SBIRT in Hospitals: It Can Be Done

IRETA staff member Dr. Dawn Lindsay shares a manifesto and model project

In early April, I had the opportunity to travel to Newark, Delaware to attend “Addressing Substance Use in the Hospital: Building Bridges to Community Treatment.” I always enjoy conferences (they bring me back to my academic roots) and no matter how many I attend, I never fail to learn something new.

While the one-day conference at Christiana Care Health System was a relatively small and regional gathering of around 50 attendees, it did not fail to deliver. The presentations were enlightening, the breakout sessions were engaging, and the panel discussion, “From a patient’s perspective,” was moving. All in all, an extremely well spent day.

Presenter Lauren Broyles shared her “manifesto”

I was delighted to find that Lauren Broyles, PhD, RN, who is based in Pittsburgh and has worked with us at IRETA, was delivering one of the morning presentations. Dr. Broyles, research scientist at Pittsburgh’s VA Center for Health Equity Research and Promotion and an assistant professor at the University of Pittsburgh School of Medicine, has become an important voice for the role of the nurse in Screening, Brief Intervention and Referral to Treatment (SBIRT), particularly in hospitals.

Of the conference, Dr. Broyles said: “It was nice to be back in a venue where people were thinking about addressing substance use in the hospital setting.”

Dr. Broyles has a well-defined vision for how nurses can contribute meaningfully to the conversation, summed up by her self-described “manifesto,” which goes like this:

I believe in addressing the entire SPECTRUM of alcohol use; having a preventative, health promotion orientation.
I believe that nurses can be effective agents in changing the conversation about alcohol–that is, how, when, and where we talk about it–with ALL of our patients.
I believe that nurses’ visible, active engagement in the SBIRT process is critical, regardless of their practice setting, specialty, or patient population.
I believe that through nurse-delivered SBIRT, we can develop a nursing workforce that is equipped and motivated to actively and collaboratively respond to the spectrum of use, across practice levels, across practice settings.
I believe that as nurses, we bring distinct assets to changing this conversation and moving SBIRT into routine clinical practice—that we are not just another group to potentially pick up what others CAN’T do, WON’T do, or assert that they simply don’t have TIME to do.
And finally, I believe that by embracing SBIRT as a part of our practice, supporting genuine workforce development, and actively collaborating—not only in patient care delivery of SBIRT, but in the decisions and processes that support its implementation into our everyday practice settings and routines, we CAN change how people think and talk about alcohol use, prevent alcohol-related harm, and more efficiently identify and manage alcohol use disorders, for ALL of our patients.

Project Engage: A Model

Project Engage brings SBIRT to two Wilmington, DE hospitals

From Dr. Broyles’s perspective, Project Engage is a great working example of “how substance use can be addressed in the inpatient setting and how the provider can then follow the patient through to the community.”

Launched at Wilmington Hospital and now expanded to Christiana Care, Project Engage embeds an outreach coordinator with intervention expertise full-time in the hospital. The coordinator counsels patients with substance abuse problems at their bedside and encourages them to go directly into treatment when they leave the hospital. In this way, Project Engage offers patients help when they need it most and provides a clear pathway directly to treatment. Staff even go so far as to offer patients bus passes or rides to treatment facilities.

The outreach coordinator comes to the hospital through a partnership with a local treatment provider, Brandywine Counseling & Community Services. This is an example of a promising approach to SBIRT: a treatment provider offering SBIRT in a medical setting as part of their prevention services (a northeast Ohio FQHC is doing the same thing and seeing success).

At the conference, Terry Horton, M.D., chief of Christiana Care’s Division of Addiction Medicine and medical director for Project Engage, delivered a presentation highlighting the initiative’s positive outcome data so far. Between 2008 (when the project began) and November 2012, more than 1,000 patients have participated and about 30 percent of them followed through with treatment.

Staff offer patients rides or bus passes directly to treatment

“Many of these patients cycle repeatedly in and out of the hospital or the Emergency Department,” Horton said in an article on the project’s website. “We are encouraged by the success we have had in both reducing patients’ suffering, as well as their health care costs.”

In 2011, David K. Mineta, Deputy Director of the White House Office of National Drug Control Programs (ONDCP), visited Christiana Care and praised the model.

“What makes Project Engage so interesting,” said Mineta, “is there’s a research piece, a financing piece, a provider piece, and a [state] government piece. It’s unusual to see all these pieces in one place integrating substance use care with primary care.”

For me, Project Engage points to an important insight about transforming systems of care, and specifically implementing SBIRT in hospital systems: that sometimes it’s not about the grant funding (Project Engage began as a pilot project with minimal funding), but rather about the commitment, creativity, and passion of key people within an organization.

