1. 1 Co-Occurring Disorders Conference September 29, 2006 Washington State Screening, Brief Intervention, Referral, and Treatment Project Stephen H. O’Neil, MA, CCDC III Washington State Division of Alcohol and Substance Abuse Co-Occurring Disorders Conference Expanding the Continuum – Improving Care

2. 2 Co-Occurring Disorders Conference September 29, 2006 WASBIRT Overview Nine of Washington’s busiest trauma hospitals, located in six separate counties, are hosting 30 Chemical Dependency Professionals (CDPs) in Nine of Washington’s busiest trauma hospitals, located in six separate counties, are hosting 30 Chemical Dependency Professionals (CDPs) in their Emergency Departments (EDs). These professionals provide screening, brief intervention, and referral for those who need a higher level of care. Brief therapists located in 11 community agencies provide a link to community services. Brief therapists located in 11 community agencies provide a link to community services.

3. 3 Co-Occurring Disorders Conference September 29, 2006 Why SBIRT Prior studies have shown that interventions, when delivered to injured patients in hospital emergency departments and on hospital inpatient units can: Prior studies have shown that interventions, when delivered to injured patients in hospital emergency departments and on hospital inpatient units can: - Reduce alcohol and/or other drug use; - Prevent re-injury; and, - Help patients with more severe problems access intensive, community based chemical dependency services.

4. 4 Co-Occurring Disorders Conference September 29, 2006 WASBIRT Services Screening Only – Patient screened for alcohol and/or other drug use; brief intervention not given. Screening Only – Patient screened for alcohol and/or other drug use; brief intervention not given. Brief Intervention – Patients screened for alcohol and/or other drug use and receive a Brief Intervention in the Hospital. Brief Intervention – Patients screened for alcohol and/or other drug use and receive a Brief Intervention in the Hospital. Brief Therapy – Patient receive a Brief Intervention in the hospital plus community based Brief Therapy sessions. Brief Therapy – Patient receive a Brief Intervention in the hospital plus community based Brief Therapy sessions. CD Treatment – Patient receive a Brief Intervention in the hospital plus traditional chemical dependency treatment. CD Treatment – Patient receive a Brief Intervention in the hospital plus traditional chemical dependency treatment.

5. 5 Co-Occurring Disorders Conference September 29, 2006 WASBIRT Performance Between April 2004 and July 2006 47,809 screenings have been conducted: Between April 2004 and July 2006 47,809 screenings have been conducted: 22,912 screen only (48%) 22,912 screen only (48%) 23,190 screen and brief intervention (49%) 23,190 screen and brief intervention (49%) 1,707 have engaged in additional services (4%) 1,707 have engaged in additional services (4%)

6. 6 Co-Occurring Disorders Conference September 29, 2006 WASBIRT Structure All patients aged 18 and over who present in the emergency department are eligible to be screened with the following exclusions: All patients aged 18 and over who present in the emergency department are eligible to be screened with the following exclusions: Unconscious or otherwise unable to consent Unconscious or otherwise unable to consent (intoxication, psychosis, extreme trauma) (intoxication, psychosis, extreme trauma) In police custody In police custody Patients who are admitted to other hospital units may receive a WASBIRT consult if requested by their attending physician. Patients who are admitted to other hospital units may receive a WASBIRT consult if requested by their attending physician.

7. 7 Co-Occurring Disorders Conference September 29, 2006 WASBIRT Process When a patient enters the emergency department WASBIRT staff review their status: When a patient enters the emergency department WASBIRT staff review their status: Reason for admission, age, current status, and pending consults (radiology, phlebotomy) Reason for admission, age, current status, and pending consults (radiology, phlebotomy) If the patient meets the broad eligibility requirements WASBIRT services may be provided at anytime during the patients stay: If the patient meets the broad eligibility requirements WASBIRT services may be provided at anytime during the patients stay: WASBIRT staff may consult with medical, nursing, or social work staff either pre or post the screening process WASBIRT staff may consult with medical, nursing, or social work staff either pre or post the screening process

8. 8 Co-Occurring Disorders Conference September 29, 2006 Staff collect data on personal digital assistants and place a note in the patient chart. Staff collect data on personal digital assistants and place a note in the patient chart. If a referral for additional services is necessary WASBIRT staff serve as “case managers” making direct linkages (detox, traditional inpatient treatment) or arranging appointment times with their brief therapy counterpart. If a referral for additional services is necessary WASBIRT staff serve as “case managers” making direct linkages (detox, traditional inpatient treatment) or arranging appointment times with their brief therapy counterpart.

9. 9 Co-Occurring Disorders Conference September 29, 2006 Patient Contact A screening takes approximately 4 minutes: A screening takes approximately 4 minutes: AUDIT and DAST 10 AUDIT and DAST 10 A screening and BI takes approximately 6 minutes: A screening and BI takes approximately 6 minutes: Additional GPRA data gathered and brief intervention provided Additional GPRA data gathered and brief intervention provided A screening with BI and referral takes approximately 10 minutes: A screening with BI and referral takes approximately 10 minutes: Patient provided with direct referral Patient provided with direct referral

10. 10 Co-Occurring Disorders Conference September 29, 2006 Cost of SBIRT Services Within the current structure each screen (including a brief intervention and referral) costs approximately $53.00. Within the current structure each screen (including a brief intervention and referral) costs approximately $53.00. Washington State anticipates being able to cut this cost by ½ with reduced administrative overhead and increased number of screens per FTE. Washington State anticipates being able to cut this cost by ½ with reduced administrative overhead and increased number of screens per FTE.

