Transcript Norm Wetterau, MD - The New York Society of Addiction Medicine

Substance Use Disorders, Primary Care,
Screening and Brief Intervention
Norman Wetterau, MD, FASAM
President: New York Society of
Addiction Medicine
Health Care Reform
Better Health
Less cost
Alcohol brief screening and interventions
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AT SIX MONTHS, MEN DOWN FROM 21.3 TO 14.4 DRINKS A
WEEK, WOMEN FROM 14.8 TO 8.4
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HEALTH CARE UTILIZATION: 20% LESS ER VISITS
37% FEWER HOSPITAL DAYS
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CONTROL GROUP: 55% MORE CRASHES (31 VS. 20)
46% MORE ARRESTS (41 VS. 28)
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BENEFIT: MEDICAL $712 MINUS $166 COST= $546
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SOCIETAL $7,985 PER PATIENT MINUS $205 COST
LONG TERM EFFICACY AND BENEFIT - COST ANALYSIS
MICHAEL FLEMING ET AL. ALCOHOL CLIN. EXP RES. VOL 26 NO 1 PP 36-43
US Preventive Task Force: SBIRT
• Score of 9 out of 10 for cost
effectiveness and usefulness
• Only Immunizations, and discussing
aspirin and tobacco received 10
• Paps: 7 breast cancer 6 diabetes 2
• Solberg et al American J of Prev. Med.34: 143-152
NCQA requirements for certification as a
medical home
To be certified as a medical home NCQA
will require screening for alcohol and
other substance use and an attempt to
address the issue and treat or refer.
Much Federal Money to implement SBIRT
programs in Ers, Hospitals, Practices
and residencies
OUTLINE
• 1. What is screening and brief intervention
about?
• 2. Who does it? How is it done?
• 3. Screening: single question or AUDIT
• 4. Assess: Audit or abuse, dependency
questions
• 5.Advise and Assist
• 6 Follow-up
• 7. Our role
What is SBIRT
• We ask questions to determine if people are
nondrinkers, safe drinkers, at risk drinkers,
harmful drinkers or dependent drinkers
• For those who are at risk, we provide a brief
intervention
• For those whose drinking is harmful or
dependant, we still do a brief intervention but
may also refer the patient for further
treatment.
Safe Drinking
• Men: 14 standard drinks a week, no
more than 4 on one occasion
• Women and men over age 64: 7 drinks
a week, no more than 3 on one
occasion
Demand Treatment!The Risk Paradigm
• A shift toward earlier detection, brief
intervention, and strategic follow up…..
Initial Screening Questions
• Do you sometimes drink beer, wine or
other alcoholic drinks?
• How many times in the last year have
you had (Men 5, woman 4) or more
drinks?
• Or Give them the first 3 questions of the
audit (positive score woman 4, men 8)
• Or give them the whole audit
For positive screens
• Access using the audit or abuse,
dependency questions
• If at risk, provide a brief intervention
• If harmful or dependent, consider
referral
• Follow-up
• Consider offering medications
WHO DOES THIS?
• Initial screen: anyone
– Ask or hand out audits to everyone
– Can be part of other questions that are
asked of all patients
Rest of process: physician, assistant, booklet
or online. It is very helpful if the physician
is involved in some part of this.
Rethinking Drinking
• On one page they list the pros and cons
• Ready or not: keep track, notice how
drinking affects you, make or remake a
list of pros and cons about drinking
• Ask for support from your doctors, a
friend or someone else you trust
strategies for cutting down
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Keep track
Count and measure
Set goals
Pace and space
Include food
Find alternatives
Avoid triggers
Plan to handle urges
Known your no
Planning for change
From rethinking drinking
List goals
Timing: I will start on
Reasons: My most important reasons to
make these changes
Strategies
People who can help
Signs of Success
Approach & Purpose: Alcohol Screening
and Brief Intervention
• STEP 1-ASK ABOUT ALCOHOL USE
& Safe Drinking……………
Safe Drinking:
Men: 14 drinks/week
no more than 4 on one occasion
Women: 7 drinks/week
no more than 3 on one occasion
Alcohol Screening and Brief
Intervention
Ask about alcohol and Drug Use
Specific Screening Questions
• How many drinks do you consume in an average week?
• What is the most drinks you have had on one occasion in the past
month?
• Has alcohol ever caused any problems for you?
• Do you use any drugs other than those prescribed by a
physician?
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If they drink over the safe amount we give patient the Audit.
Demand Treatment!The Risk Paradigm
• A shift toward earlier detection, brief
intervention, and strategic follow up…..
Approach & Purpose
STEP 2: ASSESS FOR ALCOHOL
RELATED PROBLEMS
1. At Risk Drinking….More than safe
amount but no problem yet….