Media

Slideshow presentation about Project Engage

PBS First for Friday video on Project Engage

Conference Sponsors

Christiana Care Health System

The Department of Psychiatry at the University of Pennsylvania’s Perelman School of Medicine

The Delaware Valley Node of the NIDA Clinical Trials Network

Resources

Treatment Research Institute

Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System

Dr. Dawn Lindsay joined IRETA in April 2011. She completed her graduate work in clinical psychology at the University of Cincinnati in 2002 and was on the faculty in the Department of Psychiatry at the University of Pittsburgh before coming to IRETA. She has eight years of experience conducting NIDA- and NIAAA-funded research in the area of adolescent substance use disorders. She is a member of American Psychological Association and the American Evaluation Association. Click here for a list of her publications

Regulation will Change Cigarettes in the Future–The Question is When

May9 by Justine Coyne

The FDA is working to adjust nicotine to “non-addictive levels”

Image credit: BeTobaccoFree.gov

Since its founding in 1906, the function of the Food and Drug Administration (FDA) has been to protect and promote public health by ensuring that the products placed for sale on the market are safe for consumers. But with the passage of the Family Smoking Prevention and Tobacco Control Act (FSPTCA) in 2009, for the first time in its history, the agency was faced with regulating a product that–when used as intended–kills up to half of the people who use it: tobacco.

According to a 2004 Surgeon General’s Report, smoking harms nearly every organ of the body, causing a myriad of diseases and reducing the health of smokers in general. It is responsible for nearly one out of every five deaths each year in the US and disproportionately harms behavioral health patients, as nearly 50% of the people who die each year have a mental illness.

The cost, of course, is huge: smoking accounts for more than $75 billion in direct medical costs annually.

It’s no secret that smoking is bad for you. The Surgeon General released the first report warning of its dangers of in 1964. Yet today, 40 million Americans are still smoking.

“Forty years have passed since the first landmark Surgeon General’s report on smoking and health. Yet, smoking remains the leading preventable cause of death in this country. It continues to cost our society too many lives, too many dollars, and too many tears,” wrote Secretary of Health and Human Services Tommy G. Thompson in 2004.

Nicotine’s addictive power

For nonsmokers, it’s always surprising that so many people smoke when the dangers are so well-known. This behavior, we know, has to do with addiction.

Nicotine is addictive because it is quickly absorbed into the bloodstream. Within 10 seconds of entering the body, nicotine reaches the brain, causing the release of adrenaline. This creates a temporary “buzz” of pleasure and energy to the consumer.

As the body builds tolerance to nicotine, it requires more cigarettes in order to achieve this effect. The body will crave more nicotine and, as with other drugs, when a smoker does not have nicotine in his or her system, they experience withdrawal. This cycle repeats over and over again, furthering the addiction.

Thus, while the initial decision to smoke a cigarette is an individual’s choice, the addictive nature of nicotine often leads to continued smoking behavior despite serious adverse health effects. And research published earlier this year showed that people with certain genetic profiles are more likely to become quickly addicted and have more difficulty quitting.

Each day, more than 3,600 people under 18 smoke their first cigarette, and more than 900 begin smoking on a daily basis.

FDA Regulation: Where did this come from?

The concept of the FDA regulating tobacco products is nothing new. In fact, in 1994, the agency wrote a letter to the Coalition on Smoking or Health announcing its intention to consider regulating cigarettes.

The letter’s premise was that the vast majority of tobacco users self-administer the product for the drug effects of nicotine and to sustain their addiction and that cigarette manufacturers control the levels of nicotine in cigarettes to maintain this addiction.

Therefore, the FDA argued, cigarettes could be regulated on the basis of their nicotine content to prevent addiction. Today, nearly 20 years later, this possibility has come to fruition.

FDA regulation: What does it mean?

When President Obama signed the FSPTCA into law, it seemed like a big offensive move in the fight against smoking.

With more than 40 million Americans addicted to nicotine, FDA regulations could potentially curb this public health crisis. Under the FSPTCA, the FDA is able to establish product standards, which includes imposing standards for the nicotine content of cigarettes.

The FDA now has the power to reduce nicotine to “non-addictive levels” in an effort to greatly lower the number of individuals who are currently addicted and prevent many others from becoming addicted in the future.

What is a “non-addictive level” of nicotine?

A study published by the American Journal of Public Health in February 2013 found that most American adults support reducing nicotine in cigarettes to prevent people, especially children, from becoming addicted to smoking.

Researchers surveyed 511 nonsmokers and 510 smokers aged 18 and older and found that, overall, two-thirds supported reducing nicotine levels in cigarettes to non-addictive levels.

