ~ 126.8 million
Little attention has been paid to the latter “risk groups”
(Klitzner et al., 1992; Fleming, 2002)
Targeting Latter Risk
Groups
AOD risk settings….
AOD Risk Settings
Health (including mental) Care
– Primary care
– Emergency Rooms/Trauma Centers [40%
of visits are injury-related and 50% of them
are alcohol-related (Nilsen et al., 2008)]
Educational institutions
Criminal justice settings
Others…
– Dental offices
Research of Identification in Health
Care Settings
CASA Health care study:
included 650 primary care
physicians with over 500 patients
in tx for chronic diseases:
Findings:
– LESS than 1/3 of PCP’s
Screen for Substance Use
– ~50% of patients said “PCP
asked nothing of AOD use”
– 10% said “PCP asked, but did
nothing”
Missed Opportunity: National Survey of Primary Care Physicians and Patients, the
National Center on Addiction and Substance Abuse (CASA) @ Columbia University, NY
2000
Research of Identification in Health
Care Settings
Results from a member survey of
American Association for the Surgery
of Trauma:
– Majority (~50%) screen
LESS than 25% of their patients
– Issues:
>80 % no training in
AOD screening
75% not familiar with standard
screening instruments
Arch. Surg. Vol 134, May 1999
A Public Health Early Intervention Solution:
Screening, Brief Intervention & Referral to
Treatment - SBIRT
Identify patients who
may not perceive a need
for behavior change
Focus on at-risk vs.
dependent individuals
Why SBIRT?
Approaches are deemed
an evidence based
practice
Approaches are clinically
effective and cost-efficient
SBIRT Approaches: Definitions
Screening: assesses the severity of substance use
& identifies the appropriate response
Brief Intervention: focuses on increasing insight &
awareness regarding substance use and
motivation toward behavioral change:
Give feedback about screening results, inform
patient about consuming substances, advise on
and assess readiness to change, establish goals
and strategies for change, and follow-up
SBIRT Approaches: Definitions
Brief Treatment: consists of a limited number of
highly focused and structured clinical sessions
with the purpose of eliminating hazardous and/or
harmful substance use -- usually increased
intensity and shorter duration than traditional
treatment
Referral to Treatment: provides those identified
as needing more extensive treatment with
increased access to specialty treatment
SBIRT Approach Framework:
Response Depends on Score*
Screening Score
Negative Screen
Positive Screen
Positive
Reinforcement
Moderate Use Moderate/High Use Abuse/Dependence
Brief
Intervention
Brief
Treatment
Referral to
Treatment
*Severity & Consequences of use
Overall SBIRT Goals
Increases access to care for persons with or
at-risk for substance use disorders
Improves linkages between at-risk & AOD
settings
Fosters a continuum of care: integrates
prevention, intervention, and treatment
services
Takes advantage of the
“intervention moment…”
The Good News…
It Works!
It Works!
Well supported in health care settings
– Major impact on reducing morbidity & mortality
– Saves $: each dollar spent on SBIRT
saves 4 dollars in other health-related
costs
So…
– SBIRT required for certification of all
Level I & II Trauma Centers
– U.S. Preventive Services Task Force
recommends routine SBIRT in primary care
settings
Babor & Kadden, 2005; Gentilello et al, 2005
Examples of Reductions in Morbidity & Mortality
Study
Results
Reference
Trauma
patients
48% fewer re-injury (18 months)
50% reduced re-hospitalizations
Gentilello et al,
1999
Hospital ER
screening
Reduced DUI arrests (1 DUI arrest
prevented for 9 screens)
Schermer et al,
2006
Physician
offices
20% fewer motor vehicle crashes over
48 month follow-up
Fleming et al,
2002
Metaanalysis
Interventions reduced mortality
Cuijpers et al,
2004
Metaanalysis
Interventions can provide effective
public health approach to reducing
risky use.
