Screening, Brief Intervention and Referral to Treatment

1
Screening, Brief Intervention and Referral to
Treatment (SBIRT) in the Primary Care Setting
Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP
16th Annual Primary Care Conference Monday ,
March 26, 2012 Millennium Centre, Johnson City,
TN
2
ObjectivesAt the completion of this
presentation, the participant will be able to

• Describe the steps involved in proper screening,
  brief intervention, and referral to treatment
  (SBIRT) for substance abuse in the primary care
  setting.
• Select the appropriate tools to screen for
  alcohol and drug abuse in the primary care
  setting.
• Apply the principle of motivational interviewing
  and stages of change in the SBIRT process.
• Examine principles of coding, billing and
  reimbursement for SBIRT in the primary care
  setting.

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What is SBIRT?

• SBIRT is a comprehensive, integrated, public
  health approach to the delivery of early
  intervention and treatment services
• For persons with substance use disorders
• Those who are at risk of developing these
  disorders
• Primary care centers, trauma centers, and other
  community settings provide opportunities for
  early intervention with at-risk substance users
• Before more severe consequences occur

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SBIRT Core Clinical Components

• Screening Very brief screening that identifies
  substance-related problems
• Brief Intervention Raises awareness of risks and
  motivates patient toward acknowledgement of
  problem
• Brief Treatment Cognitive behavioral work with
  patients who acknowledge risks and are seeking
  help
• Referral Referral of those patients with more
  serious addictions for outpatient or inpatient
  treatment

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Nationwide Movement Toward Standard of Care

• US Preventive Services Task Force
• The Patient Protection and Affordable Care Act
  2010
• 240 million in federal SBIRT funding to states
  and residency training programs (ETSU!)
• NIH funding
• JACHO proposed standard
• Reimbursement codes - Centers for Medicare
  Medicaid Services the AMA (CPT codes) and EM
  codes

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Evidence to Support SBIRT in Primary Care

• Systematic review of 22 randomized controlled
  trials (RCT) of brief alcohol interventions in
  primary care settings
• 15 minutes or less
• At least one follow-up
• Average number of drinks/week reduced by 4 drinks
  over controls
• 10-19 more participants drinking at moderate or
  safe levels than controls
• One study showed maintenance of improved drinking
  for up to 48 months

Whitlock EP, Polen MR, Green CA, et al. Annals
Int Med 2004104(7)557-580. Kaner EF, Dickinson
HO, Beyer F, et al. Drug Alcohol Rev 2009
28(3)301-23.
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Evidence to Support SBIRT in Primary Care

• A meta-analysis suggests an overall reduction of
  56 in number of drinks consumed per week
• The effect size for a brief motivational
  intervention of all types ranged from 0.25 to
  0.57, with participants followed from 3 to 24
  months
• Research has shown brief interventions can reduce
  alcohol use for at least 12 months in patients
  who are not alcohol dependent
• 10-30 of patients can be expected to change
  their drinking behaviors as a result of a brief
  intervention

Burke BL, Arowitz H, Menchola M.Consult Clin
Psychol 200371(5)843-6 Babor TF,
Higgins-Biddle JC. Addiction 200095(5)677-86.
Fleming M, Manwell LB. Alcohol Res Health
199923(2)128-37.
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SBIRT Prospective Cohort Study

• 6 clinical sites
• 459,599 patients screened
• Hazardous use or current substance abuse
  disorder 22.7
• At 6-month follow up
• Drug use 67.7 ?
• Alcohol use 38.6 ?
• Self reported improvement in general health,
  mental health, employment, housing status and
  criminal behavior

Madras BK, Compton WM, Avula D, et al., Drug
Alcohol Depend 200999280-95.
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Major Impact on Public Health?

• Stem progression to dependence
• Improve medical conditions exacerbated by
  substance abuse
• Prevent medical conditions resulting from
  substance abuse or dependence
• Reduce drug-related infections and infectious
  diseases
• Improve response to medications
• Identify those at higher risk of abusing
  prescription drugs
• Identify abusers of prescription drugs or OTC
  drugs
• Have positive influence on social function

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Characteristics of a Good Screening Tool

• Brief (10 or fewer questions)
• Flexible
• Easy to administer, easy for patient
• Addresses alcohol other drugs
• Indicates need for further assessment or
  intervention
• Has good sensitivity and specificity

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Sensitivity and specificity

• Sensitivity refers to the ability of a test to
  correctly identify those people who actually have
  a problem, e.g., true positives
• Specificity is a tests ability to identify
  people who do not have a problem, e.g., true
  negatives
• Good screening tools maximize sensitivity and
  reduce false positives

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SBIRT Goals

• Increase access to care for persons with
  substance use disorders and those at risk of
  substance use disorders
• Foster a continuum of care by integrating
  prevention, intervention, and treatment services
• Improve linkages between health care services and
  alcohol/drug treatment services

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Poll the Audience

• What percentage of your primary care patients
  would be classified with alcohol abuse or
  dependence?
• What percentage would be classified as at risk
  drinkers?
• What percentage of your primary care patients
  have used illicit drugs in the past month?