In 1994, renowned tobacco researchers Neal Benowitz and Jack Henningfield published a letter in the New England Journal of Medicine explaining that the optimal nicotine yield is less than 0.2 milligrams because it is likely below the threshold for addiction. By contrast, an average American cigarette yields about one milligram of absorbed nicotine.

They write: “The rationale behind the strategy for regulating the nicotine content of cigarettes is to prevent the development of nicotine addiction in young people. To minimize the hardship to already addicted adult smokers, the level of nicotine in tobacco could be reduced gradually, with a goal of reaching a target nicotine level over perhaps 10 to 15 years.”

Nicotine reduction is designed to reduce addiction, not experimentation (photo: smokersworld.info)

Nicotine reduction is an attempt to prevent addiction, not experimentation (photo: smokersworld.info)

While cigarettes would still be sold, they argued, the number of addicted smokers would be greatly reduced. The goal was not to prevent experimentation or occasional smoking, but to reduce nicotine dependence, causing a substantial reduction in the rates of tobacco-related illnesses.

“It is difficult to prevent adolescents from experimenting with cigarettes,” they write. “However…it may be possible to prevent the transition from experimental or occasional smoking to addiction.” The entire letter is worth reading; it offers a good public health perspective on smoking.

What is the next step? More research

While data have shown that cigarettes with lowered nicotine content reduce carcinogen exposure, relieve withdrawal and curb cravings, the FDA will not change the entire tobacco market without further research.

Dr. Lawrence Deyton, former Director of the FDA Center for Tobacco Products

Lawrence Deyton, the FDA’s former chief tobacco regulator, told the Washington Post that in order to take steps such as dialing back the amount of nicotine in tobacco products, the agency must undertake exhaustive scientific research demonstrating that its decisions are not “arbitrary and capricious.”

Thus, researchers are looking to further study the potential effects of reducing nicotine in cigarettes and other tobacco products. One such study is being conducted at the University of Pittsburgh.

The NIDA-funded Center for the Evaluation of Nicotine in Cigarettes at the University of Pittsburgh is working to assess the potential impact of regulated reduction of the nicotine content of cigarettes as a means of improving public health.

While the study has not yet begun, it will examine the effects of reduced nicotine cigarettes on smoking behavior, toxicant exposure, dependence and abstinence.

Other preliminary research supports the feasibility and safety of gradual reduction of the nicotine content in cigarettes.

A 2013 study showed that reduced nicotine cigarettes lower cravings as well as regular cigarettes

What does it mean for the future?

Mitch Zeller, current Director of the FDA’s Center for Tobacco Products

Ideally, once all of the research is gathered, the FDA can move forward and lower the nicotine content in cigarettes, thereby improving public health.

And while the media has been outspoken about the FDA’s lack of progress in the last two years, the appointment of long-time tobacco industry critic Mitch Zeller as director of its Center for Tobacco Products in March means we may now see more aggressive efforts to regulate tobacco products.

Before tobacco products on the market can change, however, we need a larger body of research about exactly how they should be changed.

***

Recommended Resources

What New Recovery Research is Teaching Us

May3 by Justine Coyne

First-of-its kind survey begins to measure the effect of recovery

Researchers have been investigating addiction for decades. What causes addiction? What is its impact on society? How many Americans are battling addiction? How do we treat it?

But when it comes to the effect of recovery from addiction, research has been noticeably absent.

As the first step toward bridging this gap, Faces and Voices of Recovery (FAVOR), a nonprofit organization that advocates for public action and works to promote recovery, released the results last month from the first-ever nationwide survey looking at the effects of recovery over time.

“Because of healthcare’s focus on the causes and costs of substance use disorder, combined with widespread social disapproval of addicts, the research community has largely ignored the many success stories,” Michael Dahr writes for The Fix.

The study was overseen by Dr. Alexandre Laudet, an internationally recognized expert in addiction recovery and longtime advocate for building the science of recovery.

According to FAVOR, there are over 23 million Americans in recovery from addiction. The report, “Life in Recovery,” attempts to measure and quantify the effects of recovery over time and highlights the need to remove discriminatory barriers to it.

Results show dramatic improvements associated with recovery that affect all areas of life, including:

A ten-fold decrease in involvement with the criminal justice system and use of costly emergency room departments
Steady employment increased by over 50 percent relative to active addiction
Financial problems such as debt and bankruptcy were reduced by 50 percent
Over 80 percent of people in recovery paid taxes, compared to just more than half in active addiction
A 50 percent increase in participation in family activities
Domestic violence dropped from over 40 percent down to 10 percent
Two-thirds of those in active addiction had untreated mental health problems, but those numbers decreased by a factor of more than four with recovery

Source: FAVOR’s “Life in Recovery“

“These findings underline the fact that recovery is good not only for the individual, but also for families, communities, and the nation’s health economy,” the report concludes.