Whitlock et al,
2004
Research To date: Mostly Alcohol
Evidence for illicit drugs sparse…but promising
– Burke et al. 2003: Meta-analysis
– Bernstein et al. 2005: Randomized Controlled Trial
– WHO study 2008: Randomized Controlled Trial in
multiple sites internationally
– Madras et al. 2009: SAMHSA program evaluation at
multiple sites (intake vs 6 mo follow-up)
Overall Findings: SBIRT efforts related to positive
outcomes (abstinence, increased health, social, legal,
economic, and vocational outcomes)
California Response
How has California been
responsive to initiatives
that use ‘screening & case
finding’ techniques to
identify individuals with
substance use disorders?
Importance of SBIRT in California?
SBIRT is a system change that will move
a core mission of ADP forward…
…moving the AOD system to a
comprehensive and integrated
continuum of services system model
Source: UCLA ISAP State Treatment Needs Assessment, 2001.
SBIRT in the AOD Service Delivery
Continuum of Care
Prevention
Primary
Secondary
Reducing the
probability that a
substance use
problem develops
Minimizing the
severity of a
substance use
problem if it occurs
Intervention
Screening/Assessment
Brief Intervention or
Referral to Treatment
Intervention/Treatment
Screening/Assessment
Brief Treatment
Treatment
Tertiary
Minimizing the
disability caused by
substance use
problems
Recovery Support
Continuing Care
Care Management
Brief History: SBIRT Efforts in CA
California was selected as 1 of 7 states to
participate in a national SBIRT demonstration
project funded by SAMHSA (5-year cooperative
agreement) – called CASBIRT
CASBIRT initiative
– Administered by CA ADP
– Managed by San Diego County, Alcohol & Drug Services
AND San Diego State University, Center on Alcohol and
Other Drug Studies & Services
What is the CASBIRT Model?
SBIRT implemented in trauma, emergency (chest pain
urgent care), & primary care settings throughout San
Diego County
Patients 18+ are routinely screened by certified Health
Educators during their visit using a standardized,
scripted screening instrument
SBIRT service response made depending on score
CASBIRT staff: conduct evaluation by tracking patients
deemed as “at-risk”, provide follow-up booster calls, and
facilitate their participation in appropriate services
CASBIRT Effectiveness
 To date, over 500,000 patients have received SBIRT
services in SD county
 Between 2005-06 alone, SBIRT performed with
125,000 patients
– 48% of high risk clients completed at least one
Brief Treatment session
– 74% stopped or reduced their substance use
Current status: funding by San Diego county AOD
agency supported CASBIRT services through June
2009 (now looking to other grant mechanisms)
SBIRT in Educational Settings
SAMHSA Cooperative Agreement to implement
SBIRT in College setting: UCLA Access to
Care Project (2006-2009)
1st pick: Student Health Center
(although not interested)
2nd pick: Counseling &
Psychological Services
– Given the prevalence of co-occurring substance
abuse/mental health disorders, counseling centers
are good places for early intervention
– Serves over 6,000 students a year
Spear & Rawson
Access to Care Project Team
• SBIRT Implementation: UCLA
Counseling & Psychological
Services center clinical staff
(n=28):
•Psychologists & LCSWs
•Interns (social work, post-docs)
• Project Liaison: ensure proper implementation
by clinical staff
• SBIRT Evaluation: UCLA ISAP team
(Spear, Rawson, Ransom)
Spear & Rawson
SBIRT Implementation in Access to
Care Project
Student
completes
pre-screen
at routine
intake*
AUDIT-C plus 1
question on
illicit drug use in
past 30 days
*performed at
Kiosk
Pre-screen
score
tabulated by
Kiosk
computer
If +, clinician
conducts
ASSIST in 1st
therapy session
as well as brief
intervention (if
deemed
appropriate)
Clinician
refers student
to UCLA ISAP
Evaluation
Students
given ASSIST
are GPRA’ed
at intake & 6mo follow-up
Spear & Rawson
