Transcript BRITE - Florida Alcohol and Drug Abuse Association

The Florida BRITE Project: Screening and
Brief Interventions for Older Adult at Risk
of Substance Misuse
Larry Schonfeld, Ph.D.
Interim Executive Director, Florida Mental Health Institute
[email protected]
http://BRITE.fmhi.usf.edu
Presented at the FADAA/FCCMH Conference Aug. 7, 2013
Today’s presentation
• Overview of substance abuse issues and
treatment for older adults
• Presentation on the Florida BRITE Project
– Pilot project funded by Florida DCF (2004-07)
– Expansion through national SBIRT initiative
funded by SAMHSA/CSAT $14 million grant
• Lessons learned from conducting SBIRT in
Florida
Alcohol and Illicit Drugs
National Household Survey: % Adults Aged 18+ Reporting past
month use of alcohol/drugs by age group in 2000 (NHSDA, 2001)
18 to 25
56.8
58.3
53.0
70
60
26 to 34
35 to 54
55 or Older
30.3
40
7.6
5.3
2.3
12.8
9.4
7.8
4.9
1.0
10
21.1
30
20
37.8
37.5
50
15.9
Percent Reporting Use in Past Month
12% of 55+ age group are either
binge or heavy alcohol users
0
Any Illicit Drug Any Alcohol
Use
Use
"Binge"
Heavy Alcohol
Alcohol use
Use
U.S. Substance Abuse Treatment Admissions in 2006
Trunzo & Henderson (Gerontological Society of America presentation 2008)
NALL ADMISSIONS = 1,798,000
NADMISSIONS OVER 50 = 189,000
35-44 yrs
27%
50-54 yrs: 6%
50+ yrs
11%
25-34 yrs
25%
55-59 yrs: 3%
18-24 yrs
18%
60-64 yrs: 1%
65+ yrs: <1%
Admissions Under 50 and Age 50+
by Primary Substance
9%
13%
14%
18%
17%
12%
8%
14%
11%
11%
6%
9%
7%
3%
Sedatives/Tranqs.
11%
Narcotic Analgesics*
Methamphetamine/Amphets.
12%
Cocaine
15%
18%
18%
Heroin
58%
18%
38%
66%
70%
47%
Marijuana
Alcohol & Drug
20%
<50
* Excludes methadone
Alcohol Only
50-54
55-59
60-64
65-69
70+
Older adults are often
“hidden” alcohol abusers
• Fewer indicators compared to younger adults:
•
• DUI’s
• Work-related problems
• Marital Problems
• Peer pressure
In contrast, older adults are more likely to be isolated,
drinking alone
– More likely to identified in healthcare settings as
secondary problem to the reason for admissions to
ER, primary care.
Alcohol Affects the Elderly Differently
• Induced impairment increases with age due to:
– Higher body fat content, less lean muscle mass, and
reduced water volume (alcohol is water soluble)
– Decreased absorption rate in gastrointestinal system
due to decreased blood flow
• Affects alcohol’s distribution within the body
• Affects alcohol’s elimination
• Results in increased sensitivity and decreased
•
tolerance to alcohol and drugs in older individuals
Drugs and alcohol remain in the body longer and
at higher rates of concentration
Medication misuse
Older Adults: Adverse Drugs Events
• People age 65+ make up 12% of U.S. Population, but
– account for 34% of all prescription medication use
– account for 30% of all over-the-counter medication use
– Annually, 1 in 3 adults ages 65+ experience adverse
drug events
• Susceptible to problems due to altered:
– pharmacodynamics (how the drug affects individual)
– pharmacokinetics (how the body absorbs, distributes,
metabolizes, eliminates a drug)
Misuse in older people is often unintentional
(Glantz, 1981; Schwartz et al., 1962).
•
•
•
•
•
•
•
•
•
Difficulty of regimen (too many meds to keep track)
Memory issues
Adverse drug reactions
Synergistic effects of multiple drugs
Cost & Access
Multiple prescribing physicians
Lack of understanding of the instructions
– They are less likely to ask physician or pharmacist
questions or receive written information about
prescriptions (Olins, 1985).
Use of/interactions with OTC meds (Coons et al., 1988)
Early discontinuation of medications
Medications & Alcohol Use
• Use of drugs in combination with alcohol
carries greater risk:
– hepatoxicity with acetaminophen
– increased lithium toxicity
– enhanced CNS depression for those
prescribed tricyclic antidepressants
– death - for those taking
benzodiazepines and barbiturates
Treatment Recommendations
Expert panel
recommendations
for screening and
treating the older
adult:
SAMHSA/CSAT
Treatment
Improvement
Protocol (TIP) #26
TIP#26 Expert Panel Recommendations
1. Age-specific, group treatment that is supportive, not
confrontational
2. Attend to depression, loneliness; address losses.
3. Teach skills to rebuild social support network
4. Employ staff experienced in working with elders
5. Link with aging, medical, institutional settings
6. Content should be age-appropriate and offered at a
slower pace.