“It’s time to take action to end discrimination facing people in or seeking recovery from addiction,” former Congressman Patrick Kennedy said in a statement. ”As this survey from Faces & Voices documents, recovery benefits everyone.”

Faces & Voices Board chair Dona Dmitrovic said the survey provides evidence, for the first time ever, that investing in recovery makes sense.

The study also found that discriminatory practices in housing, employment, health insurance coverage and elsewhere remain tremendous barriers to recovery. FAVOR advocates for action against these barriers.

“We call on states and the Congress to reform drug policy by addressing and removing discriminatory barriers; ensuring access to and financing for a full range of health care and other services to support Americans in initiating and sustaining their recovery; and to invest in research to identify quality and cost-effective recovery-promoting policies and practices,” Dmitrovic said.

Research limitations and challenges

This report represents a first step toward understanding the nature of long-term recovery and clearly has significant limitations.

Of the of limitations noted by Laudet, the most apparent is the likelihood that the survey population does not adequately represent the nation’s recovery population. The survey was conducted exclusively online over a relatively short period (two months) and racial minorities are underrepresented, as are individuals without a college education or who are unemployed.

Another potential limitation of this survey centers on reporting bias—namely, the possibility that respondents over-reported negative experiences in active addiction and/or positive ones in recovery. The study also failed to differentiate responses by substance.

In a review of 415 scientific studies of recovery outcomes published last March William White highlighted the challenges of conducting research studies on recovery and of drawing conclusions based on evidence from these studies.

“Efforts to measure recovery are challenged by the lack of professional and cultural consensus on the definition and measurement of key constructs (recovery, remission, abstinence, and subclinical/asymptomatic/controlled/moderate use) and by conflicting rates of recovery–rates reported across clinically and culturally diverse populations in studies marked by widely varying methodologies, follow-up periods, and follow-up rates.”

In short, so many divergent portrayals of “recovery,” often results in an “apples and oranges” comparison.

Comparing recovery research can be difficult because we don’t all agree on what recovery means

This is not, however, reason to shrug our shoulders and leave the question blank.

There are grave consequences, White argues, to disregarding the effects of recovery and focusing instead on the effects of addiction: ”The pessimism flowing from such selective attention feeds misunderstanding and fuels stigma and its far-reaching consequences.”

And popular media has primarily muddied the waters.

“The constant media onslaught of celebrities heading back to ‘rehab’ after their latest falls from grace has produced a public unsure of exactly what ‘recovery’ means and whether it is really attainable for all,” White observed.

“The failure of a celebrity to achieve stable recovery garners great cultural attention, while the masses of those in long-term recovery pass invisibly through our culture each day.”

IRETA’s Work Included in 2013 Drug Control Strategy

Apr24 by Jessica Williams

Presentation at Hopkins featured an interesting blend of science and law enforcement

This morning, the Office of National Drug Control Policy (ONDCP) Director R. Gil Kerlikowske, NIDA Director Dr. Nora Volkow and Baltimore City Police Commissioner Dr. Anthony Watts presented the 2013 National Drug Control Strategy at Johns Hopkins University in Baltimore. The presentation streamed live online. The full strategy is available for download now.

Drug Control Strategy presenters Mr. Kerlikowske, Dr. Volkow, and Dr. Batts

Drug Control Strategy presenters Mr. Kerlikowske, Dr. Volkow, & Dr. Batts

On the wall behind them hung a picture of one of the founders of Johns Hopkins, William Stewart Halsted, who was addicted to cocaine during much of his career. Evidence, said Dr. Eric Strain, director of the Center for Substance Abuse Treatment and Research at Hopkins, that addiction can happen to anyone.

A New Orientation

Leading up to its release, ONDCP emphasized the strategy’s newness: that the war on drugs is over and our country will approach substance use and its consequences with:

A focus on prevention over incarceration ($10.7 billion tagged for prevention & treatment versus $9.4 billion for police and incarceration)
Science informing policy
Overall, the lens of public health

For the first time, this year’s Drug Control Strategy budget favors prevention and treatment

@ONDCP’s twitter hashtag for the presentation, #DrugPolicyReform, further accentuated their message the strategy as a new direction.

SBIRT Featured in the Strategy

At IRETA, we were delighted that Screening, Brief Intervention and Referral to Treatment got major billing in this morning’s presentation and in the strategy itself.

Kerlikowske commented that healthcare professionals have become dissociated from substance use disorders, but that early detection in healthcare systems will take on new importance as millions of Americans gain insurance coverage under the Affordable Care Act.

