The Need for Adolescent SBIRT in School-based Health Centers

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1 The Need for Adolescent SBIRT in School-based Health Centers August 7, 2015 Marla Oros, RN, MS

2 Substance Abuse: A National Public Health Problem There are over 22 million Americans who meet the medical definition of abuse or addiction to drugs and alcohol Over 94% of those Americans are unaware that they need help and have not sought treatment or intervention Approximately 10% of U.S adolescents (ages 12-17) report past month use if illicit drugs Nearly 18% of U.S. adolescents report binge drinking within the past 30 days An estimated 50% of high school seniors report using marijuana at least once Source: NSDUH, 2014; CDC,

3 U.S. Adolescent Past-Month Illicit Drug Use Source: NSDUH, 2014

4

5 Substance Abuse: Impact on Maryland s Adolescents Approximately 43,000 (9.5%) Maryland adolescents used an illicit drug in the past month: 32,000 (6.0%) used marijuana 17,000 (3.5%) used an illicit drug other than marijuana No difference in illicit drug use between adolescent males and females Over 14% of Maryland adolescents (ages 12-20) report binge alcohol use in the past month Approximately 21,000 Maryland adolescents needed but did not receive treatment for past-year drug problems Source: NSDUH,

6 Past-Month Illicit Drug use Among Maryland Adolescents ( ) Source: NSDUH, 2014

7 Maryland SBIRT Grant On August 1, 2014, the MD DHMH was awarded a $9.8 million, five year grant from SAMHSA to implement and expand SBIRT across Maryland Expansion to 53 medical centers in 15 jurisdictions Expected to reach at least 90,000 individuals across the state Targeted populations: Low-income Marylanders Minority populations Veterans

8 Conrad N. Hilton Foundation Adolescent SBIRT 3-Years $1 million grant focused on adolescents SAMHSA-project health centers, large pediatric practices and school-based health clinics Started January

9 What is SBIRT? Screening Brief Intervention Referral to Treatment Application of a simple test to determine if a patient is at risk for or may have an alcohol or substance use disorder Explanation of screening results, information on safe use, assessment of readiness to change, advice on change Patients with positive results on a screening may be referred for an in depth substance abuse assessment and/or treatment 9

10 What is SBIRT? SBIRT is an evidence-based and cost-effective method for helping individuals to reduce or stop alcohol and other drug use SBIRT focuses on identifying people with at-risk and dependent substance and alcohol use behaviors prior to the need for more extensive or specialized drug treatment Research suggests that as little as 2-3 minutes of provider counseling can bring about a percent reduction in substance abuse, with effects lasting up to one year (Knight, 2011) 10

11 Steps to Conduct SBIRT Screen for alcohol and illicit drug use with evidencebased tools Provide brief advice/intervention for those with at risk answers/scores Refer patients with high risk scores to treatment Follow-up visits as appropriate

12 Screening Tools: CRAFFT

13 Screening Tools: Patient Health Questionnaire - 9 (PHQ-9)

14 What is a Brief Intervention? A brief intervention consists of one or more time-limited conversations (3-5 minutes) between an at-risk drinker or substance user and a provider Brief interventions are motivation enhancing discussions focused on increasing insight and awareness of substance use disorders

15 Rationale for a Brief Intervention Brief interventions are designed to be: Time efficient A possible first step in change Helpful with patient s not ready for change Based on key techniques that are simple to use and easy to remember Motivational

16 Goals of a Brief Intervention The goals of a brief intervention can vary depending upon the patient: Help client change the way they see, understand, or feel about a particular risk factor or behavior Empower the client to take action Reduce the risk of harm from the substance use or other risky behaviors Increase awareness of the impact of substance use on medical issues Provide an open forum for client to talk candidly about their tobacco, alcohol and/or drug use without external judgment Assist the client in accessing treatment if appropriate

17 SBIRT Effectiveness Studies Reduced health care costs For each $1 spent on SBIRT we save $3.81-$5.60 Reduced ED visits 20% Reduced hospitalizations 37% Reduced non-fatal injuries 33% Reduced car crashes 50% Reduced severity of drug & alcohol use Reduced employer costs - $771 per staff Reduced arrests 46% For references: See SAMHSA-HRSA Center for Integrated Health Solutions SBIRT Fact Sheet 17

18 Making a Measurable Difference Since 2003, SAMHSA has supported SBIRT programs, more than 1.5 million persons screened Outcome data confirm a 40 percent reduction in harmful use of alcohol by those drinking at risky levels and a 55 percent reduction in negative social consequences Outcome data also demonstrate positive benefits for reduced illicit substance use Based on review of SBIRT GPRA data ( )

