>>KOPELOW: So, we’ve talked a lot in a generic fashion
>>MADRAS: Yes.
>>KOPELOW: the fact that physicians can intervene, there’s questions for them to ask. And I know that this process has a name.
>>MADRAS: There are a number of questioners out there. We can’t specifically recommend one. But, the World Health Organization has done phase one, phase two and phase three clinical trials with ASSIST. And the advantage of ASSIST is that it covers illicit drugs, prescription drugs as well as alcohol. And, that’s a critical thing, because all three of them present a potential hazard to patients.
>>KOPELOW: But, this overall approach has a name: Screening and Brief Intervention and
>>MADRAS: Yes. Screening and Brief Interventions has an acronym based on the federal program SBIRT Screening Brief Intervention Referral to Treatment. And this program began in 2003 in seven states. It’s now expanded enormously on to college campuses, 12 campuses, into 11 states and now we even have a program that will be issued within a few months for medical residency training in this area.
>>KOPELOW: Now, you’ve done research on this, some of your other government agencies have produced data that describes the effectiveness SBIRT?
>>MADRAS: SAMSA or Substance Abuse and Mental Health Services Administration has organized the program, has funded the program and data gathering is part of a government reporting performance measures. You have to see whether a program is effective. We have studied in depth all the data that have come out of six sites in six different states. Actually multiple sites screening we stopped the clock at 464,000 people. And when we stopped the clock we looked at what the outcome measures were. For illicit drugs there was a very significant drop in use when the same subjects were interviewed six months later. And the same very large drop in heavy alcohol use also occurred. So, we are very, very committed to promulgating this kind of program in as broad a spectrum of medical and health care settings as possible.
>>KOPELOW: Now, when, sorry, but when you talk about numbers of hundreds of thousands that you’re studying
>>MADRAS: Yes.
>>KOPELOW: And when you think about those large numbers, when you think about the list of other medical problems that can be associated with substance abuse that you’ve spoken and written about this must have an impact at a population level at an epidemiologic level there must be other medical problems and societal problems that are addressed and overcome by these multiple one on one physician/patient encounters through SBIRT?
>>MADRAS: Well, let’s take a look at how big the problem is 460,000 people screened, 23 percent are screening positive for illicit drugs, alcohol, and a small percentage for prescription drugs. Because, when the program began prescription drug screening was not really a major part of it. Now we have the vast majority of sites are screening for that as well. There is a massive number of people between a quarter and 20 percent of our population is engaged in risky substance abuse.
>>KOPELOW: You think that 20 percent is generalizable to the whole population?
>>MADRAS: I think it’s generalizable to people who present in health care settings.
>>KOPELOW: Good, ok. Now what about if we cure it, if we intervene, if, if SBIRT has an impact on this 23 percent of the people what kinds of other things going to change in the community? Are motor vehicle accidents going to change, is it going to what we see in emergency departments going to change?
>>MADRAS: It’s an excellent question. Motor vehicle accidents have traditionally only tested for alcohol. So that the data for illicit drugs is not as mature although we’re soon going to be getting some federal data on that. There is obviously, there are several papers that show that DUIs go down. But, we don’t even know the extent of motor vehicle accidents for illicit drugs. Based on informal polling of trauma surgeons they think that a lot of trauma if it’s not alcohol it’s going to be illicit drugs. And a very beautiful study came out in the Journal of Trauma, December of ’07, showing that a significant population showing up in California trauma center tested positive for methamphetamine. And not only were the outcomes worse, but also the condition of the patients was much more treacherous than if they came in for trauma for other reasons. In terms of needing ventilation assistance, in terms of morbidities and outcomes, in terms of injury as level of outcomes and in terms of health care costs. So, we have to consider illicit drugs as a major contributor to trauma and to health care as well. We have very solid evidence that cocaine and other psycho-stimulants can precipitate strokes. There is growing evidence that it can exacerbate diabetes. That some of these drugs can compromise the efficacy of prescription drugs. We have to look at the whole picture of substance abuse and not restrict it to one class of substances as opposed to another. And let me focus for a moment on prescription drug abuse. There is a growing body of evidence that people who have a history of alcohol and /or illicit drug abuse are much more prone to abuse prescription medications that have abuse potential. And that correspondence holds for high school students, it holds for college students and it holds for people who present themselves for treatment for prescription drug abuse. Those folks have a history of illicit drug abuse or alcohol. And it is so critical to screen patients for substance abuse in order to try to identify patients who are at risk for abusing their prescription medication, the ones that have abuse potential.