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Compare Demographics

• How did your answers compare with statistics for
  the general population?
• Percent with alcohol abuse or dependence
• 7 or about 1 in 14
• Percent at risk drinkers
• 23 or nearly 1 in 4!
• Percent using illicit drug
• 8 or about 1 in 12

SAMHSA, National Survey on Drug Use and Health,
2008 Ages 12 in the United States
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Why Screen?
SCREENING WIDENS THE NET
AT-RISK ALCOHOL DRUG USE
ABSTAINERS LOW RISK USE
ABUSE/ DEPENDENCE
Specialized Treatment
Brief Intervention
Primary Prevention
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Annual Screen

• Description
• One question regarding alcohol use
• One question regarding drug use
• Method
• Written form given once a year by front office at
  check-in
• Verbally once a year at triage or by nursing when
  patient is being roomed
• Pre-screens are NOT reimbursable
• Purpose
• Quickly identify patients at risk of misusing
  alcohol or drug and warrant further screening

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Annual Screening

• Once a year, all our patients are asked to
  complete this form because drug use, alcohol use,
  and mood can affect your health as well as
  medications you may take. Please help us provide
  you with the best medical care by answering the
  questions below.

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Full Screen

• Description
• The AUDIT (Alcohol Disorder Identification Tool)
  is a 10-item questionnaire for alcohol use
• The DAST-10 (Drug Abuse Screening Tool) is a
  10-item questionnaire for drugs
• Method
• Given to patients who are positive on annual
  screen
• Written form(s) given when patient is taken into
  exam room by nursing
• Purpose
• Stratify patients into zones of substance use and
  informing the clinician who does a brief
  intervention

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The AUDIT

• Developed by World Health Organization
• Accurate measure of risk across gender, age,
  cultures
• 3 domains of drinking
• Scores 8 gt indicate risky drinking
• Scores 20 gt may indicate need of treatment

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The AUDIT

• Advantages
• Validated on primary health care patients in six
  countries
• Identifies hazardous and harmful alcohol use as
  well as possible dependence
• Brief, rapid, and flexible
• Can be administered as questionnaire or interview

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The AUDIT

• Limitations
• Limited to alcohol screening
• May be too lengthy for some situations (e.g.
  emergency department)
• Not enough research has been completed to
  determine precise cut-off points

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DAST-10
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DAST-10

• Advantages
• Brief and inexpensive
• Provides a quantitative index of the extent of
  problems related to drug abuse
• Can be administered to adults as well as
  adolescents
• Can be administered as questionnaire or interview

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DAST-10

• Limitations
• Does not screen for alcohol use/abuse
• Clients may fake results
• Scores may be misinterpreted
• Should NOT be administered to persons actively
  under the influence of drugs or who are
  undergoing drug withdrawal reaction

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Scoring the DAST-10

• For questions 1 2, score 1 for every YES
  response
• For question 3, score 1 for a NO response
• For questions 4-10, score 1 for every YES
  response

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Scoring the DAST-10

• Score Degree of Problem
• 0 None Reported
• 1-2 Low Level
• 3-5 Moderate Level
• 6-8 Substantial Level
• 9-10 Severe Level

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DAST Interpretation Guide

• Score Action ASAM
• 0 Monitor None
• 1-2 Brief Counseling Level I
• 3-5 Outpatient Level I or II
• 6-8 Intensive Level II or III
• 9-10 Intensive Level III or
  IV

ASAM American Society of Addiction Medicine
level/category
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Brief Intervention

• Description
• Evidence-based and can be performed in as little
  as 3 minutes, typically 5-15 minutes
• Based on motivational interviewing
• Method
• Delivered by the clinician after the full screen
  has been scored
• Purpose
• Motivate patients to reduce their use, abstain,
  or accept a referral to treatment

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Effectiveness of Brief Intervention

• 32 controlled studies found brief interventions
  often as effective as more extensive treatments
• Reduction in the following as a result of brief
  intervention
• Alcohol and other substance consumption/use
• Harmful physical consequences
• Social consequences
• Sick days, missed work
• Hospitalizations
• Trauma/accidents/injuries

Fleming M, Manwell LB. Alcohol Res Health
199923(2)128-37.
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What is Motivational Interviewing?

