PowerPoint Presentation Ensuring Solutions to Alcohol Problems THE GEORGE WASHINGTON UNIVERSITY MEDI

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Center for Integrated Behavioral Health
Policy Department of Health Policy, The George
Washington University Medical Center
Alcohol and the Workplace
Buyers Health Care Action Group April 9,
2009 Minnetonka, MN
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Binge Alcohol Use in Past Month among Persons
Aged 12 or Older, Annual Averages Based on 2005
and 2006 NSDUHs
MN 12-17 y.o. 12.8 1825 y.o. 50.4 26
y.o. 25.8
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Alcohol Dependence or Abuse in Past Year among
Persons Aged 12 or Older Annual Averages Based on
2005 and 2006 NSDUHs
MN 12-17 y.o. 6.6 1825 y.o. 20.9 26
y.o. 7.5
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Nearly as Prevalent as Diabetes
18.2 million2
17.6 million1
Alcohol Abuse Dependence
Diabetes

• References
• National Institute on Alcohol Abuse and
  Alcoholism. Updating Estimates of the Economic
  Costs of Alcohol Abuse in the United States
  Estimates, Update Methods, and Data.
  http//pubs.niaaa.nih.gov/publications/economic-20
  00. Accessed June 25, 2008.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.

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And an Economic Cost

• Greater than High Blood Pressure, Asthma and
  Diabetes
• combined

185 billion1,2
11 billion2
98.1 billion2
40 billion2

• References
• Grant BF, et al. Alcohol Res. and Health. 2006
  2977.
• National Center for Chronic Disease and
  Prevention and Health Promotion. National
  Diabetes Fact Sheet. http//www.cdc.gov/diabetes/p
  ubs/estimates.htm. Accessed June 25, 2008.

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Problems Impacting Work
Source National Cormorbidity Survey
Replication, http//www.icpsr.umich.edu/cgi-bin/SD
A/SAMHDA/hsda?ncs2, accessed September 11, 2006.
Analyses conducted online by Ensuring Solutions
(Goplerud) September 11, 2006, NSDUH 2005,
accessed April 15, 2007
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Problems at Work (National Co-Morbidity Survey
-- Replication, 2006)
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The Health Impact of Heavy and Sustained Alcohol
Use

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Cause of adult dementia second only to
  Alzheimers1
• Worsened symptoms of mental illness and
  interference with treatment1
• Co-occurs with major depression in about 25 of
  cases

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Increased risk for cancer of larynx1,3
• Male 50 Female 40
• Increased risk for cancer of esophagus1,3
  75
• Increased risk for cancers of lip, mouth, and
  pharynx1,3
• Male 50 Female 40

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Hypertension, cardiomyopathy, arrhythmias,
  stroke

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Alcoholic liver disease and alcoholic
  pancreatitis1,2 60
• Liver cancer4 25

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Ulcers, gastritis, gastroesophageal hemorrhage1
• Gastrointestinal disease3 20
• Increased colon and rectum cancer risk1,2

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Large red blood cell anemia, decreased platelets,
  reduced efficiency of white cells1
• Impaired immune system and increased
  susceptibility to pneumonia, TB and septicemia1
• Reduced bone density and increased risk of
  fractures1,2

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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The Health Impact of Heavy and Sustained Alcohol
Use

• Premature birth, low birth weight babies, fetal
  alcohol spectrum disorder (FASD)1,2
• Breast cancer4
  7
• Increase frequency of hospitalizations and
  increased length of stay1
• Violence, inducing homicide3 46
• Motor vehicle accidents4 20

• References
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems. Primer 1
  Treating Alcoholism as a Chronic Disease.
  http//www.ensuringsolutions.org/usr_doc/PDF_Versi
  on_of_Primer.pdf. Accessed June 18, 2008.
• National Institute on Alcohol Abuse and
  Alcoholism. Alcohol Alert No. 72. Alcohol
  Metabolism An Update. July 2007.
  http//pubs.niaaa.nih.gov/publications/AA72/AA72.h
  tm. Accessed June 18, 2007.
• The George Washington University Medical Center.
  Ensuring Solutions to Alcohol Problems.
  Presentation by E. Goplerud to Pacific Business
  Group on Health. April 28, 2006.
• eMedicine from WebMD. Alcoholism. May 15, 2008.
  http//www.emedicine.com/med/topic98.htm.
  Accessed June 19, 2008.

