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 ObjectivesPresentation Objectives

Provide you with an overview of the NQF Domain I: Identification of Substance Use in relation to: – What we know?What we know? – California’s Response

History of SBIRT development

Current efforts

The future

What do we know?

NQF: Identification DomainNQF: 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 UseIdentification of Substance Use is a is a

Public Health PriorityPublic Health Priority……

Challenges

Striking disconnect Striking disconnect between the proportions of individuals between the proportions of individuals reporting misuse of substances or diagnosed with substance reporting misuse of substances or diagnosed with substance abuse/dependence and those abuse/dependence and those receiving treatmentreceiving treatment

Little attention Little attention has been paid to the has been paid to the latter “risk groups” latter “risk groups” (Klitzner et al., 1992; Fleming, 2002)(Klitzner et al., 1992; Fleming, 2002)

In Treatment ~1.8 million

Abuse/Dependence ~22.3 million

Misuse of alcohol ~ 126.8 million

Misuse of Illicit Drugs ~ 19.9 million

Targeting Latter Risk Groups

AOD risk settings….

AOD Risk Settings

Health (including mental) Care– Primary care

– Emergency Rooms/Trauma Centers [40% 40% of visits are injury-related and 50% of them of visits are injury-related and 50% of them are alcohol-related (Nilsen et al., 2008)]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

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 screening75% not familiar with standard screening instruments

Research of Identification in Health Care Settings

Arch. Surg. Vol 134, May 1999

Why SBIRT?Why SBIRT?

A Public Health Early Intervention Solution:Screening, Brief Intervention & Referral to

Treatment - SBIRTIdentify patients who may not perceive a need for behavior change

Approaches are clinically effective and cost-efficient

Focus on at-risk vs. dependent individuals

Approaches are deemed an evidence based practice

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: DefinitionsBrief 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

Screening Score

SBIRT Approach Framework:Response Depends on Score*

Negative Screen

Positive Reinforcement

Brief Intervention

Brief Treatment

Referral to Treatment

Moderate Use Moderate/High Use Abuse/Dependence

*Severity & Consequences of use

Positive Screen

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

Meta-analysis

Interventions reduced mortality Cuijpers et al, 2004

Meta-analysis

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?

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

Importance of SBIRT in California?

Source: UCLA ISAP State Treatment Needs Assessment, 2001.

Prevention

SBIRT in the AOD Service Delivery Continuum of Care

Primary Secondary

Reducing the probability that a

substance use problem develops

Screening/AssessmentBrief Intervention or

Referral to Treatment

Screening/AssessmentBrief Treatment

Treatment

Continuing CareCare Management

Intervention Intervention/Treatment Recovery Support

Tertiary

Minimizing the severity of a

substance use problem if it occurs

Minimizing the disability caused by

substance use problems

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 SettingsSAMHSA 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 yearSpear & 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

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

Student completespre-screen at routine

intake*AUDIT-C plus 1

question on illicit drug use in

past 30 days

*performed at Kiosk

Spear & Rawson

Students given ASSIST are GPRA’ed at intake & 6-mo follow-up

As of Oct 2008: 6,786 students coming for initial appointments were pre-screened– 38% of students scored positive

Of those who scored positive 60% received the ASSIST screen & brief intervention (n=1,442)

Access to Care Results

Spear & Rawson

GPRA Results (2007) GPRA Results (2007)

Means* Male n=324 Female n=495

Gender 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

Spear & Rawson

GPRA Results: Binge DrinkingGPRA 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 UseGPRA 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 6-month 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 & pilot-tested 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

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

UCLA hosted and trained (1 day) 11 counseling centers on SBIRT & use of the ASSIST

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

CentersTimeline: 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 GPRAPhase IV: Follow-Up (6-mo GPRA)

Rawson & Freese

Criminal Justice SBIRT Flow Chart

Short-term Detainees Pre-screened with

AUDIT-C+

Low-Risk DetaineesCASC

ASSISTModerate –

High Risk Detainees

Parker Center(n=5,000)

Information and Referrals Provided

Brief InterventionReferral if indicated

GPRA6-Month Follow-up

Twin Towers(n=5,000)

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*

Professional Settings– 8 Administration – 7 Education– 6 Addiction Counselor– 5 Social Work/Human Services– 2 Medicine– 2 Psychology – 1 Medicine-Primary Care– 5 Other

Agencies: 10Gender: 20 Female; 5 MaleEthnicity/Race:– 3 Hispanic/Latino– 14 American Indian– 6 White– 3 Native Hawaiian/Pacific

Islander– 1 Asian

*2nd Training evaluation in progress 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 ADPMichael Cunningham

Tony Becerra

UCLA ISAPRichard A. Rawson

Suzanne SpearLoretta RansomThomas Freese

Jerry CartierDan DickersonAnne 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!Thank you!

Contact: – Rachel Gonzales

rachelmg@ucla.edu (310) 267-5316– Thomas Freese

tfreese@mednet.ucla.edu (310) 267-5397

“Be kind, for everyone you meet is fighting a great battle.”

Philo of Alexandria