• Helps identify and encourage behavior change
• Increase patients awareness of problems,
  consequences, and risks related to behavior
• Assists patient to explore and resolve
  ambivalence toward behavior and increase
  motivation to change
• Motivation to change is elicited from the person,
  not mandated from the outside

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Principles of Motivational Interviewing

• Express empathy
• Develop discrepancy
• Roll with resistance
• Support self-efficacy

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Four Components of Brief Intervention

• Raise the subject
• Provide feedback
• Enhance motivation
• Negotiate and advise

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Raising the Subject
Would you mind taking a few minutes to talk about
your X use? Before we go further, Id like to
learn a little more about you. What is a typical
day like for you? Where does your X use fit in?

• Build rapport

2. Ask about Pros Cons
Help me understand through your eyes the good
things about using X? What are
some of the not so good things about using X?
So on the one hand you said ltPROSgt, and on the
other hand ltCONSgt.
Summarize
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Providing Feedback
3. Feedback

• I have some information on low-risk guidelines
  for drinking, would you mind if I shared them
  with you?
• We know that drinking
• 4 or more (F)/ 5 or more (M) drinks in 2 hours
• more than 7(F)/14(M) drink in a week
• use of illicit drugs
• can put you at risk for illness and injury. It
  can also cause health problems like insert
  medical information.
• What are your thoughts on that?

Ask permission Give information Elicit
reaction
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Assessing Readiness to Change
4. Readiness to Change
This Readiness Ruler is like the Pain Scale we
use to measure pain levels. On a scale from
1-10, with one being not ready at all and 10
being completely ready, how ready are you to
change your X use? You marked ___. Thats
great. That means youre ___ ready to make a
change. Why did you choose that number and not a
lower one like a 1 or 2?
Readiness ruler Reinforce positives
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SBIRT READINESS RULER
Categories of drinking
Low-risk drinking limits
IV
Dependent 5
III
Harmful 8
II
Risky 9
I
Low risk or Abstain 78
Not at all
0cm
1
2
3
4
5
6
7
8
9
10
Very

• If its okay with you, lets take a minute to
  talk about the annual screening form youve
  filled out today.

Raise the subject

• As your doctor, I can tell you that drinking
  (drug use) at this level can be harmful to your
  health and possibly responsible for the health
  problem you came in for today.

Provide feedback
SAMHSA Referral Helpline 1-800-662-HELP

• On a scale of 0-10, how ready are you to cut
  back your use?
• If gt0 Why that number and not a ____ (lower
  one)?
• If 0 Have you ever done anything while drinking
  (using drugs) that you later regretted?

Enhance motivation

• What steps can you take to cut back your use?
• How would your drinking (drug use) have to
  impact your life in order for you to start
  thinking about cutting back?

Negotiate plan
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Stages of ChangeProchaska DiClemente
Precontem- plation
Contemplation
Recurrence
Preparation
Maintenance
Action
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Creating an Action Plan
Create action plan
What are some options/steps that will work for
you? What do you think you can do to stay healthy
and safe? Tell me about a time when you overcame
challenges in the past. What kinds of resources
did you call upon then? Which of those are
available to you now? You have some great ideas,
would you mind if we wrote them down on to keep
with you as a reminder? Will you summarize the
steps you will take to change your X use?
Identify strengths supports 5. Prescription
for Change Write down action plan
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How does it all fit together?
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Video Demonstration
http//www.sbirtnc.org/
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Brief Intervention and Referral

• Description
• Clinician advises further assessment and
  treatment from a specialized facility or resource
• Method
• Referrals can be advised as part of the
  intervention
• Clinic staff will actively facilitate the
  referral
• Purpose
• Motivate and engage patients to see further
  assessment and/or treatment as part of the brief
  intervention.

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Does Treatment Work?

• Providers sometimes feel discouraged about
  referring patients for substance abuse treatment.
  Sometimes it seems like it just isnt worth the
  effort. But relapse rates are really no
  different than other chronic diseases

http//www.nida.nih.gov/PODAT/faqs.htmlComparison
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Referral to Treatment Guidelines

• To maximize the likelihood of success, assess
  level of care needed
• Determine if patient is drug or alcohol dependent
  (and needs medical withdrawal) (inpatient) or is
  a substance abuser (outpatient unless has other
  risk factors)
• Determine if patient has other risk factors that
  would make them better candidates for inpatient
  treatment than outpatient treatment
• Co-occurring mental illness (may need a
  psychiatry consult)
• Polysubstance use and dependence on multiple
  substances
• Serious medical illnesses that may be exacerbated
  when substance use changes

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Other Factors to Consider

• Insurance coverage
• Private must check with insurer to determine
  what kind of treatment and what facilities they
  will pay for
• Public assistance (VA vs. TN Medicaid)
• Language ability/cultural competence
• Treatment history (have they failed outpatient
  treatment in past?)
• Location/transportation can the patient and
  their family easily access the treatment facility?