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Top 10 Leading Causes of Death in the United
States for 2005 (CDC)
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Estimated Percentage of Commercial-sector Health
Plan Members with an Alcohol Use Disorder
Recent estimates suggest that almost 9 of the US
adults has a diagnosable alcohol use disorder
(NSDUH, 2005)
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How Many Get Identified?
1 of plan members are diagnosed in Minnesota
(eValue8 2008)
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2007 HEDIS Scores Chemical Dependency Data from
the 2008 eValue8
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What do these HEDIS numbers from eValue8 mean to
Minnesota businesses?1,000 adult beneficiaries
in Minnesota
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Identification Rates for Alcohol Use Disorders
and Other Common Health Conditions
What percentage of affected individuals are
identified?
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Why Minnesota Businesses and those in other
states may be Overlooking 26 Billion in
Alcohol-Related Health Care Costs?

• Spending on alcohol treatment now less than 0.1
  of health care costs (administrative data)
• Approximately 10 adult beneficiaries in 1,000 use
  alcohol or drug services
• EAPs offered as response to alcohol, drug and
  other work and family life problems
• Less than 5 beneficiaries in 1,000 use alcohol
  and drug services

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The Alcohol Cost Calculator for Business

• www.alcoholcostcalculator.org\
• Computes the costs of untreated alcohol problems
  to individual companies
• Identifies steps that employers can take
• No cost, anonymous
• Research-based, using 2005-2007 National Survey
  on Drug Use and Health epidemiology data with
  more than 210,000 respondents
• Endorsed and used by businesses and business
  groups

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Spectrum of Alcohol Problems
Willenbring, 2007
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SBIRT Core Components
Brief Treatment Cognitive behavioral,
medications with clients who acknowledge risks
and are seeking help
Moderate
Screen Identification of behavioral problems
(alcohol, drug, depression. tobacco? anxiety?

• Brief Intervention
• Raises awareness of risks and motivates client to
  change

Low
Severe
Referral to TX Referral of those with more
serious or complicated mental or substance use
conditions
Adapted from Tom Stegbauer, DHHS, 2008
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A Comprehensive Approach is Needed

• Treatment should target both psychosocial
• and physical drivers of alcohol dependence

Cortex Role Decision-making Thinking Reasoning R
ationalizing
Limbic Region Role Drive generation

• Pharmacotherapy targets limbic region
• May enhance psychosocial treatment1

• Psychosocial therapy targets cortex region
• An essential component of treatment

• Reference
• National Institute on Alcohol Abuse and
  Alcoholism. Helping Patients Who Drink Too Much
  A Clinicians Guide. http//pubs.niaaa.nih.gov/pub
  lications/Practitioner/CliniciansGuide2005/guide.p
  df. Accessed July 13, 2008.

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2008 eValue8 Module Scores-BH
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2008 eValue8 Section Scores-BH
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Whats the SBI target?
32.5 million people could benefit from brief
intervention.
Routine screening is preventive.
The most severe problems need specialty treatment.
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Converting evidence to care
Original research
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variable
Negative results
Dickersin, 1987
Submission
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0.5 year
Kumar, 1992
17 years to apply 14 of research knowledge to
patient care!
Koren, 1989
Acceptance
Negative results
0.6 year
Kumar, 1992
Publication
1714
Expert opinion
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0.3 year
Poyer, 1982
Balas, 1995
Lack of numbers
Bibliographic databases
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6. 0 - 13.0 years
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
9.3 years
Inconsistent indexing
Patient Care
Balas Yearbook Medical Informatics 2000gtre4,
courtesy M Overhage
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Has enough time passed for SBI?