The National SBIRT-ATTC, housed at IRETA, was specifically mentioned in the Strategy, as a federally-funded entity to provide “extensive resources for the implementation of SBIRT to SAMHSA grantees (with the exception of current SBIRT grantees) and other interested health care entities” (page 15).

Science to Guide Policy

The Strategy finds a middle ground between our country’s historically punitive approach to drug abuse and the legalization movement. Neither incarceration nor legalization, said Kerliwkoske, will address the consequences of drug use in America. He criticized any policy that “fits on a bumper sticker” as unlikely to work.

Dr. Nora Volkow, who has led NIDA for ten years, emphasized scientific gains in our understanding of addiction. She suggested that the US, as a leader in addiction research, has much to offer other countries who struggle with substance use and its effects.

The Strategy rejects bumper sticker policy

“Let’s export that research,” said Kerlikowske. To reduce substance-related harms, he said, “We can export more than just helicopters.”

The interplay between law enforcement representatives and researchers was a unique aspect of this morning’s presentation.

Kerlikowske, former police chief of Seattle, and Police Commissioner Watts both discussed their growth as law enforcement officers and policymakers as they came to a deeper scientific understanding of addiction. Both of their presentations displayed the Strategy’s commitment to “smarter policing,” informed by data, an understanding of the social underpinnings of crime, and ongoing addiction research.

And Kerlikowske pointed out that police officers often don’t get credit for their work preventing drug abuse, that they are rewarded for arrests and other interdiction activities. The 2013 strategy points to many current and potential vital contributions on the part of law enforcement toward prevention efforts.

Dr. Holly Hagle, Director of the National SBIRT-ATTC, had a positive take-away from this morning’s presentation and on the newly-published Strategy. She said, “I’m thrilled that substance use is being embraced as a public health issue. I think that’s great for everyone involved.”

Recommended Resource

Download the National Drug Control Strategy Fact Sheet

Family Secrets and Hope

Apr5 by iretablog

IRETA’s Dr. Holly Hagle opens up about how an overdose touched her life and discusses its impact on others

Dr. Holly Hagle

My last blog entry was about trauma, a depressing subject, so I vowed my next post would be more cheerful and optimistic. This blog is about prescription drug overdose and how it affected my family. Not exactly cheerful and optimistic. In fact, a horrible experience for the family left behind.

I hope my story brings about greater awareness of and early intervention for prescription drug abuse.

Let me tell you my story. People in my family talk about it behind our backs. Now that my father has passed away, maybe people will talk about it with me. Maybe I feel like I can talk about it since my Dad recently passed (not of a drug overdose; he was addicted to tobacco…that’s another blog.) Now I can let my secret out.

My mother died 10 years ago from an accidental drug overdose. At least that is what it says on her death certificate. I have never spoken of this despite my position within the addictions education field. I have never talked about how it affected my life. I have struggled with keeping it a secret. I am revealing the truth hoping something good will come from it, that maybe others will tell their stories, too.

The author and her parents

My mom was a great, fantastic, super person. She was a loving wife, mother and daughter; her love was true and unconditional. There was something special about her and my dad. They adopted three children all outside of their race (in 1971 before Angelina and Brad made it cool). I felt honest, unconditional love from both my parents.

But Mom also suffered from chronic debilitating depression her entire life. She also suffered from chronic migraines and a degenerative disc disorder that were treated with prescription medication and eventually led to a fatal addiction.

Other families: What’s left after a loved one dies of a drug overdose?

Henry Louis Granju

I was curious about other families in the wake of overdose deaths: how do they go on? The tragedy of the situation, of losing someone you love to an overdose, leaves a gaping hole in your heart that can never be filled. It really is horrific.

About a Boy Named Henry Louis Granju, told by Henry’s mother, is the story of how the drug overdose of her 18 year old son has affected her family. His mother wrote about their experiences in a blog and a local news station did a short documentary about their lives. She wrote about how he was much more than his disease of addiction.

Stubborn hope–and beautiful music

The Lumineers

I can’t carry a tune or play a note, but I turn, as many of us do, to music to help heal my pain and sorrow…or to cheer me up. That’s why I was touched by the story of how The Lumineers came together.

The two founding members of the band began making music together after Josh Fraites, brother of Jeremiah Fraites and best friend of Wesley Schultz, died of a drug overdose. Out of their grief came musical collaboration.

In a 2012 interview with USA Today, they said that the overdose “influences what we talk and write about. There’s a certain level of growing up overnight that happens. As a band, it adds something that’s very elusive — it’s hopefulness, but there’s also some sorrow behind it, and there’s some depth that defines who you are.”

Best illustrated by their single Don’t Wanna Go, the Lumineers convey the conflict of pain and sorrow and fear that overdose encompasses.