Access to Care Results
As of Oct 2008: 6,786 students coming
for initial appointments were prescreened
– 38% of students scored positive
Of those who scored positive 60%
received the ASSIST screen & brief
intervention (n=1,442)
Spear & Rawson
GPRA Results (2007)
Means*
Male n=324
Female n=495
39.6%
60.4%
Mean Age
21.5 yrs
21.6 yrs
Avg binging (5+ drinks)
past mo
5.3 days
3.6 days
Marijuana use (past mo)
8.9 days
5.5 days
Cocaine use (past mo)
< 1 day
< 1 day
Hallucinogen use (past
mo)
< 1 day
<1 day
Meth use (past mo)
<1 day
< 1 day
Gender
Spear & Rawson
GPRA Results: Binge Drinking
85% of binge drinkers
(n=425) received a
brief intervention
46% of binge drinkers
reported no binging at
6-mo follow up
Spear & Rawson
GPRA Results: MJ Use
37% (n=303) of students
reported any marijuana use in
past 30 days at intake
Of these students, 87%
(n=264) received a brief
intervention
Half (53%) of marijuana
users reported no use at 6month follow up
Spear & Rawson
Lessons learned: SBIRT in Educational
Mental Health Settings
Has made mental health staff more aware of
substance use issues among students
Offers mental health staff a more systematic
approach for identification (less of a “judgment
call”)
Allows college students to:
– express concerns about their substance use
– “shift their thinking” about their use
Spear & Rawson
Lessons learned: SBIRT in Educational
Mental Health Settings
Implementation challenges
– Interrupts routine clinical flow: difficulty dedicating
15-20 minutes of customary 50-minute routine
intake session to SBIRT
– Not enough time to do (and score) SBIRT in
routine assessments (generally 30 minutes)
To address: UCLA ISAP team developed & pilottested a self-administered computer version of
ASSIST (which is now used)
– Briefer, efficient, feasible
Spear, S.E., Tillman ,S., Moss, C., Gong-Guy, E., Ransom, L., Rawson, R. Another way of talking about
substance abuse: Substance abuse screening and brief intervention in a mental health clinic. In press.
Journal of Human Behavior in the Social Environment.
Sustaining Implementation of
SBIRT within College Campuses
System-wide training across the State
1st Training: March 2008
UCLA hosted and
trained (1 day) 11
counseling centers on
SBIRT & use of the
ASSIST
CSU Bakersfield
UC Merced
UC San Diego
UC Irvine
University of San Diego
CSU Long Beach
UC Riverside
Vanguard University
Occidental College
UC Santa Barbara
Woodbury University
Spear & Rawson
Evaluation of 1st Training
Survey sent assessing implementation of the
screening tool at their centers (n=11)
7 centers responded:
– 3 reported using the ASSIST
– 4 reported not doing any screening, but indicated
that they “intend to use” the ASSIST when they
have more time and staff to develop a plan
Spear & Rawson
2nd Training: Oct 2008
UCLA conducted day
long SBIRT training
with 7 additional
colleges
Hosted at UCSF
UCSF
San Jose State University
CSU Sacramento
Notre Dame de Namur
University
San Francisco State
University
Santa Clara University
UC Berkeley
Spear & Rawson
Evaluation of 2nd Training
Survey sent related to implementation of
screening tool
– Only 2 implementing ASSIST
Barriers cited included:
– Lack of time
– Short staffed
– Clinicians focused on other priorities
– Limited resources
– Need additional training
– ASSIST doesn’t relate to students
Spear & Rawson
Integrating SBIRT into
California Trauma
Centers
Timeline: April 09-Nov 09
Under collaboration with
ADP, UCLA is conducting
large scale SBIRT
training effort
– Series of day-long
workshops on SBIRT
with trauma centers,
emergency
departments & primary
health care settings
Trainings offered during
Spring, Summer and Fall
2009
Participant Counties (n=9)
– Alameda
– Ventura
– Los Angeles
– Santa Clara
– Contra Costa
– Santa Barbara
– Fresno
– Solano
– Nevada
Data collection: GPRA
Freese & Rawson
Integrating SBIRT in CA
Criminal Justice Settings
Implementation by CASCs
– Homeless Healthcare LA
