1. 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 schonfel@usf.eduhttp://BRITE.fmhi.usf.edu Presented at the FADAA/FCCMH Conference Aug. 7, 2013

2. Today’s presentation Overview of substance abuse issues and treatment for older adults Overview of substance abuse issues and treatment for older adults Presentation on the Florida BRITE Project 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 Lessons learned from conducting SBIRT in Florida

3. Alcohol and Illicit Drugs

4. National Household Survey: % Adults Aged 18+ Reporting past month use of alcohol/drugs by age group in 2000 (NHSDA, 2001) Percent Reporting Use in Past Month 12% of 55+ age group are either binge or heavy alcohol users

5. U.S. Substance Abuse Treatment Admissions in 2006 Trunzo & Henderson (Gerontological Society of America presentation 2008) 50+ yrs 11% 25-34 yrs 25% 35-44 yrs 27% 50-54 yrs: 6% 55-59 yrs: 3% 60-64 yrs: 1% 65+ yrs: <1% N ALL ADMISSIONS = 1,798,000 N ADMISSIONS OVER 50 = 189,000 45-49 yrs 11% 18-24 yrs 18% <18 yrs 8%

6. Admissions Under 50 and Age 50+ by Primary Substance * Excludes methadone

7. Older adults are often “hidden” alcohol abusers Fewer indicators compared to younger adults: Fewer indicators compared to younger adults: DUI’sDUI’s Work-related problemsWork-related problems Marital ProblemsMarital Problems Peer pressurePeer pressure In contrast, older adults are more likely to be isolated, drinking alone 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.

8. Alcohol Affects the Elderly Differently Induced impairment increases with age due to: 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 distribution within the body Affects alcohol’s elimination Affects alcohol’s elimination Results in increased sensitivity and decreased tolerance to alcohol and drugs in older individuals 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 Drugs and alcohol remain in the body longer and at higher rates of concentration

9. Medication misuse

10. 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)

11. Misuse in older people is often unintentional (Glantz, 1981; Schwartz et al., 1962). Difficulty of regimen (too many meds to keep track) Difficulty of regimen (too many meds to keep track) Memory issues Memory issues Adverse drug reactions Adverse drug reactions Synergistic effects of multiple drugs Synergistic effects of multiple drugs Cost & Access Cost & Access Multiple prescribing physicians Multiple prescribing physicians Lack of understanding of the instructions 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) Use of/interactions with OTC meds (Coons et al., 1988) Early discontinuation of medications Early discontinuation of medications

12. Medications & Alcohol Use Use of drugs in combination with alcohol carries greater risk: 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

13. Treatment Recommendations

14. Expert panel recommendations for screening and treating the older adult: SAMHSA/CSAT Treatment Improvement Protocol (TIP) #26

15. TIP#26 Expert Panel Recommendations 1. 1.Age-specific, group treatment that is supportive, not confrontational 2. 2.Attend to depression, loneliness; address losses. 3. 3.Teach skills to rebuild social support network 4. 4.Employ staff experienced in working with elders 5. 5.Link with aging, medical, institutional settings 6. 6.Content should be age-appropriate and offered at a slower pace. 7. 7.Create a “culture of respect” for older clients 8. 8.Broad, holistic approach recognizing age-specific psychological, social & health aspects. 9. 9.Adapt treatment as needed to address gender issues

16. 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) 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) 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 Replications - programs in other states based on our model Chelsea Arbor Older Adult Recovery Center in Ann Arbor, Michigan (1990’s)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)GET SMART Program (West Los Angeles VA Hospital; 2000-2011) (Schonfeld et al. 2000) Zablocki VA Medical Center (Milwaukee, 2006)Zablocki VA Medical Center (Milwaukee, 2006) Older Adult Substance Abuse Treatment Program – Tennessee (2005 - 2008) (Outlaw et al. 2012)Older Adult Substance Abuse Treatment Program – Tennessee (2005 - 2008) (Outlaw et al. 2012)

17. The Result: A 16-session curriculum manual for conducting brief treatment (Dupree & Schonfeld, CSAT, 2005) http://kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf

18. 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.

19. 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.

20. 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: 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. 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

21. SBIRT A national initiative for screening, brief intervention, and referral to treatment

22. Specialized Treatment Primary Prevention Brief Intervention None Mild Moderate Severe Substance Abuse Severity and Level of Care Adapted from the SAMHSA TIP #34 (1999) and Institute of Medicine (1990) Substance Abuse Severity

23. Screening and Brief Interventions Early Examples Used within Emergency Departments 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 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

24. http://sbirt.samhsa.gov/about.htm

25. SBIRT Core Components

26. 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 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). 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 in- session behavior of the counselor. With MI, resistance is viewed as a reaction to the in- session behavior of the counselor.