Prominent people are affected by this, too

Recently, President Clinton requested that CNN’s Dr. Sanjay Gupta do a story about America’s number one accidental killer, prescription drug overdose. A close friend of the former president’s lost his son, who died after mixing a prescription pain reliever with alcohol.

Dr. A. Thomas McLellan
Credit: Brendan Smialowski for The NYT

Renowned addiction researcher and former deputy director of the White House Office of National Drug Control Policy A. Thomas McLellan reveals his personal and professional perspective on overdose in this interview with the New York Times where he discusses his son’s overdose death from anti-anxiety medication and alcohol. He characterizes the problem of addiction as the country’s “most entrenched problem.”

Prevention

The really sad thing is that overdose can be prevented! What if my dad had a Narcan kit at the house? Or what if we had gone to seek help at a place like The Bridge to Hope, an organization for families who need support in addressing substance abuse and addiction?

Understanding the Issue

Here are some links to information about some of the issues surrounding overdose, its rise, and prevalence:

This article by the Washington Post captures the troubling history of OxyContin and its perceived “minimal risk of addiction:” Rising painkiller addiction shows damage from drugmakers’ role in shaping medical opinion

This article in Join Together highlights the FDA’s upcoming decision to right a wrong: FDA to Consider Tighter Regulations for Hydrocodone

This article by the CDC highlights the commonalities between a 53-year-old mother, her 35-year-old son, and seven others who all died of prescription drug overdoses in a nine month period: Policy Impact: Prescription Painkiller Overdoses

What do we all have in common? We are all a stone’s throw away from this affecting us: Painkiller Overdose Death Rate Triples In Ten Years, USA

Drug overdose death rates by state per 100,000 people (2008)
source: CDC Vital Signs

Sharing Stories

If you want to share your story in hope of de-stigmatizing addiction, here are some interesting sites to check out: http://not-even-once.com/ and Experience Project: I lost someone to overdose stories

I would like to think that maybe she felt in the end…that she didn’t wanna go. So I am left with this: maybe if I tell this story, others will tell theirs, too.

SBIRT Fits in Today’s (and Tomorrow’s) Provider Business Model

Apr5 by Jessica Williams

An Ohio treatment center provides SBIRT at an FQHC, a region works cooperatively, and everybody wins

SBIRT in the Mahoning Valley
Photo credit: Wikipedia

It was 2010 when Doug Wentz first heard the word “SBIRT.”

He’d been volunteering for the Ohio National Guard offering D&A services to men and women returning from Iraq and Afghanistan. He was in a meeting about the behavioral health problems they were seeing among returning veterans.

“And I’m making suggestions based on my prevention background. And then a woman named Geneva Sanford said, ‘You know what, I think we ought to SBIRT these people,’ and I had no idea what she was talking about,” Wentz recalled.

“And as she talked, I thought ‘Gee, this makes sense,’ so Jerry Carter, my executive director, and I took her to lunch.”

That lunch was the beginning of something big for Wentz, something that has continued to grow and evolve. Wentz is the Community Services Director at Neil Kennedy Recovery Clinic in Youngstown, Ohio, a subsidiary of Gateway Rehabilitation Center. He’s a Certified Prevention Specialist who’s worked in the field since 1977. His career, he says, has consisted of constantly reinventing himself. This time, it’s Screening, Brief Intervention and Referral to Treatment (SBIRT).

There has been a groundswell of SBIRT activities in northeastern Ohio, a movement that Wentz has helped to stir up and currently includes multiple treatment centers, three sites of one Federally Qualified Health Center (FQHC), an adolescent mental health center, a couple of universities, and a private psychiatry practice. And it’s just getting started.

***

In the last two years, Wentz and two trainers, Sanford and Kriss Herron of Kettering Hospital, have begun leading trainings and dedicating time to moving SBIRT into practice in various locations in northeastern Ohio. The most prominent of these locations is One Health Ohio, an FQHC located in Youngstown.

There are so many unique aspects to this particular SBIRT movement that it’s hard to point them all out. Perhaps most unique, though, is that much of the SBIRT activity is being funded by a treatment center.

Neil Kennedy receives federal prevention dollars and has dedicated some of them to developing SBIRT programs. Specifically, the agency dedicates prevention funds toward a part-time CPS to do SBIRT at One Health Ohio and a percentage of Wentz’s time developing trainings and overseeing SBIRT projects.

In Ohio, said Wentz, “We obviously want to see the Medicaid codes get turned on. If there’s a payer source, the medical community will do SBIRT. But in the meantime, I think this is really doable [for Neil Kennedy].”

This arrangement is an interesting example of “segregated no more” action on the part of a treatment provider, a model of addiction treatment that Dr. Tom McLellan foretold “the swift, the smart and the flexible” will see great success with in under healthcare reform. As McLellan (among others) pointed out when he worked at the White House, patients need a continuing care model for substance use and that means primary care and addiction treatment providers need to work together.