– Behavioral Healthcare Services
Community Transition Unit Participants
– LA County Jail (Twin Towers)
– LA County Police Department (Parker Center)
Evaluation: UCLA doing GPRA
Rawson & Freese
Integrating SBIRT in CA
Criminal Justice Settings
Under a SAMHSA grant, ADP, LA County (DPH,
ADPA) & UCLA are conducting a 2-year pilot
demonstration project:
– Implementing SBIRT in 2 Community Transition
Units
Phase I: training staff on SBIRT & the ASSIST
Phase II: Pre-screening all short-term stay
detainees to identify AOD risk (low vs high) using
AUDIT-C+ (3 etoh/2 drug)
Phase III: ASSIST & BL GPRA
Phase IV: Follow-Up (6-mo GPRA)
Rawson & Freese
Criminal Justice SBIRT Flow Chart
Parker Center
(n=5,000)
Low-Risk Detainees
Information and
Referrals Provided
Short-term Detainees
Pre-screened with
AUDIT-C+
CASC
ASSIST
GPRA
6-Month Follow-up
Twin Towers
(n=5,000)
Moderate –
High Risk Detainees
Brief Intervention
Referral if indicated
Rawson & Freese
Integrating SBIRT in CA Tribal Settings
Under a SAMHSA initiative, UCLA partnered with California
Rural Indian Health Board (CRIHB) to provide SBIRT training
for tribal organizations
– Phase I: CRIHB identified specific tribal organizations and
clinics interested in training (Oct 08 – Mar 09)
N=24
– Phase II: UCLA conducted SBIRT/ASSIST training with
identified tribal organizations (2 large trainings: Apr 09 &
Aug 09)
– Phase III: ASSIST implementation by tribal organizations
Depending on tribal community desires: ASSIST will be
conducted with paper and pencil, using a personal
interview or via computers
– Phase IV: Evaluation of adoption in tribal communities
(future)
Rawson, Freese, Dickerson
Training Participants*
Agencies: 10
Gender: 20 Female;
5 Male
Ethnicity/Race:
–
–
–
–
3 Hispanic/Latino
14 American Indian
6 White
3 Native Hawaiian/Pacific
Islander
– 1 Asian
*2nd Training evaluation in progress
Professional Settings
–
–
–
–
–
–
–
–
8 Administration
7 Education
6 Addiction Counselor
5 Social Work/Human Services
2 Medicine
2 Psychology
1 Medicine-Primary Care
5 Other
Rawson, Freese, Dickerson
Assessment &
Diagnosis
What is Assessment/Diagnosis?
Gathering information to:
Confirm the presence of an AOD problem
Identify the severity of the AOD problem & factors that
affect AOD problems:
– Social support networks
– Employment
– Health
– Housing
– Motivation to change
– History of physical/sexual abuse
– Mental illness status
Determine what services/treatment would be most effective
California Illustration II
Identification of Substance Use Disorders
domain: Diagnosis and Assessment
California initiatives that require or
recommend the use of a standardized
biopsychosocial tool(s) for
diagnosing and assessing individuals
with substance use disorders
Pilot Project Efforts Underway
UCLA-ADP COSSR Evaluation work
– Alameda working on developing a framework
to address this area
Issues:
– Clarity on difference between assessment
and diagnosis (where does placement fit in?)
– Identification on specific instrument to use for
each
– Who should do the assessing & diagnosing?
Issues with staffing, training, conflicts of interest
Future Efforts
•Continuing evaluation of
current efforts
•Establishing more funding to
keep activities ongoing
•Expanding partnerships into
other diverse settings, i.e.,
EDD, dental offices, juvenile
justice, high schools, etc.
•White paper on SBIRT to
disseminate CA experience
Acknowledgements
State ADP
Michael Cunningham
Tony Becerra
UCLA ISAP
Richard A. Rawson
Suzanne Spear
Loretta Ransom
Thomas Freese
Jerry Cartier
Dan Dickerson
Anne Bellows
For More Information
http://sbirt.samhsa.gov/grantees/statecali.htm
http://www.casbirt.org/
www.uclaisap.org
www.sbirt.samhsa.gov
www.psattc.org
Thank you!
Contact:
– Rachel Gonzales
[email protected] (310) 267-5316
– Thomas Freese
[email protected] (310) 267-5397
“Be kind, for everyone you meet is
fighting a great battle.”
Philo of Alexandria