>>KOPELOW: So, there’s a, we’ve made a case for the fact that there’s a quality gap, a health care gap. We’ve made a case that there’s challenges to the profession of
>>MADRAS: Yes.
>>KOPELOW: physicians that can be characterized as professional practice gaps
>>MADRAS: Yes.
>>KOPELOW: We’ve talked about the fact that there are knowledge issues for the physicians to address. There are strategies in place and strategic things for the physicians to learn. There’s performance issues that can have an impact on the patient in the larger community. Now, let’s talk in the context of the accredited continuing medical education provider. A set of organizations and institutions, who have educational missions, who are interested in improving patient care, who are interested in improving the health of people. Let’s talk about a strategic plan for them to address these challenges. Let’s start with knowledge. Where should they look for the information that they should pass on to the physicians, where is it available?
>>MADRAS: There are Web sites that by SAMSA , Substance Abuse and Mental Health Services Administration that provide links to the screening questionnaires as well as through NIH, through NIAAA and soon through NIDA.
>>KOPELOW: The ACCME and the Office of National Drug Control Policy can put on our Web site information that are links that will access the information to some of the knowledge issues that underlie some of these professional practice gaps.
>>MADRAS: Good.
>>KOPELOW: What would you think would be the first one or two or three knowledge areas that if you had all the docs in front of you right now that you’d want them to know about this?
>>MADRAS: There are three areas that are so crystal clear. First, become aware that substance abuse, illicit drugs as well as alcohol as well as prescription drugs can severely compromise the health of your patient. That’s the motivation.
>>KOPELOW: OK. So, first this matters, this is important
>>MADRAS: This matters.
>>KOPELOW: This has a big impact.
>>MADRAS: Correct. The second issue is, that screenings and brief interventions can be done within your office, within a practice either by yourself or an assistant and there are billing codes now that enable you to bill for these procedures. That give you stand alone time that is not part of evaluation and management codes, but part of preventive medicine. And the third thing is, learn how to do it, because these are protocol driven manualized procedures that will require continuing medical education
>>KOPELOW: So the
>>MADRAS: These are not intuitive. That’s the key.
>>KOPELOW: So, the first part of this for the CME provider would be to translate these into knowledge and information for the physicians about the scope of the problem, the scope of the strategies that are available to them, just to turn these physicians from a group of people who don’t know into a group who know they don’t know about how to address.
>>MADRAS: And also to make physicians aware that you can’t and should not ignore this. It should be a part of medical practice, because substance abuse can impact enormously the health of your patients.
>>KOPELOW: In CME we talk about knowledge and competence, competence being strategies. And you’ve just described clearly a strategy for the physicians to intervene. At an individual level, SBIRT. You’ve talked about screening and brief intervention as a tool and that there are, there are information sources, there are descriptive information on Web sites
>>MADRAS: Yes.
>>KOPELOW: Sites and published information available for our CME providers to build educational activities upon, to learn the skills, am I right?
>>MADRAS: You’re absolutely correct. Yes. And also, there should be an awareness that these billing codes became effective in January of ’08 and as of present time Evaluate has researched the country for health care providers and found that 86 of them, 86 major insurance companies are willing to reimburse for these codes and for these procedures.
>>KOPELOW: Now, part of our requirements at the ACCME accreditation requirements is the activities that are developed the CME program that’s put on should match the scope of practice of the learners.
>>MADRAS: Yes.
>>KOPELOW: We’ve talked about family docs, talked about pediatricians. But I get the sense that if 23 percent of the population of America and I’ll generalize that number you didn’t generalize that number. But. if 23 percent of the people are somehow affected by the by this that means every health care provider, every physician is seeing people that are affected by this. So this isn’t necessarily a tool just for the primary health care physician is it?
