Substance Abuse: Screening, Intervention and Treatment

SBIRT PROGRAM OF US DEPARTMENT OF HEALTH AND HUMAN SERVICES

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HOST:

Dr. Bill Rutenberg.

GUEST:

Dr. Bertha Madras.

Dr. RUTENBERG:

What is SBIRT and can you get pay for it? You are listening to the Clinician's Roundtable on ReachMD XM 157, the channel for medical professionals. Welcome to the Clinician's Roundtable. I am Dr. Bill Rutenberg, your host, and with me today is Dr. Bertha Madras.

Dr. Bertha Madras is the Deputy Director of Demand Reduction in the White House Office of National Drug Control Policy.

Prior to joining ONDCP, Dr. Madras was professor of psychobiology at Harvard Medical School and chaired the division of neurochemistry at the New England Primate Research Center. Today, we are discussing the SBIRT program of the US Department of Health and Human Services.

Dr. RUTENBERG:

Hi Dr. Madras. Great of you to join us at the Clinician's Roundtable.

Dr. MADRAS:

I am delighted to be here.

Dr. RUTENBERG:

So, what is SBIRT and can I get paid for it?

Dr. MADRAS:

It is a great question. SBIRT stands for screening, brief intervention, brief treatment, and referral to treatment and yes, there are codes now, CPT codes for third party insurance, codes for Medicare, codes for Medicaid that can reimburse for these procedures.

Dr. RUTENBERG:

How long has the program been around and how can we get more information about it?

Dr. MADRAS:

The program has been around for decades, believe it or not. Through World Health Organization initiatives, through private investigator initiated research. We have known for more than 20 years that a brief intervention that is nonjudgmental, non-confrontational with receptive people is going to change their behavior with regard to heavy alcohol use. It has been use in emergency departments and trauma centers for a number of years. The real turning point came when SAMHSA, our sister federal agency, organized grants to states to implement them in a number of states in our country. We now have 12 SBIRT sites on college campuses, we have them in a tribal organization, and out of this massive amount of input and research and data, it is clear that it can work in general populations.

Dr. RUTENBERG:

With screening itself as the first step, where is that being done, what location specifically and what type of healthcare provider does this?

Dr. MADRAS:

The screening in the Federal Program is implemented in emergency departments, trauma centers, primary healthcare clinics, rural clinics, college campuses, and even in high schools, and we urge as many primary care physicians as well as tertiary care to be engaged in this because it can make an enormous difference in the health and well being of patients.

Dr. RUTENBERG:

Are there specific screening instruments that should be used and how does one get training in these things if they exists?

Dr. MADRAS:

There are number of instruments. The audit is used for alcohol and in fact the VA System has now mandated that screening and brief intervention for alcohol be implemented throughout the VA system. The ASSIST, another World Health Organization screening questionnaire, combines alcohol with illicit drugs and it makes an <_____> lot of sense to combine them because in certain sectors of healthcare system, especially trauma centers and emergency departments, there is a very high incidence of both alcohol and other intoxicating drugs that appear to be associated with or causative of trauma, injury, and significant risk to life.

Dr. RUTENBERG:

If somebody wanted to learn more about the screening incidence themselves, are they available?

Dr. MADRAS:

They are available. One can just pump in the word AUDIT, ASSIST, or DEAF, these are three that are out there that are well documented and you can find the screening questionnaires come up on the screen. You can go the SAMHSA web site and the questionnaires will emerge. You can go to www.niaaa.gov which is the National Institute in Alcohol Abuse and Alcoholism and it will emerge there as well, and all three of them. So there is plenty of assistance for people to learn not only the screening questionnaires, but NIAAA has a training program onsite to train with brief interventions. To the best of our knowledge, these brief |interventions work equally well for drugs as for alcohol.

Dr. RUTENBERG:

Could you talk a little bit more about brief intervention, what's actually taking place, what kind of an intervention is this?

Dr. MADRAS:

Once you get an objective screening score, which takes into account frequency, amount, adverse consequences, whether or not you are injecting IV, for example for illicit drugs, with that score the physician decides what will the appropriate response be? If the score puts you in a moderately low to moderate risk category, then they can institute a brief intervention on the spot. This is an opportunistic teaching moment for the patient to learn that their use of intoxicants is a outlier and that it would be wise for them to cut down. What you do is you try to extract from the patient themselves some of the consequences they felt and try to get them to associate the consequences with their use of drugs. Consequences could be medical consequences, social, educational, employment, whatever, whatever they in fact could offer to you and then you begin to assist them in developing a strategy for cutting down. It does not take very long. It can be as short as 15 minutes and as long as 30 minutes.

Dr. RUTENBERG:

Without reinforcement, has this been effective?

Dr. MADRAS:

Without reinforcement, it has been very effective. The data indicates the number are quite across the map. Some say about 15% reduction in heavy use, others say 40% reduction in heavy use, or reduction to abstinence, but generally speaking that's the scale in which you can observe changes between 15 and in some cases even as high as 50%. The World Health Report just did a multinational randomized control trial using the assist for illicit drugs and they found overall a 60% change in the patients in their catchment.

