Substance Abuse Disorders in Primary Care Improving Evidence Based Practice

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Substance Abuse Disorders in Primary Care
Improving Evidence Based Practice

• David W. Oslin, MD
• University of Pennsylvania, School of Medicine
• And
• Philadelphia, VAMC

Hazelden Research Co-Chair on Late Life
Addictions
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Which Hat?
Geriatrics
Addictions
Primary Care
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Introduction

• Alcohol use and abuse costs the nation 150
  Billion / annum
• Alcohol use and abuse is common in primary care
  practices
• Very little research has focused on illicit
  substance use disorders in the context of primary
  care

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90-Day Prevalence in Primary Care (n21,282
patients in 88 primary care clinician offices)
At-risk Drinkers 9
Problem Drinkers 8
Alcohol Dependent 5
Low-risk Drinkers 38
Abstainers 40
Manwell, et al. Journal of Addictive Diseases.
19971767-81.
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The Bad News

• Individuals with alcohol disorders or problem
  drinking who seek help
• ECA 11 specialty mental health/addictive
• services 8 voluntary support network
• NLAES 10
• RAS 7-10
• Rates of Early Drop-out from Alcoholism Treatment
  (less than four sessions) range from 44 - 75

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Breaking down the Problem

• Identification
• Assessment
• Initial Intervention
• Referral and Follow-up

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How is Identification Accomplished?

• Systems
• VA, Kaiser, Group Health
• Individual Practitioners
• State, City, other agencies

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Examples Screening Instruments

• Michigan Alcoholism Screening Test (MAST)
• Health Screening Survey (including other health
  behaviors, e.g. nutrition, exercise, smoking,
  depressed feelings)
• CAGE (Cut down, Annoyed by others, feel Guilty,
  need Eye-opener)
• AUDIT-C/AUDIT

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Identify What?

• Abstinence
• Moderate Drinking
• At risk drinking
• Problem drinking / alcohol abuse
• Alcohol Dependence

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VA Experience

• Prior to 2003 CAGE
• 11/03 AUDIT-C
• 2781 screens in those that drink over a 4 month
  period
• 32.6 positive

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The First Challenge

• Assessing individuals to understand what level of
  care is needed

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BEHAVIORAL HEALTH LAB
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Research to PracticeBehavioral Health Laboratory

• BHL is designed to provide clinical services to
  support providers in Primary Care and Behavioral
  Health
• It is intended to be analogous to Clinical
  Chemistry or Radiology Laboratories
• The BHL is an automated telephone assessment,
  triage, and monitoring service for patients
  identified by primary care providers as having
  depressive symptoms or at-risk drinking.
• The BHL conducts a brief telephone (20-30
  minutes) assessment generating a report for the
  PCP including diagnosis, severity, and general
  treatment recommendations.

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How it works at the PVAMC

• Mechanisms for requesting an assessment
• Screening
• Referral
• Disease management
• The BHL receives a printed consult request.
• The BHL reports findings, provides
  interpretation, and recommendations.
• Where appropriate, BHL staff facilitate referral
  or the appropriate level of intervention.

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What does the Service Provide?

• Assessment of major illnesses depression,
  anxiety, substance use
• Screening for other domains cognition, smoking,
  psychosis, mania
• Initial Treatment recommendations
• Patient engagement
• Monitoring of initial treatment for depression
  adherence, adverse effects, symptoms

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BHL Flow
Annual Screening
Direct consult
New treatment for depression
Consult request
Full Assessment
Recommendations to PCP and Patient
Referral to ARU
At-Risk Drinker
Referral to Specific Research
No Treatment Recommended
Brief Intervention
Watchful Waiting 8 weeks
Referral Management
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Referrals
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5 Month Referral Success

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Characteristics of Patients
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Does the BHL change practice?

• 25 reduction in the number of patient not
  screened for depression
• 10 increase in the screen positive rate for
  depression
• Significant increase in the identification of
  patients with suicidal ideation
• Possible improvement in EPRP measures for
  depression

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Engagement in Care
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Conclusions

• BHL is a flexible, evidence based program
• Fills gaps in the VHA system
• Provides valid information and documentation
• Acceptable to veterans
• Valued by provider
• Can function at low cost across diverse settings
• Useful for outreach
• Can provide coordination as well as assessment
• Disease Management
• Referral Management
• Valuable as a tool for improving system
  performance

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But?

• The number of patients referred doesnt match
  those assessed.

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Referrals for depression
17,543 Patients Screened
3008 already in MH/SA care
1232 positive screens (7)
740 Patients referred to the BHL (60)
104 Unable to contact (14.1) 56 Refused 7.6)
580 Completed Assessment
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Referrals for Alcohol Misuse
2781 patients who drank screened
In MH/SA care not an option
906 positive screens (32.6)
118 Patients referred to the BHL (13)
17 Unable to contact (14.4) 7 Refused (5.9)
94 Completed Assessment
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What about the Instrument?

• Q1 How often did you have a drink containing
  alcohol in the past year?
• Never (0 points)
• Monthly or less (1 point)
• Two to four times a month (2 points)
• Two to three times per week (3 points)
• Four or more times a week (4 points)

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What about the Instrument?

• Q2 How many drinks did you have on a typical
  day when you were drinking in the past year?
• 1 or 2 (0
  points)
• 3 or 4 (1 point)
• 5 or 6 (2 points)
• 7 to 9 (3 points)
• 10 or more (4 points)

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What about the Instrument?

• Q3 How often did you have six or more drinks on
  one occasion in the past year?
• Never (0 points)
• Less than monthly (1 point)
• Monthly (2 points)
• Weekly (3 points)
• Daily or almost daily (4 points)

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Is the Screener to sensitive
2 Drinks/day
3-4 Drinks/day with binges
10 Drinks/day
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Does the Type of Provider Matter?
Choices MD CRNP/PA Residents/ Fellows Other
Residents/ Fellows
Other
MD
CRNP/PA
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Do Clinician Beliefs Matter?
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Do Clinician Beliefs Matter?
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Starting a New Practice

• Identify a thought leader / Champion
• Define practice specific needs screening,
  referral, resources
• Define practice specific procedures
• Announce the availability of the service
• Face-to-face
• Email
• Letters / Brochures

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Other Marketing Strategies

• Business cards for patients
• Business cards for providers
• ELM interface
• Listing of providers
• Staff in practice / Screening of patients
• 877 number

• Pens
• Sticky pads
• Business size card for computer
• Monthly email reminders
• Clinic feedback
• In-service by staff on MH/SA topics
• Website

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A Platform for other activities

• Telephone disease management for problem drinking
  
• Supported by VA HSRD
• Developing watchful waiting strategies
• Supported by Robert Wood Johnson Foundation
• ExTENd Use of naltrexone in managing alcohol
  dependence
• Supported by NIAAA R01
• DIADS depression of Alzheimers disease
• Supported by NIMH R01
• Family caregiver Support
• Depression Treatment Monitoring
• PTSD
• Referral Management