11. Co-Occurring Disorders Conference September 29, 2006 11 WASBIRT Outcomes Initial Six-Month Follow-up

12. 12 Co-Occurring Disorders Conference September 29, 2006 Average days of alcohol use in the past 30 days declined significantly BRIEFINTERVENTION(n=348) BRIEF INTERVENTION PLUS REFERRAL BUT NO TREATMENT (n=152) BRIEF INTERVENTION PLUS BRIEF THERAPY OR CD TREATMENT (n=65)

13. 13 Co-Occurring Disorders Conference September 29, 2006 Binge drinking in the past 30 days declined significantly BRIEFINTERVENTION(n=348) BRIEF INTERVENTION PLUS REFERRAL BUT NO TREATMENT (n=152) BRIEF INTERVENTION PLUS BRIEF THERAPY OR CD TREATMENT (n=65)

14. 14 Co-Occurring Disorders Conference September 29, 2006 Illegal drug use in the past 30 days declined significantly BRIEFINTERVENTION(n=348) BRIEF INTERVENTION PLUS REFERRAL BUT NO TREATMENT (n=152) BRIEF INTERVENTION PLUS BRIEF THERAPY OR CD TREATMENT (n=65)

15. 15 Co-Occurring Disorders Conference September 29, 2006 Abstinence from both alcohol and other drugs increased for all interventions BRIEFINTERVENTION(n=348) BRIEF INTERVENTION PLUS REFERRAL BUT NO TREATMENT (n=152) BRIEF INTERVENTION PLUS BRIEF THERAPY OR CD TREATMENT (n=65)

16. 16 Co-Occurring Disorders Conference September 29, 2006 Social and Cost Offset Analysis WASBIRT evaluators are linking with 5 external data bases to analyze social and cost offsets: WASBIRT evaluators are linking with 5 external data bases to analyze social and cost offsets: Washington State Department of Social and Health Services Washington State Department of Social and Health Services Washington State Department of Health Washington State Department of Health Washington State Employment Security Department Washington State Employment Security Department Washington State Institute on Public Policy Washington State Institute on Public Policy Washington State Patrol Washington State Patrol A fact sheet will be completed by October 2006. A fact sheet will be completed by October 2006.

17. 17 Co-Occurring Disorders Conference September 29, 2006 An Expanded Model A Continuum of Substance Use Problems, Interventions, and Care

18. Co-Occurring Disorders Conference September 29, 200618 Is SBIRT Risk Reduction? If substance abuse is placed on a continuum from abstinence to severe dependence, any move toward moderation and lowered risk is a step in the right direction and not incongruous with a goal of abstinence as the ultimate form of risk reduction. (Marlatt et al., 1993)

19. Co-Occurring Disorders Conference September 29, 200619 Why Motivation? Research has shown that motivation-enhancing approaches are associated with greater participation in treatment and positive treatment outcomes. (Landry, 1996; Miller et al., 1995a) A positive attitude and commitment to change are also associated with positive outcomes. (Miller and Tonigan, 1996) (Prochaska and DiClemente, 1992)

20. Co-Occurring Disorders Conference September 29, 200620 What is Motivation? Motivation is not something one has but is something one does. Motivation is a key to change. Motivation is dynamic and fluctuates. Motivation can be influenced. Motivation can be modified. The clinician can elicit and enhance motivation.

21. Co-Occurring Disorders Conference September 29, 200621 If it Already Works…. Treating those with substance use problems is difficult. We have done well, particularly with those at the far end of the continuum.

22. Co-Occurring Disorders Conference September 29, 200622 Make it Work Even Better Is it possible to expand upon the good work we are doing….and for some patients….help them even more? What ideas might help us reach and effectively treat those at an earlier point in the continuum?

23. Co-Occurring Disorders Conference September 29, 200623 Current View The disease of addiction is a progressive condition that, if left untreated, must lead to full dependence and jail, institutions, and death.

24. Co-Occurring Disorders Conference September 29, 200624 Expanded View Substance use disorders exist on a continuum that includes risky use, problematic use, varying levels of abuse, to dependence as defined by the DSM IV.

25. Co-Occurring Disorders Conference September 29, 200625 Current View Progression is inevitable and automatic.

26. Co-Occurring Disorders Conference September 29, 200626 Expanded View Progression is not inevitable or automatic. Many individuals never move beyond risky use. Many cycle between abstinence, risky use, abuse, and dependence.

27. Co-Occurring Disorders Conference September 29, 200627 Current View Recovery equals ongoing, stable, long term abstinence.

28. Co-Occurring Disorders Conference September 29, 200628 Expanded View Recovery is a multi-dimensional process that differs among people and changes over time within the same person.

29. Co-Occurring Disorders Conference September 29, 200629 Conclusion Research supports changing the way we understand program effectiveness, apply counseling theory, and provide care for the substance using population.

30. Co-Occurring Disorders Conference September 29, 200630 The current view of substance use as a progressive illness, and recovery as abstinence is being expanded.

31. Co-Occurring Disorders Conference September 29, 200631 The expanded view of substance use as a continuum and recovery as individually defined is evidence based and supported by practice.

32. Co-Occurring Disorders Conference September 29, 200632 SBIRT Allows Identification of substance use problems not just abuse or dependence. Intervention earlier with less cost and time intensive care. Provision of treatment at any place in the continuum. Integration of evidence based practice. Linkages between substance use and public health, the health care system, and health care providers.

33. Co-Occurring Disorders Conference September 29, 200633 For Additional Information Steve O’Neil WASBIRT Project Director Washington State Department of Social and Health Services Division of Alcohol and Substance Abuse PO Box 45330 Olympia, WA 98504-5330 Phone: (360) 725-3718 Fax: (360) 438-8078 E-mail: oneilsh@dshs.wa.gov