At One Health Ohio, “working together” means literally working in the same room. They use the “Oregon Model” of clinic flow, which consists of an initial six-question screen that patients complete before the medical intake process. If the patient screens positive, it triggers a second, more specific test to look at whether the patient has the propensity to have alcohol, drug or behaviorally related problems.

The Oregon Clinic Flow Model

The doctor then determines if she will do the intervention personally or refers the patient to Wentz’s staff. If referred, the patient meets with Wentz’s staff person in the morning or a trained FQHC employee in the afternoon. During the meeting, the AUDIT or DAST screen is administered and, if appropriate, brief interventions and referrals to treatment are offered.

Although the project kicked off at One Health Ohio in February of this year, the data already looks encouraging. “The number of people that they’ve identified in the past is way smaller than this, so they feel they’re beginning to make some headway,” said Wentz.

An FQHC with eight locations and a mobile medical/dental program

The CEO of One Health Ohio is Dr. Ron Dwinnells, whose enthusiasm has been a major driver for SBIRT’s quick, comprehensive implementation in his clinic. Dwinnells not only oversaw training for his staff members, he also saw an opportunity to research SBIRT’s effectiveness by comparing the identification of substance misuse at his Youngstown clinic with his two other FQHC locations in Alliance and Warren, Ohio. To compare outcomes between the test site and the two control sites, Dwinnells reached out to researchers at Kent State University and Northeastern Ohio College of Medicine, who are assisting in the evaluation of the project.

Of Dwinnells, Wentz said, “He’s a visionary and quickly grasped how important this would be.”

Wentz also pointed out that the partnership with Neil Kennedy offers One Health Ohio a valuable service. With the changes accompanying healthcare reform, he said, “Everybody is courting the FQHCs. In our case, we didn’t want anything from them. We said, ‘We want to give you this program.’ This is a different approach for an SUD provider to take. ‘We don’t want your money. We just want to coordinate with you to improve patient care.’”

Wentz is continuing to offer trainings that FQHC staff can attend, as well as a range of other healthcare providers and community members. Since January 2012, One Health Ohio has conducted three six-hour trainings throughout northeastern Ohio with over 150 professionals in attendance.

These trainings have led to SBIRT implementation in a variety of settings in the region, including a private psychiatric practice, an adolescent mental health clinic, and a for-profit D&A treatment provider. Wentz is happy to help facilitate the process and to learn from the experiences of these other sites.

NIDA’s free online screening tools

For example, he led a training for residents working in the dental clinic at St. Elizabeth’s Hospital. Because they use electronic records, the clinic decided to use the NIDAMED online screening tool that integrates with EHRs.

“So we played around with that tool and it was a lot of fun,” said Wentz. “It only takes ten or fifteen minutes to use the whole thing. It’s pretty cool.”

***

Why are these SBIRT trainings so well attended and why are so many different groups in the region interested in SBIRT and willing to work together to implement it? Wentz offered a couple explanations.

The first is the value placed on relationships in the region. “I have great respect for my professional colleagues across the Mahoning Valley here,” he said. “Everybody kind of knows everyone here. It’s connections, it’s relationships and it’s professional reputations.”

And secondly, “Everybody is seeing that we’re in a crisis. We are losing four Ohioans every day to prescription overdose deaths. 75 to 85 percent of our patients in our detox beds are opiate addicts and the people we’re seeing are younger and younger.”

source: http://www.galliacpr.org/

“We’re all waking up to it and thinking, ‘Jeez, we’ve got to do something. We can’t wait for these people to show up in drug courts or in the federal pen or in an emergency room. We’ve got to do something sooner.’ I think this response is coming from the community—from everybody, including the docs.”

Neil Kennedy is a part of that community, and a part specially equipped with an understanding of substance abuse. The majority of the patients that use the One Health Ohio, of course, don’t need specialty treatment. But some do. And many may benefit from brief interventions, but not need referrals to treatment.

“Ninety-five percent of the patients we screen are not going to be our customers,” Wentz said. “As part of our business model, we obviously do hope to get some referrals, but our business is not just addiction treatment. It’s also prevention. It’s being good citizens in the community.”

As the National SBIRT-ATTC, we will follow this project’s developments and its outcomes. Stay tuned for an update on One Health Ohio, Neil Kennedy and SBIRT in Ohio’s Mahoning Valley on The Institute Blog.

Is Liquor Privatization a Public Health Issue?