>>MADRAS: It is not necessarily a tool and we can think instantly of specialties that should engage in this: obstetrics and gynecology, pediatrics, emergency physicians, trauma surgeons, internists, infectious disease people, oncologists, I think that there so many specialties for which this can have an association or a causality that the physicians of multiple specialties should be aware that not only can this have an impact on the health of the patient, but that they personally can do something to intervene and to begin to alleviate the problem.
>>KOPELOW: And also, we’re talking about medical education but we work in partnership with the nurses with the pharmacists, clearly there’s roles for those other professions as they interact with the public, and with the patients to potentially screen and to raise insight and awareness about this.
>>MADRAS: I think there’s clearly a role. I don’t know if you interact with dentists do you?
>>KOPELOW: Only as a patient.
>>MADRAS: Dentists, again, are people who could have an impact.
>>KOPELOW: I mean they take my blood pressure.
>>MADRAS: Yes.
>>KOPELOW: When I go and they’re involved in screening, so can
>>MADRAS: And they issue prescriptions for abusable drugs.
>>KOPELOW: So this is really, this is really something that interacts with everyone. So when the CME providers are thinking about putting on activities and putting on programs they also can think about doing it in an interdisciplinary, inter-professional kind of way. Planning educational activities by the whole health care team, by several professions, and presenting them to the whole health care team. Specially in institutions, most of our accredited providers are hospitals. Most of the accredited providers are accredited within our state system, where the local and regional practices and smaller hospitals are accredited to provide continuing medical education they’re very much team based. They’re very much inter-professional in the nature of the way they practice medicine. And there could be a role for education that crosses the professions for our providers which is something that the Institute of Medicine, the National Academy of Sciences, has been focusing us on over the last five or ten years and that could have a considerable and important impact.
>>MADRAS: It can have a very important impact because training and dissemination of these procedures is not only going to impact health and well being of individual patients but in the long run it will reduce health care costs. And there’s such good evidence for that. In terms of randomized controlled trials, in a primary health care setting, in trauma setting, but also through Medicaid. The Washington state determined that for each 1000 Medicaid eligible patients they could save the state approximately two million dollars a year because of a reduction in re-hospitalization. So, it makes sense from every sector that’s involved with health care. It makes sense from the point of view of the patient, who could benefit from this teaching moment that they may never have gotten from parents or from media or from anyone else. Especially if they’re in a social group that clusters normative behaviors of drug use or what have you. It could benefit the physician because the patients’ health will improve and it will enhance their practice. It could benefit health care costs.
>>KOPELOW: So, it helps the individual person, either recover from the abusing behavior that they’re involved in or prevent them from going on to a more serious state with substances
>>MADRAS: Prevent that progression.
>>KOPELOW: Also, therefore, it will prevent the appearance of that other multiple list of other associated problems
>>MADRAS: Yes.
>>KOPELOW: for them that it will be developed. It will decrease at a population and epidemiologic level. You were talking about trauma and decreased number of accidents and it will have an impact so the cost effectiveness of this is because it decreases the burden of disease both for at the individual level and at the whole population level.
>>MADRAS: At the whole population level and there are many other cost effectiveness components that we don’t even have a calculator yet for and that is when a person is abusing substances at the home the impact is not only on the individual it’s on the other members of the family. Not only in terms of the stress that they produce on the family but the multi-generational social normalizing of these behaviors. It’s a form of prevention for the next generation, or for siblings or for spouses. Because we know once a behavior is normalized within an individual it can spread. And reducing that also can spread in the reverse.
>>KOPELOW: So, let’s think a little bit about the continuing medical education provider who has a population of physicians and professionals that they’re trying to help.
>>MADRAS: Yes.
>>KOPELOW: And provide services to. What kind of barriers to change in the community, change of physician behavior should they expect to have to address or could they look for? It’s part of our requirements for them to try to address them and identify them. What are, share some of your experience.
