Implementing SBIRT: The Need for New Resources and Approaches for Primary Care Physicians
Michael Boyle, MA
University of Wisconsin
Paul Roman challenged the Editorial Board of The Bridge to explore what each of us could do in our professional roles to encourage the addressing of substance use by the medical profession. In recent years, I have been involved in the design and implementation of a clinical trial utilizing smart phones for recovery support, a NIATx project to assist state and provider partnerships to implement medication assisted treatment, and the design of a NIDA study combining computer delivered treatment and recovery supports. Currently, I am working with three states on a SAMHSA project aiming to promote the adoption and implementation of technologies to address brief intervention, treatment and recovery supports.
My experiences lead me to believe, with few exceptions, that primary medical care will not address substance use problems and illnesses unless they are provided with new resources and approaches. The barriers have been extensively identified, and include increased demand for primary care from newly insured patients, lack of training and skills to address substance use and lack of interest in adding a new dimension of focus in their practices. Primary care physicians are certainly not going to adopt the current system of intensive outpatient, weekly groups or hour- long individual sessions into their practices.
A delivery system is needed that can fit the work flow of primary care. I believe this new system can be achieved through adoption of developing technologies that can extend or even replace clinician delivered services while achieving improved outcomes.
Over the last decade, numerous new technologies to address substance use problems have been developed and subjected to research studies to determine their efficacy and effectiveness. I will highlight a few of these as examples.
Computerized screening and assessments for substance use are available. As one example, Dr. Reid Hester and his colleagues at the Research Division of Behavior Therapy Associates, LLC, in Albuquerque, New Mexico (www.behaviortherapy.com) have developed a web application that is a brief motivational intervention for heavy drinkers, the Drinker’s Check-up (www.drinkerscheckup.com). The Check-up screens for alcohol misuse then provides a detailed assessment of drinking, objective feedback provided in a manner that minimizes resistance, and then provides patients with exercises to resolve their ambivalence about changing their drinking. They are then presented with the options to either moderate their drinking or to stop entirely (with links to other, evidence-based web apps for moderation or abstinence). The web site also contains links to mutual aid groups for assistance in achieving the objective chosen. A new version of this system, www.checkupandchoices.com has been developed for use in primary care clinics. Computerized brief interventions have also been studied for drug use that have achieved positive results. A recently completed study demonstrated that a computerized intervention achieved equal results compared to clinical delivered intervention with more positive reductions in use for marijuana and cocaine.
Dr. Lisa Marsch, Dartmouth College, developed a computerized substance use treatment called Therapeutic Education System (TES). It has 60+ modules based on the evidence-based practice called Community Reinforcement Approach. Studies using weeks of continuous abstinence as a primary measure demonstrate the computerized system achieves outcomes equivalent to CRA treatment delivered by highly trained and supervised clinicians and the results are far superior to treatment as usual. There may also be clinician involvement in the use of TES consisting of brief, periodic 15-30 minute sessions. The clinician serves as a mentor, coach and problem solver and she/he is able to electronically monitor progress and results of the patients use of the computerized system. Of interest, these short sessions have been shown to result in development of a therapeutic alliance comparable to that achieved with longer and more frequent clinical sessions.
A recovery support system, A-CHESS, has been developed by Dr. Dave Gustafson and associates at the University of Wisconsin-Madison utilizing smart phones. Numerous apps are available on a single web site and include:
Descriptions and videos of some of the ACHESS functions can be viewed at www.innovationsforrecovery.org. A recently completed NIAAA study revealed persons using the A-CHESS system had 57% less risky drinking days and 30% higher abstinence compared to a control group at 4, 8 and 12 month follow-up.
Using an older technology, studies of telephonic continuing care have demonstrated outcomes that are equal to or superior to group continuing care sessions using a relapse prevention or 12 step approach. A continuing care model developed by Dr. James McKay at the University of Pennsylvania consists of 15-20 minute weekly phone calls delivered by a clinician.
A challenge is that dozens of computer programs and mobile apps are being marketed to address substance use illnesses, but most have not been subjected to clinical trials. I fear that some of these, perhaps developed with good intent, may be viewed as or actually be the equivalent of the “snake oil” remedies of the 19th century.
I believe there is a role for behavioral health clinicians in the implementation of these technologies but it will be a very different approach than what exists today. The sessions will be 15-30 minutes rather then the traditional “50 minute hour”, individual or family services rather than delivered in groups, tailored to the patient’s progress and very focused. Delivery will utilize phone, tele-health and other technologies in addition to face-to face services.
An ideal setting to model this new delivery system is in Federally Qualified Health Centers (FQHCs) particularly with the expansion of Medicaid coverage that is occurring in many states. The Center for Medicare and Medicaid Services mandate that states cover the delivery of behavioral health services by licensed psychologists and social workers within FQHCs. Further, the FQHCs are paid an enhanced rate compared to other primary care providers or community based substance use treatment and covered under an event mode rather than the time spent by a clinician. Thus, there is a financial incentive for brief interventions and a disincentive for hour-long discussions.
A major barrier for adoption of a new delivery system for primary care is the existence of the technologies in silos, and the current lack of opportunities to view an informational menu of choices. Each has it own web-based delivery platform. Thus, a provider would need to determine which to recommend to a patient and teach them how to access and utilize each system. Further, most patients would probably benefit from using a combination of technologies and having to open multiple web sites and passwords is a deterrent likely to reduce use of the resources.
Dr. Roman instructed us to assume we had the resources and financing to implement our recommendations. Is that were true, I would assemble a panel of experts in addressing substance use and include persons with expertise in the structure and delivery of technologies. The task would be to identify the best existing technologies in the various domains. Subsequently, the developers of these technologies would be encouraged, with funding, to collaborate in the building of an integrated platform to deliver their technologies. With business consultation, a plan for commercialization of the new platform would be developed.
In behavioral health, it has been assumed that increasing access, providing increased quality of care and reducing costs could not all be addressed simultaneously. For example, increasing access and quality would require additional costs. Conversely, decreasing costs were projected to be achieved by decreasing either the number of persons served or quality of care. In today’s world, these are false assumptions. With the assistance of new technologies, the holy grail of serving more people and achieving better outcomes at a reduced cost per episode of care can be achieved.