Apr1 by Justine Coyne

A look at potential impacts amid Pennsylvania’s legislative debate

(Photo credit: http://www.shawnhoke.com)

On March 21, the Pennsylvania State House approved a liquor privatization bill aimed at eliminating state liquor stores and allowing wine to be sold in grocery stores. While the possibility of privatization has been discussed for years, this is the first time in state history that such a bill has cleared the House.

Currently, Pennsylvania’s liquor laws are some of the most restrictive in the country.

Much of the debate regarding liquor privatization has been about whether or not it is good fiscal policy. Questions being asked are: How will this help to fill the current gaps in the budget? Is this model economically sustainable? What does it mean for taxpayers?

And while these questions are important, there is another question to add to the list: If liquor is more readily available, will we see an increase in consumption?

Some of the Research

In a 2009 study, the Commonwealth Foundation, a Harrisburg conservative think tank, looked at the effects of deregulation in Iowa and West Virginia. Researchers John Pulito and Dr. Anthony Davies, of Duquesne University, found that after breaking states down by their level of control, “evidence suggests that, while regulating liquor at the wholesale level may contribute to reduced consumption, there is no clear evidence that regulating liquor at the retail level affects consumption.”

In fact, the researchers found that with deregulation, per capita consumption decreased by as much as 5.9 percent. They said with more convenient hours and less restrictive purchasing guidelines, consumers were actually purchasing less alcohol per trip.

“Divestiture of Pennsylvania’s state liquor stores would represent a financial windfall to the state, while posing no threat to public safety, as it would not result in the social ills many opponents of privatization fear,” they write.

However, a much larger study, published last year in the American Journal of Preventative Medicine, found that it is likely that the privatization of liquor sales will lead to an increase in alcohol-related social ills.

In it, the Community Preventative Services Task Force, a resource for evidence-based recommendations and findings about what works to improve public health, recommended against the privatization of alcohol retail sales, based on their summary of 17 studies on the privatization of retail alcohol sales throughout the U.S., Canada and Europe.

They found that across the 17 studies, there was a 44.4 percent median increase in the per capita sales of privatized alcoholic beverages in locations that privatized retail alcohol sales.

The report also found that privatization may also be associated with more lax enforcement of sales regulations.

And within the last year, researchers at Drexel University projected that the number of retail alcohol outlets in Philadelphia might increase by 1, 115 “with concomitant negative health, crime and quality of life outcomes that accompany such an increase.”

What happened in Washington?

Washington State legalized alcohol sales last summer

Washington State legalized liquor last summer
(Photo credit: members.virtualtourist.com)

One way to glimpse Pennsylvania’s possible future would be to look at the impact liquor privatization has had in Washington State since it took effect in the last June.

According to the Washington Department of Revenue, during the first four months of privatization, the state’s hard liquor sales increased from a year earlier, despite higher prices.

Sales of spirits by volume increased almost three percent in the four months ending in September. Nearly 13.6 million liters were sold in the period compared to 13.2 million liters during the same four-month period a year earlier, when state-run liquor stores were still in operation.

In a survey of Washington police chiefs released in September, the Association for Washington Cities found a number of impacts related to privatization.

They found:

63% report an increase in liquor theft
30% report an increase in alcohol related crimes near grocery stores
40% said they needed more officers for liquor enforcement and alcohol-related crimes
25% said they needed more support for liquor enforcement from the Liquor Control Board

View the full report

Excessive consumption and its impact on public health

Rep. Jake Wheatley

In a statement released after the vote, Rep. Jake Wheatley, D-Allegheny, said he voted against the bill because liquor licenses could more than double under privatization.

Wheatley said the bill contains no provision that would protect Pittsburgh from being saturated with liquor stores.

“That would be devastating to our quality of life,” he said. “The bill also lacks funding to help cities and other local governments deal with the social and law enforcement impacts of increased alcohol abuse and related crimes.”

According to the Center for Disease Control, nearly 80,000 deaths in the U.S. can be attributed to excessive drinking annually, making alcohol use the third leading preventable cause of death in the country. And in 2006, the last year data is available for, binge drinking cost the U.S. economy nearly $223.5 billion in related health care costs.

The Pennsylvania Senate will be holding hearings over the next two months on the topic.

Recommended Resources

CDC: Alcohol and Public Health Website

Community Preventative Services Task Force Findings and Rationale (2011)

NIAAA’s Rethinking Drinking: Alcohol and your health Website

CDC Fact Sheet: Excessive Alcohol Use and Risks to Women’s Health

CDC Fact Sheet: Excessive Alcohol Use and Risks to Men’s Health

CDC Vital Signs on Binge Drinking: Nationwide problem, local solutions (2012)

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A look at potential impacts amid Pennsylvania’s legislative debate

Some of the Research

What happened in Washington?

Excessive consumption and its impact on public health

Recommended Resources

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