27. Key Principles of Motivational Interviewing Avoiding labeling and confrontation Avoiding labeling and confrontation Enhance Self-efficacy (confidence in one’s coping strategies) Enhance Self-efficacy (confidence in one’s coping strategies) Enhance internal-attribution Enhance internal-attribution Roll with resistance – use it to further explore client’s views 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 Use cognitive dissonance as a tool – the client is asked to provide more and more evidence that problem(s) exist

28. Videos – examples of Brief Intervention Boston University: BNI-ART Institute Boston University: BNI-ART Institute http://www.bu.edu/bniart/sbirt-in-health-care/sbirt- educational-materials/sbirt-videos/ Provide scenarios for using screening and brief intervention during the delivery of healthcare. Provide scenarios for using screening and brief intervention during the delivery of healthcare. Videos illustrate the use of MI techniques Videos illustrate the use of MI techniques

29. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) 3,497 people ages 60+ screened and/or served 3,497 people ages 60+ screened and/or served Schonfeld et al (2010) Am. J. of Public Health Four sites in pilot project Four sites in pilot project Broward County Elderly & Veterans Services = 2,116 Broward County Elderly & Veterans Services = 2,116 Gulf Coast Jewish Family Services (Pinellas) = 638 Gulf Coast Jewish Family Services (Pinellas) = 638 Coastal Behavioral Health Care (Sarasota) = 426 Coastal Behavioral Health Care (Sarasota) = 426 Center for Drug Free Living (Orange) = 317 Center for Drug Free Living (Orange) = 317 Most (67%) identified via BRITE outreach & prescreening at health fairs, senior centers, and via referral network. Most (67%) identified via BRITE outreach & prescreening at health fairs, senior centers, and via referral network. Positive prescreens invited to participate in BI Positive prescreens invited to participate in BI –Most received multiple sessions of brief intervention

30. Broward County Elderly & Veterans Services Gulf Coast Jewish Family Services Coastal Behavioral HealthCare The Florida BRITE Project Pilot Project (2004-2007) Center for Drug Free Living – added in 2005 Orlando

31. 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: 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 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

32. The Pilot: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders) 10% - referred for potential alcohol problems 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 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 8% referred for potential OTC misuse 1% referred for illicit drug use 1% referred for illicit drug use

33. Depression (Short-Geriatric Depression Scale) 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 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: Florida BRITE Project 2004-07 (BRief Intervention and Treatment for Elders)

34. Significant decrease in alcohol scores at D/C (n=102) 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) 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 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 Illicit drugs: 75% of those with flags at baseline (n=12) showed no flag at D/C Significant decrease 1 in depression scores at D/C (n=323) Significant decrease 1 in depression scores at D/C (n=323) –Further decrease at 30 day follow-up (n = 203) The Pilot: Outcomes 2004-07 Significant improvement at D/C and Follow-ups

35. From Pilot Project to Federal Grant

36. State SBIRT Grants Through 2010

37. Florida BRITE Project – the SBIRT Grant: (BRief Intervention and Treatment for Elders) $14 million SAMHSA/CSAT grant to Florida $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) Majority of people are expected to screen negative (receive Screening & Feedback only) Positive screens were typically followed by 1 session of Brief Intervention Positive screens were typically followed by 1 session of Brief Intervention People could receive 5 BI or 12 BT sessions People could receive 5 BI or 12 BT sessions Referred out for detox, residential care, etc. Referred out for detox, residential care, etc.

38. 30 provider agencies contracted to conduct screening in over 70 sites in 18 counties

39. SBIRT Approach Universal prescreening (7 items: alcohol, drugs, medications, depressive symptoms) Universal prescreening (7 items: alcohol, drugs, medications, depressive symptoms) Full screen (ASSIST) for those with positive prescreens Full screen (ASSIST) for those with positive prescreens Level of risk dictates type of service: 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

40. Prescreen – Part 1

41. Prescreen – Part 2

42. Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) World Health Organization (WHO) An interview style screen administered only if there is a positive prescreen 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 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: 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

43. Florida BRITE Project Reasons for Positive Screens at Baseline (n=8,165)

44. BRITE Services Received For those who screened positive and agreed to receive services: For those who screened positive and agreed to receive services: o BI n = 6,338 o BT n = 675 o RT n = 899

45. Positive Screens – by Provider Category TotalAging Mental Health Care Substance Abuse Positive Screens Total Screened % Positives 8,165 85,001 9.6% 1,994 16,019 12.4% 1,358 14,649 9.3% 3,469 43,772 7.9% 1,281 10,490 12.2%

47. Past 30 Day Use of Alcohol and Drugs: Baseline versus Six Month Follow-up Initial Interview Follow-up Interview ASSIST QuestionsNDaysN % DecreaseSig. p) Use any alcohol1339.011342.4173.3<.001 Use alcohol to intox. with 5+ drinks315.10312.6847.5.024 Used alcohol to intox. with 4 or fewer drinks and felt “high 324.81322.8441.0.031 Used illicit drugs1327.371331.8974.4<.001 Used both alcohol & drugs on same day148.29142.8665.5.038

48. Sustainability of SBIRT Nationally, a number of actions and events are fostering SBIRT’s sustainability: 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)

49. 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 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 Florida has not approved Medicaid codes for billing purposes

50. PayerCodeDescription Fee Schedule Commercial Insurance 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 Medicare 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 Medicaid H0049Alcohol and/or drug screening$24.00 H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

52. Health Care providers who can provide SBIRT services under Medicare Medicare pays for medically reasonable & necessary SBIRT services in physicians’ offices & outpatient hospitals 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 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: 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-Network- MLN/MLNProducts/Downloads/SBIRT_Factsheet_ICN904084.pdf

53. 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.

54. Conclusions SBIRT is an evidence-based, national initiative applied mostly in hospitals and primary care SBIRT is an evidence-based, national initiative applied mostly in hospitals and primary care SBIRT focuses on risky/problematic use SBIRT focuses on risky/problematic use Florida BRITE Project found that: 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 SBIRT model is sustainable

55. The End Questions?