Dr. RUTENBERG:

I mean that's phenomenal!

Dr. MADRAS:

It is phenomenal that sometimes defies credibility, but it really is well documented and they did save 1, 2, 3 clinical trials with the questionnaires so there is a weight of some very systematic approach to documenting the effectiveness of it. The only country that did not show as good data was the US in the World Health Report, but in the Federal SBIRT program, we are seeing very significant change.

Dr. RUTENBERG:

So we have gone through the training and brief interventions; brief treatment, again, what does that entail, how much sessions, how long, and who is providing the services?

Dr. MADRAS:

Brief treatment is a centrally cloning of the brief intervention, but on repeated number of occasions, so that you can do 6 to 10 separate episodes where you reinforce the message that at moderate-to-high risk, it is wise for you to change your behavior and let's help you change it. What are some of the obstacles to changing it. So it's a reasonable dialogue between a healthcare professional and a patient, as I reiterated before, is non-confrontational and is nonjudgmental, but tries to get the person himself to become more and more self-aware that engagement in this risky behavior can lead to a cascade of adverse events in their lives.

Dr. RUTENBERG:

Your background is in neurochemistry and psychobiology and many changes take place in the nervous system, the old cells that fire together, wire together, the pleasure response from these medications or substances with a brief treatment, and on top of that again, as a pediatrician, I use the old 'immortality of youth,' can you really change the behaviors in this brief treatment when something is truly an addicting substance?

Dr. MADRAS:

Well, as I said, if a person is addicted, they need referral to specialty treatment, but if it is a brief treatment only, what we are seeing in our Federal program is very significant changes and self-reports. These are 6 months after they received a brief treatment. In randomized control trials that have been done in trauma centers for example, and in primary health care, the brief intervention persists for a year, that's one of the periods of time that was looked at. In one case in one publication, it was 48 months. So it's certainly not a magic bullet, it's not a cure because there are plenty of people who are not receptive to the message. They say they have heard it before, this is nagging. The World Health Organization in their report documented the kind of pushback they got from people who are refractory to this kind of input, but most people thought it was very lightening and important, and the first time in their life that a medical professional engaged them in something that could lead to tremendous cascade of health consequences. It's quite a statement because generally speaking, physicians are trained to use the cage and to identify alcoholism and this is quite different, this is to identify a full spectrum of youth that is risky, that is problematic, that could rise to abuse and to addiction, that's the critical difference. The physicians role is inserted at the early stages rather than at the late stages when they are, generally speaking, not trained to deal with addiction, but they can be readily trained to deal with these early onset periods and assist people in changing behavior.

Dr. RUTENBERG:

It would seem like this would be a natural program to teach to reveal at National Specialty Society Meetings. Is the government doing any of those things, bringing it to the American Academic of Pediatrics National Convention for instance?

Dr. MADRAS:

I have actually tried to insert myself on every National Meeting for the National Academy Pediatrics, American College of Physicians, of Surgeons, and they have just pushed back on it and it made no sense to me.

Dr. RUTENBERG:

They pushed back on it?

Dr. MADRAS:

American Academy certainly, yes, and all these annual meetings, well, part of it was not the lack of interest but part of it is because we work on much shorter time lines from these annual meetings. So inserting an individual in a plenary, for example, or symposium you have to do that 2 years in advance for many of them and we just got in on the bottom four a little bit too late to get inserted.

Dr. RUTENBERG:

We have a little bit of time left. What is new, tell me something new about prevention that I don't already know about, anything new in terms of research, translational research, what sort of a next step?

Dr. MADRAS:

I think that this is one of the most profound and dramatic transformational strategies that we have seen in a long time in terms of prevention because this truly is a form of prevention, it is to preempt the potential for re-hospitalizations and we have seen tremendous cost savings, it's so interesting. We have seen in Medicaid in Washington State a very detailed epidemiological analysis of people who received these services and they were then examined with regard to re-hospitalizations and based on their calculations, for each 1000 Medicaid patients that were seen and offered SBIRT, they saved the state approximately 2 million dollars a year. So you translate that upward into all you Medicaid eligible patients and that's beginning to reckon to very hefty healthcare saving costs.

Dr. RUTENBERG:

I would like to thank Dr. Bertha Madras who has been my guest and we have been discussing the SBIRT drug screening, brief intervention and referral to treatment program.

I am Dr. Bill Rutenberg and I invite you to listen to our on-demand library by visiting us at www.reachmd.com, register with promo code “radio” and receive 6 months of free streaming audio. If you have comments or suggestions, call us at AAA-MD-XM-157.

Thanks for listening.

Until next time, I wish you good day and good health.

You have been listening to public health policy in America, a special ReachMD XM157 interview series with our nation's top thought leaders in public health. This month ReachMD XM157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programming information, visit us at www.reachmd.com.