7. Create a “culture of respect” for older clients
8. Broad, holistic approach recognizing age-specific
psychological, social & health aspects.
9. Adapt treatment as needed to address gender issues
FMHI - developed group treatment
Relapse prevention, Cognitive-behavioral/Self-management skills
• Gerontology Alcohol Project (1979-1981) –successfully treated
late onset, older alcohol abusers and improving social support, mood
(Dupree, Broskowski & Schonfeld, 1984)
• Substance Abuse Program for Elderly (1986-1994) extended
GAP approach to all older adults irrespective of age of onset and
type of substance (Schonfeld & Dupree, 1991; Schonfeld , et al., 1995;
Schonfeld & Dupree, 1995; 1998)
• Replications - programs in other states based on our model
• Chelsea Arbor Older Adult Recovery Center in Ann Arbor, Michigan
(1990’s)
• GET SMART Program (West Los Angeles VA Hospital; 2000-2011)
(Schonfeld et al. 2000)
• Zablocki VA Medical Center (Milwaukee, 2006)
• Older Adult Substance Abuse Treatment Program – Tennessee (2005 2008) (Outlaw et al. 2012)
The Result:
A 16-session
curriculum manual
for conducting brief
treatment
(Dupree & Schonfeld, CSAT,
2005)
http://kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf
A Three Stage CBT/Self-Management
Treatment Approach
(Dupree
& Schonfeld, SAMHSA/CSAT manual, 2005)
1. For each person begin by identifying his/her
antecedents and consequences for substance use to
create an individualized “substance use behavior
chain” using the Substance Abuse Profile for the
Elderly
2. Teach the person how to identify the components of
that chain so that he or she can understand the high
risk situations for alcohol or drug use.
3. Teach specific skills to address these high risk
situations to prevent relapse.
A Three Stage CBT/Self-Management
Treatment Approach
(Dupree
& Schonfeld, SAMHSA/CSAT manual, 2005)
1. For each person begin by identifying his/her
antecedents and consequences for substance use to
create an individualized “substance use behavior
chain” using the Substance Abuse Profile for the
Elderly
2. Teach the person how to identify the components of
that chain so that he or she can understand the high
risk situations for alcohol or drug use.
3. Teach specific skills to address these high risk
situations to prevent relapse.
However, a change was needed
• In Florida, the actions of several task forces and Florida
Coalition on Optimal MH and Aging shaped a new
agenda:
– identified elders as an underserved population
– Policy changes identifying them as a target pop.
• Despite older adults’ positive outcomes in treatment
programs, relatively few actually entered treatment.
– In 2000, less than 2% of adults in Florida’s treatment
for substance abuse problems, were age 60+ despite
the fact that they represent about 24% of the
population
SBIRT
A national initiative for screening,
brief intervention, and referral to
treatment
Substance Abuse Severity and Level of Care
Adapted from the SAMHSA TIP #34 (1999) and Institute of Medicine (1990)
None
Mild
Moderate
Severe
Specialized
Treatment
Brief
Intervention
Primary
Prevention
Screening and Brief Interventions
Early Examples
• Used within Emergency Departments
– Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based
intervention to increase access to primary care, preventive services, and
the substance abuse treatment system. Ann Emerg Med , 1997;
30:181-189.
• Used within primary care practices as
“Brief Physician Advice” for older adults
– Fleming, MF., Manwell, LB, Barry, KL, Adams, W, & Stauffacher, EA
Brief physician advice for alcohol problems in older adults: A
randomized community-based trial. J Fam Pract; 1999 48(5): 378-84
http://sbirt.samhsa.gov/about.htm
SBIRT Core Components
Motivational Interviewing (MI)
• People who “screen positive” for substance misuse may
be reluctant to seek help and are often ambivalent
about making a decision to change behavior
• Confrontation & labeling will produce “resistance” or the
person will be labeled as being “in denial.” Resistance
can also be raised prior to treatment (e.g., spouses,
employers, coercion from the legal system).
• With MI, resistance is viewed as a reaction to the insession behavior of the counselor.
Key Principles of Motivational Interviewing
• Avoiding labeling and confrontation
• Enhance Self-efficacy (confidence in one’s
•
•
•
coping strategies)
Enhance internal-attribution
Roll with resistance – use it to further explore
client’s views
Use cognitive dissonance as a tool – the client
is asked to provide more and more evidence
that problem(s) exist
Videos – examples
of Brief Intervention
• Boston University: BNI-ART Institute
http://www.bu.edu/bniart/sbirt-in-health-care/sbirteducational-materials/sbirt-videos/
• Provide scenarios for using screening and brief
intervention during the delivery of healthcare.