• Suitable methods of identification and readily
  learned brief intervention techniques with good
  evidence of efficacy are now available. The
  committee recommends broad deployment of
  identification and brief intervention.
• 1990 (19 years ago!)
• (IOM, Broadening the Base of Treatment for
  Alcohol Problems, 1990, p. 8)

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SBIRT is Cutting Edge

• National Quality Forum (2007) All patients be
  screened for drinking and tobacco annually and
  provided brief motivational counseling if at-risk
• 2007 Codes approved for Medicaid
• 2008 Codes approved for commercial
• insurance, Medicaid and Medicare
• Adoption of CPT codes by many health plans
• (88 last count) and 12 State Medicaid
  (including MN)
• Aetna, CIGNA, Anthem Blue Cross and Blue Shield,
  HealthPlus, HealthPartners, Office of Personnel
  Management (Federal Employees)

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Alcohol SBI Codes
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Coordination with Emergency Rooms- SBI
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Federal SBIRT Demonstration Program
Accomplishments
N 11 states
Adapted from Tom Stegbauer, DHHS, 2008
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SBIRT Program Accomplishments

• Alcohol use to level of intoxication (5 drinks)
  declined 38.4
• Use of any illegal drugs decreased 49.6
• Nearly 50 of those who received a brief
  intervention changed their patterns of misuse

Adapted from Tom Stegbauer, DHHS, 2008
N 11 States
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SBIRT Program Accomplishments
Adapted from Tom Stegbauer, DHHS, 2008
N 11 States
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Health Impact and Cost EffectivenessSolberg et
al, 2008

• Estimated net savings of 254 per person offered
  screening
• Medical care costs only, cost effectiveness
  ration of 1,755 per QALY saved
• In top 4 most cost-effective prevention
  recommendations of US Preventive Service Task
  Force recommendations
• Discuss daily aspirin use men 40, women 50
• Childhood immunizations
• Smoking cessation advice and help to quit
  adultls
• Alcohol screening and brief counseling adults

Solberg LI, et al. Primary care intervention to
reduce alcohol misuse ranking its health impact
and cost-effectiveness. Am J Prev Med. 200834(2)
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Jordan N, et al. Economic benefit of chemical
dependency treatment to employers. Journal of
Substance Abuse Treatment. 34 (2008) 311-319.
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Opportunities for Minnesota businesses, health
plans and EAPs to address alcohol-related health
problems

• Dependence
• Behavioral Health Disease Management - Alcohol
  DM
• Inclusion of anti-craving medications in
  formulary
• Harmful and Unhealthy Alcohol Use
• Mirror successful primary care screening and
  care management for depression (DIAMOND) or
  smoking
• SBI in Emergency Departments Trauma Centers
• High Risk Alcohol Use
• SBI in Employee Assistance Program
• SBI in Wellness and Health Promotion
• Screening questions in Health Risk Appraisals
  (HRAs)

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Helpful Resources

• All-in-One SBIRT Resource
• http//sbirt.samhsa.gov/index.htm
• BI for Drinking in Primary Care (WHO)
• http//whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b
  .pdf
• Helping Patients Who Drink Too Much A
  Clinician's Guide
• http//www.niaaa.nih.gov/Publications/EducationTra
  iningMaterials/guide.htm
• Cost-Effectiveness of SBIRT Worksheet
• http//gunston.gmu.edu/healthscience/730/SBIRT/
• Ensuring Solutions to Alcohol Problems
• www.ensuringsolutions.org

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Eric Goplerud, Ph.D. Director 2021 K St. NW,
Suite 800 Washington, DC goplerud_at_gwu.edu integrat
edbehavioralhealth .org