2. Harmful Drinking…..
3. Dependence….
Approach & Purpose
STEP 2: ASSESS FOR ALCOHOL
RELATED PROBLEMS: Use Audit Plus:
Medical Problems such as………
Depression, hypertension, sexual problems,
trauma, sleep disorders
Behavioral Problems such as…….
Work, family, school, accidents
BIG THREE
• Smoking
• Drinking
• Obesity
• Anxiety
• Depression
• Drinking
Approach & Purpose
STEP 2: ASSESS FOR ALCOHOL
RELATED PROBLEMS : AUDIT
Positives on 1-3 (quality questions) - AT RISK
Score of 15-20 can be harmful or dependent
Any drinking that causes problems is HARMFUL
Positives of 4-6 or score over 20 suggest ALCOHOL
DEPENDENCE
Demand Treatment!-The Drinkers’
Pyramid
SAFE DRINKING: MEN 2 DRINKS A DAY, 4 ON ONE OCCASION
WOMEN 1 DRINK A DAY, 3 ON ONE OCCASION
STEP 3: ADVISE, ARRANGE, ASSIST
• State your concerns
• Give clear advice to cut down or
abstain
• Agree on a specific plan of
action
SOLICIT THEIR RESPONSE
• Do the WHO guidelines seem low to you?
• Are there changes you might make that could
reduce your risk of alcohol related problems?
• How hard would that be?
• OFFER SUGGESTIONS TO ACCOMPLISH
THEIR GOALS
OFFER CHOICES
• I could order tests but there is a good chance
that if you reduce your alcohol intake, the
symptoms would go away.
• We can prescribe life long medication, but it
might not be necessary if you are able to
reduce you alcohol use.
• I would like to prescribe this medication but I
cannot unless you are able to stop drinking
EXPLORING PROS AND CONS
• WHAT DO YOU LIKE ABOUT DRINKING?
Acknowledge what they said
• WHAT DO YOU LIKE LESS ABOUT
DRINKING? IS THERE ANYTHING ELSE?
• SUMMARIZE: on the one hand you said... but
then you said …Where does this leave you?
Who should be strongly advised
to abstain rather than just cut
back?
1. Those who have failed before to cut back
and to remain cut back
2. Those who are pregnant, hypertensive or
have abnormal liver function
3. Those taking medicine that should not
be taken with alcohol
4. Those who are depressed
5. Those who might be depressed
Who should be referred?
1. Those with alcohol dependence
2. Those who try to cut down or quit and are
unable to follow through
3. Those who have multiple alcohol related
problems who are unable to stop drinking
4. Patients who have been prescribed medication
for anxiety or depression, have been advised to
stop drinking, and are unable to do so.
PRACTICAL CONCERNS:
TIME AND YOUR STYLE
Example 1. If patient presents with a problem that has
some relationship to alcohol, you could deal with it quickly.
The patient will likely be more responsive right then.
“…. your blood pressure is high today. I noted on
your screen that you drink 20 or so drinks a week.
Although one drink a day might help the heart, 20 a
week can contribute to high blood pressure and harm
the hear ……. Would you be able to cut back or possibly
abstain from alcohol until we sort this problem out?….”
PRACTICAL CONCERNS:
TIME AND YOUR STYLE
“…. . I can see that your anxiety (or
depression) is a real problem. Do you ever have a drink to
calm you down or make your feel better? …….. Alcohol
may make you feel better for a short while, but it actually
increases depression and anxiety levels. I would like to help
you with your problem, but would like to ask you to stop all
alcohol use for a while. Is this something you could do?….
Example 2.
If the person has a significant problem or high audit score
you might say,… “In addition to some counseling around
your problems, I could give you someone to work with you
in trying to cut down or stop drinking…..”
PRACTICAL CONCERNS:
TIME AND YOUR STYLE
Example 3.
. . If the person is simply at risk, you can
provide some advice in just a few minutes, and if necessary,
give them some material and let them know you could talk
to them later about this if they wish;
If you have 5 minutes, you can do a brief
intervention and have them come back later
Specific Protocol
• THE AUDIT
– 1. WHERE WILL THEY BE KEPT?
– 2. WHO WILL GIVE THEM TO THE AT
RISK PATIENT?
Specific Protocol:
Specific Questions on Logistics
• Who will you screen?
• Will this be in a questionnaire format or will the
questions be asked in an interview?
• Who will do the screening? (e.g. nurse, physician)
• What specific questions will you ask?
• If drinking is above safe limits, what will you do
next?
• Where will materials be kept?
BILLING
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214: 1 new complicated problem or 3 chronic problems
Update at least one element of past history
Review of at least 2 systems
• USE WRITTEN SCREEN AS YOUR DOCUMENTATION OF
PAST HISTORY
• IF SCREEN IS POSITIVE, YOU HAVE A NEW PROBLEM AND
A 214
• ON FOLLOWUP, USE ALCOHOL ABUSE AS ONE OF THREE
CHRONIC CONDITIONS YOU ADDRESS.