19 IMPLEMENTING SBIRT SERVICES IN SCHOOL-BASED SETTINGS

20 Why Intervene in a School-based Setting? SBIRT will identify individuals that are both known and unknown to have at risk drug and alcohol use Through doors already open to students, quick and easy screening can uncover a need for further counseling It is an opportunity to begin to normalize the conversation around alcohol and drug use as a health issue Brief interventions are proven to reduce or eliminate substance use and help individuals get any needed treatment 20

21 Why Intervene in a School Setting? Brief interventions can be completed by any professional that has a trusting relationship with the adolescent, which expands access to intervention School-based health staff have trusted relationships The rate of positive drug screens using a common survey instrument (CRAFFT) among 12-to-17 year-olds has been found to be up to 29.5% in schools Research has shown that SBIRT in school settings is effective: In a study of 13 schools, students who received an intervention (regardless of intensity level) reported decreases in self-reported days of drinking to intoxication Findings also showed decreases in self-reported drug use at follow-up Source: Mitchell et al. 2013

22 Rationale for School-based SBIRT Services The majority of at-risk adolescent users do not seek specialty treatment services Need to provide services at different levels Effects of substance abuse on youths are substantial A significant percentage of adolescent substance use does not yet require treatment, but SBIRT may reduce likelihood of increased problematic use Sources: Mitchell et al

23 Rationale for School-based SBIRT Services Alcohol and drug use consistently found with trauma symptoms Rates of substance use disorders (SUDs) among homeless youth- two to three times higher than housed peers 11% of youth in child welfare systems have SUD 46% of youth entering juvenile justice systems have SUD 77% of criminal-justice involved youth reported substance use (mainly marijuana) in past 6 months Nearly 50% of all juvenile detainees have a SUD Source: SAMHSA, 2013

24 Correlates of Substance Use During Adolescence & Young Adulthood Brain damage Injuries (intentional, unintentional) Emergency room visits (e.g., overdose) School failure Violence Arrests, incarceration Sexual assaults Unprotected intercourse Sexually transmitted diseases HIV/AIDS Fetal alcohol syndrome Others? 2007 Center for Adolescent Substance Abuse Research, Children s Hospital Boston. All rights reserved. Jessor et al., 1991; DuRant et al., 1997; 1999; Hingson et al., 1990

25 Planning is Essential Key to figure out SBIRT integration into your site s workflow Spend time to understand how your site delivers SBIRT: Can be done routinely Is as efficient as possible Builds on existing staff strengths Fits with the flow of health center interventions Put the SBIRT protocol on paper just like other school policies and procedures Go live and be prepared to modify

26 Planning Process Steps Assemble the planning team Conduct a workflow analysis Develop an implementation model Select screening instruments Address documentation and EHR Develop a protocol

27 SBIRT Training Time must be dedicated for a minimum of 90 minutes of training for all staff Best to train along roles and separate screening training from BI training as appropriate Utilize experienced trainers Relate training to existing patient population Be interactive Use case studies Build in time for discussion Provide follow-up booster training Food 27

28 Keys to SBIRT Success Good fit with organizational mission Leadership buy-in; champions on all staff levels Organizational culture supportive of addiction as a chronic illness Resource support for planning and implementation Integration into existing workflow & each setting s unique operations Data driven quality monitoring and improvement Integration into EHR to institutionalize & sustain practice Have referral systems available and working for treatment 28

29 Overall Lessons Learned for Adolescent Pilots Use the model implementation process for any setting Reach adolescents before substance use progresses to more serious use Provide a safe environment to encourage conversation Use negotiating skills to achieve results Build relationships with treatment providers Develop strategies for working with parents Seek universal screening Identify the appropriate screening instrument Messages communicating adolescent SBIRT to students and parents 29

30 Questions For additional questions please contact: The Mosaic Group (p) (fax) Marla Oros-

31 SBIRT in SBHCs SHIP Conference August 7, :30 AM Letitia Winston

32 Adolescent substance use/abuse 2 year pilot 9 grantees/13 SBHCs Screening, Intervention, Referral

33 SBIRT in SBHCs Initiative CRAFFT & PHQ-9 Brief Advice or Intervention Referral to intervention or Treatment

34 SBIRT in SBHCs Initiative Lessons A QI team is essential to the success of implementation Support for integration of SBIRT and Teen Intervene is critical Decreased use is a success Establishment of a new community for students

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