• Videos illustrate the use of MI techniques
The Pilot: Florida BRITE Project 2004-07
(BRief Intervention and Treatment for Elders)
• 3,497 people ages 60+ screened and/or served
Schonfeld et al (2010) Am. J. of Public Health
• Four sites in pilot project
•
•
• Broward County Elderly & Veterans Services = 2,116
• Gulf Coast Jewish Family Services (Pinellas) = 638
• Coastal Behavioral Health Care (Sarasota) = 426
• Center for Drug Free Living (Orange)
= 317
Most (67%) identified via BRITE outreach & prescreening
at health fairs, senior centers, and via referral network.
Positive prescreens invited to participate in BI
– Most received multiple sessions of brief intervention
The Florida BRITE Project
Pilot Project (2004-2007)
Gulf Coast
Jewish Family
Services
Coastal
Behavioral
HealthCare
Center for
Drug Free
Living –
added in
2005
Orlando
Broward
County
Elderly &
Veterans
Services
The Pilot: Florida BRITE Project 2004-07
(BRief Intervention and Treatment for Elders)
• Purpose: to identify people ages 60+ who misused or
•
were at risk for misusing:
– Alcohol
– Prescription medications
– Over-the-counter (OTC) medications
– Illicit drugs
Depression and suicide risk also screened by BRITE
– Depression - most frequent antecedent to substance
abuse in elders (Dupree et al., 1984; Schonfeld & Dupree, 1991,
Schonfeld et al., 2000)
– Elders - highest rate of suicides among all age-groups
The Pilot: Florida BRITE Project 2004-07
(BRief Intervention and Treatment for Elders)
• 10% - referred for potential alcohol problems
 69% of all 3,497 screened were drinkers
 18% of drinkers had 3 or more drinks on a drinking day
• 26% referred for prescription misuse
 32% needed education/assistance on proper med use
 17% could not recall purpose of 1 or more meds
 11% reported wrong amount for 1 or more meds
 8% took medications for wrong reasons/symptom
• 8% referred for potential OTC misuse
• 1% referred for illicit drug use
The Pilot: Florida BRITE Project 2004-07
(BRief Intervention and Treatment for Elders)
• Depression (Short-Geriatric Depression Scale)
– 64% of all referrals were for depression
 SGDS scores: 25% moderate, 10% serious
•
– Among those referred for reasons other than
depression:
 SGDS: 18% moderate, 4% serious
Suicide Risk: Only 0.6% referred for suicide risk
– But 13% contemplated suicide at some time in the
past (most of these within the past year)
The Pilot: Outcomes 2004-07
Significant improvement at D/C and Follow-ups
• Significant decrease in alcohol scores at D/C (n=102)
– No further changes at 30 day follow-ups (n =60)
• Prescription Medications: a 32% decrease in “flags” at
D/C over the number at baseline (n=180)
• OTCs: 23 of 24 people flagged at baseline, no flag at D/C
• Illicit drugs: 75% of those with flags at baseline (n=12)
showed no flag at D/C
• Significant decrease1 in depression scores at D/C (n=323)
– Further decrease at 30 day follow-up (n = 203)
From Pilot Project
to Federal Grant
State SBIRT Grants Through 2010
Florida BRITE Project – the SBIRT Grant:
(BRief Intervention and Treatment for Elders)
• $14 million SAMHSA/CSAT grant to Florida
– Five years: Oct. 2006-Sept. 2011
– Funding mostly went towards direct services
– Large scale screening in medical, other settings
• Majority of people are expected to screen negative
(receive Screening & Feedback only)
• Positive screens were typically followed by 1 session
of Brief Intervention
• People could receive 5 BI or 12 BT sessions
• Referred out for detox, residential care, etc.
30 provider agencies
contracted to conduct
screening in over 70 sites in
18 counties
SBIRT Approach
• Universal prescreening (7 items: alcohol, drugs,
medications, depressive symptoms)
• Full screen (ASSIST) for those with positive
•
prescreens
Level of risk dictates type of service:
–
–
–
–
Screening & Feedback (SF) for negative screens
Brief Intervention (BI) for moderate risk
Brief Treatment (BT) for moderate to high risk
Referral to Treatment (RT) - high risk/problem use
Prescreen – Part 1
Prescreen – Part 2
Alcohol, Smoking and Substance Involvement Screening
Test (ASSIST)
World Health Organization (WHO)
• An interview style screen administered only if there is a
•
•
positive prescreen
The ASSIST was developed to help healthcare
professionals detect and manage substance use
Scores provide a “level of risk” for alcohol or for other
substances and type of service that follows:
– Low risk = screening & feedback (SF) about results
– Moderate risk = indicates the need for brief
intervention (BI) using motivational interviewing
– Moderate to High Risk = Brief treatment (BT)
– High Risk = Referral to treatment
Florida BRITE Project
Reasons for Positive Screens at Baseline (n=8,165)
Yes
# Days
Mean (sd)
4,915 (60.2%)
18.2 (10.4)
Used alcohol to intoxication
(5+ drinks in one sitting)
1,554 (19.0%)
12.4 (10.2)
Used alcohol to intoxication
(<4 drinks in one sitting & felt high)
1,815 (22.2%)
9.7 (8.4)
Intoxication (either 5+ drinks or 1-4
drinks & felt high)
1,102 (13.5%)
17.9 (11.4)
435 (5.3%)
11.4 (10.3)
4,915 (60.2%)
18.2 (10.4)
Past 30 days of Substance Use
Used any alcohol?
