Insights in Public Health

Introduction

Addiction. One would be hard pressed to find a chronic illness more complex and enigmatic in its etiology. Yet the study of addiction, its variations and causes, has been around for over 200 years. In 1816, Dr. Benjamin Rush's “An Inquiry Into Effects of Ardent Spirits Upon The Human Mind And Body”¹ explored the consequences of chronic drunkenness and argued the condition was a “disease that physicians should be treating.” Since then we have simultaneously learned so much about the disease of addiction yet still grapple understanding how or why people acquire it. What we do know all to well is the devastation the disease causes on both an individual and societal level. It is measured in the lives lost each year to addiction, the economic and social burden suffered, and the crippling weight it has on our public health systems.

The Surgeon General's Report published last year estimates substance use disorders cost $400 billion annually; much of which is attributed to health care costs for direct treatment of addiction and treatment of associated health conditions.² The national opioid crisis is one indicator that the problem continues to worsen, with 12.5 million Americans reporting misuse of prescription pain medication in the past year and an estimated 78 deaths from opioid overdose occurring every day.² However, as alarming as this is, opioid abuse is only part of the picture. For example, alcohol misuse accounts for 1 in 10 deaths among working adults annually.² Similarly, 35% of 12th graders have used marijuana in the past year and studies show that attitudes about the risk of marijuana use has declined despite evidence that use of the drug among adolescents can have lasting impact on brain development.³ Additionally, methamphetamine is estimated to account for around 90% of all drug offenses in Hawai‘i; more than any other state.⁴

The reality is that while use of specific drugs such as those discussed above are of major concern and must be addressed, the prevalence of substance misuse, abuse, and addiction is a far-reaching problem in both Hawai‘i and across the country; some would say it is the apex predator of social issues. Indeed, it would be difficult to identify a prevalent major social issue such as homelessness or crime in Hawai‘i where prevalence estimates are neither caused or exacerbated by some form of substance use, misuse, or addiction.

Historically the United States' response to this issue has been predominantly one of law enforcement, criminalization, and interdiction with minimal success. This has nothing to do with any failing of dedication or commitment on the part of law enforcement or a desire on law enforcement's part to address the issue and see people succeed. The complexity of substance use and addiction is simply too broad to expect success unless the approach is sufficiently multi-faceted and coordinated. The key is a balanced public health/public safety response on a policy level.

Screening, Brief, Intervention, Referral to Treatment (SBIRT) is a vital element of the public health half of this type of harmonized policy. This article seeks to explore the role of SBIRT as both a public health intervention and philosophical basis for proactive health care around preventing chronic addiction and for integrating health in all policy.

Defining SBIRT

SBIRT is a comprehensive, integrated public health approach to implementing early screening and delivery of early intervention services and treatments. The SBIRT model is based on a 1990 Institute of Medicine report which recommended integrated service systems that link community screening and interventions for alcohol problems.⁵ This recommendation was based on the emerging evidence at that time that most people who misuse alcohol in a way that is causing some disturbance in their functioning, but which did not meet diagnostic criteria, were more inclined to seek medical care for the acute health consequences of their alcohol use. For example, they might present with stomach problems or trouble concentrating “… without recognizing the critical role that may be played in such problems by excessive alcohol consumption”.⁵

The report explored the vital role of primary care in detecting, intervening, and if necessary, referral for patients with emerging alcohol problems. As with so many other chronic diseases of our time, when the symptomology and the debilitating effects of the disease become readily observable it has often already progressed to an advanced stage of chronicity with significantly diminished prognosis. In practice, SBIRT for behavioral health conditions follows much the same pattern as screening and intervention for physical diseases.

Screening

Screening involves a short, often self-administered, but standardized check for any signs of substance use or misuse. If the screen identifies risk beyond a minimum threshold, the provider discusses the screen with the patient and may conduct further assessment.

Brief Intervention

If hazardous use patterns are evident, the provider might provide a brief intervention usually in the form of motivational interviewing and education around risk factors and issues with which to be aware. The provider would monitor the patient for further developments while simultaneously encouraging the patient to make better choices.

Referral to Treatment

If there is an indication that more specialized interventions or treatment is needed, the provider would refer the patient for specialized care and continue to monitor while coordinating patient care with the specialist. In the context of medical conditions such as heart disease, this process may seem so standard and second nature to physicians as to warrant no discussion at all. However, in spite of the steady increase and associated health impacts of addiction, the medical system does not universally treat or manage addiction as a chronic disease. Incorporating SBIRT practices into primary care to address addiction is an evidenced base solution to reduce negative health outcomes.

SBIRT - A Public Health Approach

The United States is spending more money on healthcare than virtually every other developed country in the world but has the worst health outcomes of those countries.⁶ One of the reasons postulated by experts as to why this is the case has to do with the prevalence of vast health disparities across the country. These disparities, having more to do with a person's zip code that their genetic code, leave the healthcare system ill-equipped and unfairly burdened with the aftermath of these health inequalities.⁷

The aftermath comes in the form of the increasing prevalence of chronic disease's such as diabetes and heart disease that are far more expensive to treat than to prevent. For many of these diseases, the risk factors are easily identified and most of them can be effectively addressed and minimized if detected early enough, thus avoiding the onset of the disease. Research indicates that many of the risk factors that predetermine chronic disease have more to do with social determinants than the overall health care received;^7,8 highlighting the disconnect between what we know about how to effectively prevent chronic disease and what we actually achieve. The most alarming aspect of this disconnect is the predictability of these risk factors along with the relative ease of identification of those factors through routine screening. Yet, prevalence continues to rise along with cost.

