In the United States, addiction and substance misuse is a widespread and growing problem; each year it costs us nationally over $300 billion dollars–about $1,450 per person. According to a 2014 Centers for Disease Control and Prevention (CDC) report, substance abuse is a common chronic condition, affecting one out of six people over their lifetime, with only a quarter of those recalling ever discussing this issue with a health care professional.
Steve Chapman, MD, a pediatrician at the Children's Hospital at Dartmouth-Hitchcock (CHaD), says substance misuse is "an enormous problem with many dimensions, and it's costing us dearly in diminished health, increased chronic care and Emergency Department costs, employability and school performance, family and social costs, not to mention the huge dollar amounts. And we're not dealing with it early on well enough."
Chapman participated in a Primary Care-specific Greenbelt class at Dartmouth-Hitchcock Medical Center (DHMC) which led to the creation of a multi-disciplinary team that created a project called Adolescent and Young Adult Screening, Brief Intervention and Referral to Treatment (SBIRT) to help combat this problem.
"We had been talking about doing a comprehensive adolescent screener for some time, and the Greenbelt project provided a framework for us to refine that tool, the Dartscreen (originally developed by Ardis Olson, MD, and picked up and enhanced by Sue Tanski, MD, MPH and Chapman), and really focus specifically on substance misuse in adolescents and young adults," Chapman says. "Like many Primary Care practices around the country, we were not screening for this, and that's needs to be our starting point. It's always better to prevent or address this early on, rather than waiting until it's a problem."
What is SBIRT?
In October 2014, with support from a grant from the New Hampshire Center for Excellence, Chapman and his team piloted the SBIRT tablet tool. When adolescents and young adults come to DHMC for their annual well-child visits, they are given a validated screening tool that includes the CRAFFT. This screening tool involves questions around substance misuse, integrated into a tablet-based screener that automatically updates in eD-H, D-H's electronic health record system.
"When kids arrive for their visits and they're in the waiting room, instead of waiting, they sit down with the tablet, and start their visit by answering the questions and filling out the screener. Then when we come in as providers, we begin with questions such as, "Tell me more" rather than starting from scratch," Chapman says.
Since the beginning of 2015, Chapman and his team have set their monthly goal of screening 80 percent of all well-child visits. "We've achieved or exceeded that goal in several months recently, and that's really encouraging.. An important part of the project is training and preparing providers to engage in conversations about the screens – encouragement and positive reinforcement for adolescents not using, and engaging in supportive and strength-based discussions using motivational interviewing techniques for those who are using substances.
"What I'm excited about with this project is seeing how it's starting to resonate elsewhere, and how we're starting to treat substance abuse as a health issue like any other," Chapman says. "We're now in a position to make a difference early."
Good work spreading system-wide
With the success of SBIRT at DHMC, and through the Children's Hospital at Dartmouth-Hitchcock (CHaD) Primary Care Collaborative, this project is spreading to other D-H locations: Family Medicine at the Heater Road location, D-H Manchester and Plymouth Pediatrics.
"Creating conversations and relationships with other sites about things we're doing well that we can share, and things we're struggling with and can learn from each other, is so important," Chapman says.
Chapman notes that the SBIRT implementation experience will help us across the D-H system. It feeds into the D-H Substance Use and Mental Health Initiative's work "as part of a broader approach in considering how best to integrate it (SBIRT) in a consistent way across DHMC." Will Torrey, MD, a professor of psychiatry and vice chair for Clinical Services for the Department of Psychiatry, is the clinical champion for this initiative, which was established in November 2015 by the D-H Population Health Management Council.
Benefits of SBIRT
Chapman says that engaging adolescents in therapeutic relationships can be very powerful, letting them know that their provider wants to know and cares about what happens to them.
If an adolescent or young adult has a positive screen after completing the SBIRT, it will be part of the initial conversation the provider has with them.
"I'll start with an open-ended question such as, 'I see that you smoke marijuana a couple of times a week. Tell me more about that?' We try to identify and build on strengths, such as, 'It's awesome that you're playing on the basketball team, or that you've got a good group of friends who support you' We try to find a discrepancy, and there often is. Then the conversation would be, 'I see that you're smoking weed, but you're worried about that because you're on the basketball team, and that's important to you,'" Chapman says.
Chapman says that SBIRT as a screening tool is part of the process, but this conversation that follows it is essential.
"Some patients need referral to treatment. Many are just experimenting and just starting to get in trouble. They're teetering on the brink. And that's exactly why we want to talk to them about at this age," he says. "We try to head off the crisis by having this conversation early on, validating that it's a health issue, and build our therapeutic relationship by listening and creating compassionate connections."
Chapman and his team built two best practice advisory alerts (BPA) into eD-H. One is an alert for a positive substance use screen, and the second guides the provider responses to a positive screen that can range from "brief intervention done, no follow-up needed," "brief intervention done, no readiness to change" to "brief intervention done, follow up in primary care" to "brief intervention done, referral to behavioral health clinician."
"This second BPA outlines six options which suggest and give courses of action to follow, which we hope will create new patterns of care, and give us a means to follow trends with data.
"How many kids have been referred to behavioral health? How many kids are already identified and are just following up? How many kids have an issue but aren't yet ready to talk about it?" Chapman says. "This is all work beyond the Greenbelt project, but we're in the position now to ask these questions and follow these kids over time."
By identifying patients early, SBIRT successfully reduces health care costs, the severity of patient drug and alcohol use and the percentage of at-risk patients who go without specialized substance use treatment.
"This work shows that substance misuse is a health issue and something that D-H could be a leader on, not just within our community but nationally," Chapman says.
This project will be presented in a poster during Dartmouth-Hitchcock’s Patient Safety and Quality Week’s Poster Fair, March 16.