Used illegal drugs
Used both alcohol & drugs on same
day
BRITE Services Received
• For those who screened positive and
agreed to receive services:
o
o
o
BI n = 6,338
BT n = 675
RT n = 899
Positive Screens – by Provider Category
Total
Positive
Screens
Total Screened
% Positives
8,165
Aging
1,994
85,001 16,019
9.6% 12.4%
Mental
Health
1,358
Health Substance
Care
Abuse
3,469
1,281
14,649 43,772
10,490
9.3%
7.9%
12.2%
Clients Receiving Either BI, BT, or RT
by Category of Service Provider
Unknown
2%
SA 10%
Aging 36%
Health
29%
Behav.
Health
22%
Past 30 Day Use of Alcohol and Drugs:
Baseline versus Six Month Follow-up
Initial
Interview
ASSIST Questions
Use any alcohol
Use alcohol to intox.
with 5+ drinks
Used alcohol to intox.
with 4 or fewer drinks
and felt “high
Used illicit drugs
Used both alcohol &
drugs on same day
Follow-up
Interview
%
Decrease
N
Days
N
Days
Sig. p)
133
9.01
134
2.41
73.3
<.001
31
5.10
31
2.68
47.5
.024
32
4.81
32
2.84
41.0
.031
132
7.37
133
1.89
74.4
<.001
14
8.29
14
2.86
65.5
.038
Sustainability of SBIRT
• Nationally, a number of actions and events are
fostering SBIRT’s sustainability:
– The BIG (Brief Intervention Group) Initiative for EAP
programs and Hospitals cross North America
– American College of Surgeons’ Committee on Trauma
requires SBIRT in Level I & II trauma centers
– Billing codes for SBIRT available to providers
– Local adoption of BRITE as a model in Florida and
nationally (to bill through Older Americans Act $s)
Billing codes for SBI were adopted Feb. 2008
• Reimbursement for screening and brief
intervention is available through commercial
insurance CPT codes, Medicare G codes, and
Medicaid HCPCS codes
• Florida has not approved Medicaid codes for
billing purposes
Payer
Commercial
Insurance
Code
Fee
Schedule
CPT
99408
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30 minutes
$33.41
CPT
99409
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater than 30
minutes
$65.51
G0396
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30 minutes
$29.42
G0397
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater than 30
minutes
$57.69
H0049
Alcohol and/or drug screening
$24.00
H0050
Alcohol and/or drug service, brief
intervention, per 15 minutes
$48.00
Medicare
Medicaid
Description
Health Care providers who can provide
SBIRT services under Medicare
• Medicare pays for medically reasonable & necessary SBIRT
services in physicians’ offices & outpatient hospitals
• Physicians, Physician Assistants, Nurse Practitioners,
Clinical Nurse Specialists, Clinical Psychologists, or Clinical
Social Workers can bill for SBIRT
• To bill Medicare, providers of MH services must be:
– Licensed or certified to perform mental health services
by the state in which they perform the services;
– Qualified to perform the specific mental health services
rendered; and
– Working within their State Scope of Practice Act
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/SBIRT_Factsheet_ICN904084.pdf
BRITE as an Evidence Based
Practice for Older Adults
• A 2012 Issue Brief published by SAMHSA and
U.S. Admin. on Aging identified BRITE as one
of the evidence-based practices for behavioral
health services to older Americans.
• For states that adopt the model, staff from
aging services can now implement BRITE and
their agency can be reimbursed by each state’s
department of aging from federal funding.
Conclusions
• SBIRT is an evidence-based, national initiative
•
applied mostly in hospitals and primary care
SBIRT focuses on risky/problematic use
• Florida BRITE Project found that:
–
–
–
–
Screening conducted in a variety of settings
Aging services have higher % of positive screens
Alcohol is the most problematic substance
Med. misuse - a major issue, but difficult to assess
• SBIRT model is sustainable
The End
Questions?