>>MADRAS: I think that the most important barrier is that physicians think since they do not have training in specialty care for addiction that this is a problem that they cannot address. That is quite a common response that one sees in the literature. It’s true for practicing physicians, it’s been studied for adolescent pediatricians, who say I don’t know what to do about I haven’t been trained. So, the first thing to bear in mind I think is that addiction and treatment of addiction is not necessarily the issue. The issue is to try to help people engaged in risky problematic use, abuse and refer those who are addicted to specialty treatment. It goes one step further. If, in fact, a person is amenable and there are medications available for certain types of addiction then an office based practice to treat the full spectrum is feasible. So the first and foremost challenge is to make physicians aware that this is a medical problem and should be medicalised. And secondly, that there is an awful lot they can do within their office space practice that is not referring a person to a specialty counseling.
>>KOPELOW: Now, let’s take it out of the scope of the CME provider and beyond the scope of the physician learner and say that we’re trying to medicalise, we’re trying to increase the number of physicians that are involved. We’ve got the physicians on board. We now have them, they know what the problems are, they’ve been briefed in SBIRT and they have the skills, they’ve practiced with simulated patients and they’re ready to go
>>MADRAS: That’s wonderful
>>KOPELOW: they’re systems their own offices their microcosmic micro-systems in which they operate are ready to do it are there societal barriers? Are there barriers outside of their practice that act as barriers to the physicians being able to do this? Have you identified any, any things that we can prepare for?
>>MADRAS: I would imagine the two major societal barriers are time
>>KOPELOW: Time with the patients?
>>MADRAS: Time with the patients, even though these are now billable the physician may feel oppressed by the number of services they have to provide to a patient. The response to that is very simple. The US preventive commission tried to place a hierarchy on what preventive measures a physician should engage in and screening and brief intervention ranked second after immunizations, smoking cessation and daily aspirin for at risk males and females. So, it’s clear that if you want to list the types of procedures that are essential for good preventive medicine this ranks very high. And do set aside the time or have a person in the office who is trained to do it on your behalf or try to generate, incorporate computerized screening. There are tools that are coming on board and even brief interventions that you can reinforce face to face through computers.
>>KOPELOW: Now addressing and dealing with substance abuse focusing and making change with the patients is is often described as a community issue. That some of the solutions are found in communities and community partnerships and other entities that are working and addressing all this. It’s probably fair to say, it’s speculation on my part, probably fair to say that the physicians and the health care system are not the only people that are trying to address this.
>>MADRAS: They’re certainly not the only people that are trying to address it. Because there are a lot of messages in the workplace, in the media, the Super Bowl ads we/our office put on, for example, trying to discourage people from using drugs. But, the interesting thing is there is a white coat syndrome. That we think facilitates behavioral change. The physician has a level of respect, authority and confidence of the patient. There is a sense of the physician is is less likely to us hyperbole, to exaggerate. And if this is done in a health care setting it could have a profound impact on patient behavior.
>>KOPELOW: So, you’ve really described a pretty neat package of information that the physician can get, skills that the physician can learn, measurable tools to measure the impact, and I believe the physician community can become part of a larger community of resources and supports that are dealing with this. Now, I had the opportunity to listen to the President to make some announcements about the impact of SBIRT and some of your programs at the a at Washington some time ago and sitting in the room, sitting in the room was a wide range of people from a wide range of community organizations, federal organizations who were addressing and assisting and working in some of these areas. If our accredited providers want to work with other community organizations where should they look?
>>MADRAS: There’s so many sectors. They should work with employment assistance programs in the workplace. They should work with health care insurance companies. And there should be a collaboration, knowing in the long run the bottom line of insurance costs is going to be positively impacted. They should work with state Medicaid directors and indicate to them that having the codes adopted within a state will facilitate the well being of the population of that state. They should work with health care service providers on college campuses, because the need is enormous on college campuses. They should work in small business associations, because there without the large bargaining powers that major corporations have small businesses have a much tougher time in terms of providing health care insurance, but this is an area that could have a positive impact on small businesses. There are many sectors of society that medical professionals can partner with that can make this a powerful prevention measure that will reduce the public health burden of the problem.
>>KOPELOW: Thank you.
>>MADRAS: You’re very welcome.