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Other Factors to Consider

• Family support
• Can the facility treat both substance use
  disorders and mental illness?
• Can the facility treat both substance use
  disorders and medical illness?
• Does the facility offer/support pharmacotherapy
  for maintenance of abstinence?
• Does the facility have a good record of keeping
  referring medical staff informed of patient
  progress and ongoing needs?

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Common Roadblocks/Mishandling

• PCP rushes into action and makes referral when
  the patient has no interest
• PCP refers to an program unable to accept patient
  due to capacity or doesnt take the patients
  insurance
• Patient feels unheard and frustrated
• PCP doesnt create a referral package
• Other strategies/programs patient can try while
  they are on a program
• PCP doesnt consider pharmacotherapy to reduce
  cravings and/or reduce suffering
• PCP gets frustrated and sees the patient as
  resistant or self-sabotaging
• Versus having a difficult chronic disease
• What could you do to avoid each of these
  mistakes? How will you assess your success?

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Key Points for Billing

• Pre-screen
• Front desk personnel, triage nurses, etc.
• Not reimbursable SBIRT services
• Full Screen
• Physicians, physician assistant, nurse
  practitioner
• Licensed behavioral health care practitioner
• Clinical social worker
• Psychologist
• Professional counselor

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Key Points for Billing - Scenario

• PCP sees a new patient with a chief complaint
  relating to physical health
• Primary care office administers pre-screen for
  drug and alcohol abuse
• Negative document negative pre-screen and do
  not pursue further SBIRT services no SBIRT
  billing
• Positive may conduct Full Screen and Brief
  Intervention Service
• Bill under regular EM code for the primary
  complaint
• SBIRT service code either 99408 or 99409,
  depending on time

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Key Points for Billing - Scenario

• If Full Screen is negative
• May choose not to pursue further SBIRT services
• No billing would occur
• Billing for services would be under EM billing
  codes, depending on time and complexity of
  primary health service
• May choose to provide general feedback,
  prevention counseling, discuss risky lifestyle
  choices, self-management
• Bill under SBIRT codes
• 99408 (15-30 minutes)
• 99409 (greater than 30 minutes)

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Key Points for Billing - Scenario

• If Full Screen is positive
• May provide more complete screening and brief
  intervention services
• Billing under SBIRT codes may occur AND
• Billing for primary health services under EM
  codes may occur

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Key Points for Billing - Scenario

• If SBIRT service experience indicates need for
  specialized alcohol and drug abuse services
• Provide services from internal behavioral
  health/addiction specialist OR
• Refer patient to outside addiction specialist
• SBIRT codes may NOT be used since services are
  beyond scope of Brief Intervention Services
  authorized

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Coding for SBIRT Reimbursement
http//www.samhsa.gov/prevention/sbirt/coding.aspx
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Helpful Resources

• SBIRT Training Skills Training for Primary Care
  Providers
• http//www.sbirttraining.com/
• SAMHSAs Motivational Interviewing Training
  Website
• http//www.motivationalinterview.org/index.html
• SAMHSAS Screening, Brief Intervention and
  Referral to Treatment website
• http//www.samhsa.gov/prevention/sbirt/

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Helpful Resources

• Substance Abuse Screening, Brief Intervention and
  Referral to Treatment North Carolina
• http//www.sbirtnc.org/
• Resource documents (screening tools,
  presentations, publications) at the University of
  Texas Health Sciences Center School of Medicine
• http//familymed.uthscsa.edu/sstart/resourcesOPEN.
  asp
• SAMHSA Mental Health Services Locator
• http//store.samhsa.gov/mhlocator

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Helpful Resources

• Institute of Substance Abuse Treatment
  Evaluation Tennessee Outcomes for Alcohol and
  Drug Services (TOADS)
• http//www.isate.memphis.edu/treatment.html
• Substance Use Screening, Brief Intervention, and
  Referral to Treatment for Pediatricians
• http//pediatrics.aappublications.org/content/128/
  5/e1330.full.html

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Screening, Brief Intervention and Referral to
Treatment (SBIRT) in the Primary Care Setting
Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP
16th Annual Primary Care Conference Monday ,
March 26, 2012 Millennium Centre, Johnson City,
TN