Addiction risk factors are no different. Like diabetes and heart diseases, there is currently no cure for chronic substance use disorders. They are expensive to treat once the condition becomes chronic but they generally can be prevented with early detection and intervention.² The public health approach to chronic disease has four basic aims: define the problem, identify risk and protective factors, develop and test prevention strategies, and assure widespread adoption.⁹ This is the reason blood pressure is checked for every patient; because blood pressure is an effective indicator of a wide range of risk factors or potential conditions.

The same is true for SBIRT when it comes to early detection of addiction and other conditions.^2,5 It's the blood pressure test for mental health. So, health care settings are by far the most logical and effective interface for screening and preventing substance use or misuse by patients before any progression into addiction might occur. Just like with heart disease, providers can identify risk through routine screening, work with a patient to address and mitigate the identified risk, and if necessary refer to a specialist.

More importantly, primary care can play an essential role in the de-stigmatization of addiction the way it has successfully done with other chronic diseases such as HIV. Patients are are generally open to discussing their substance misuse with their health care provider. Research indicates a 92% likelihood that patients will provide an honest answer when asked by their doctor about how much they drink. Additionally, 96% of patients surveyed felt that their doctor should tell them to cut down on their alcohol use if it is affecting their health.¹⁰

Reducing Addiction and Improving Health Outcomes Through Universal SBIRT

SBIRT in primary care and other medical settings has been effective in reducing hazardous or unhealthy substance use and misuse. It is also being evaluated for its efficacy with other behavioral health conditions such as depression and anxiety and indicate the benefits of behavioral health screenings in primary care settings as a more formalized method of identifying and treating individuals at risk for these conditions.¹¹

The cost savings realized from SBIRT in primary care settings makes good financial sense as well. One study estimates a savings of four dollars of healthcare cost savings for every dollar spent on SBIRT activities amounting to an 89% cost savings for each patient screened through SBIRT.¹² Additionally, SBIRT can result in improved prognosis for an individual's comorbid medical conditions because of reduced substance use.² By intervening with patients who display hazardous use patterns, providers are able to address other issues that may be caused or exacerbated by the hazardous use. Most importantly, the potential for increased care coordination for patients with multiple chronic conditions and the associated positive outcomes is reason enough to implement SBIRT.

Hawai‘i Department of Health's SBIRT Initiatives

The Hawai‘i Department of Health is involved in two major SBIRT initiatives that support its overall goal of making health Hawai‘i's shared value. The first is the pre-natal SBIRT project, which is supported through the Hawai‘i Maternal and Infant Health Collaborative (HMIHC) of which the Department is a member. The project, funded by Aloha United Way and the Omidiyar Ohana Fund, and led by Hilopa‘a has been instrumental in paving the way for universal SBIRT among prenatal care providers.¹³ This effort supports a primary goal of the Department's strategic plan to “Invest in Healthy Babies and Families.”¹⁴

The second initiative is a federal grant received by the Department's Alcohol and Drug Abuse Division (ADAD) to implement SBIRT in primary care settings across the state. The grant is awarded through the Substance Abuse and Mental Health Administration (SAMHSA) and provides $8.4 million dollars over 5 years to support the project. Together, the two projects have made great headway laying a foundation for a universal system of SBIRT across medical systems in the state.

The goals of both projects are to:

• Implement SBIRT across the state health system.

• Expand upon behavioral health and primary health care efforts initiated by the state through the State Health Innovation Plan (SHIP).

• Develop and expand state and community infrastructure to support universal and sustainable behavioral health screening throughout the state's healthcare system.

The ADAD recently awarded contracts to several health care provider groups throughout the state which will work to assist providers with integrating SBIRT into their daily workflow and begin to implement universal screening. The project will be implemented through 3 primary components:

1. Implementation of screening and brief intervention strategies within participating practices and Health Centers. This component includes the administration of universal screening to identify risk for substance use disorders and other major behavioral health issues.

2. Training for providers and other health care staff in SBIRT techniques. The training will be ongoing and supportive of SBIRT workforce development through training of trainers as well as focusing on integration of SBIRT into practice workflows.

3. A centralized referral coordination component that will focus on receiving and coordinating referrals to specialized substance abuse treatment for individuals who are identified as needing more intensive interventions and care. This allows for simplified and consistent referral practices and assists providers by having a single point of contact when referral is needed.

The Department will continue to work with providers and other state systems such as the Department of Human Services as well as private sector stakeholders to ensure that resource coordination and sustainability remain cornerstones of the project. The result of these efforts and the hard work of all involved will create a future where behavioral health screening is as commonplace and routine in health care settings as checking a patient's blood pressure.