Monday, February 28, 2011

SBIRT Doesn't Work in EDs

Another study documenting that emergency department Screening, Brief Intervention and Referral to Treatment (SBIRT) doesn't work. Unfortunately, advocates for SBIRT have moved out quite a ways ahead of the evidence. This is not likely to be harmful for patients, obviously, but it may hurt the cause in the long run. It's also a waste of money and time. By the way, the same holds true for hospitalized patients. SBIRT doesn't work because most of the patients identified are dependent drinkers.


Oxford Journals
Alcohol and Alcoholism
Volume45, Issue6
Pp. 514-519.

The Impact of Screening, Brief Intervention and Referral for Treatment in Emergency Department Patients’ Alcohol Use: A 3-, 6- and 12-month Follow-up

Academic ED SBIRT Research Collaborative

Corresponding author: Robert H. Aseltine, Jr., Division of Behavioral Sciences and Community Health, MC 3910, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3910, USA. Tel: +1 860 679 3282; Fax: +1 860 679 1342; E-mail:

Received October 26, 2009.
Revision received July 30, 2010.
Accepted August 23, 2010.


Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.

Sunday, February 27, 2011

Charlie Sheen on the Myths of Rehab - Time Gets It Right!

Here's a brief snippet from Maia Szalavitz, a health reporter at Time. She really hits the facts right on.


Can You Use Crack 'Socially?' Addiction Myth Watch: Charlie Sheen Edition
By Maia Szalavitz Tuesday, February 15, 2011

The subject of addiction swirls with myths and misinformation. It doesn't help that so many people seem to believe that their own struggle with addiction — or a few drop-ins to Alcoholics Anonymous meetings — make them unquestionable experts on the topic. As the latest news about Charlie Sheen's escapades show, sometimes the seemingly crazy statements of an apparently active addict can be more accurate than those of people who have spent years in recovery and even some "addiction experts" — if you go by the science, that is. (More on New Hope For An Anti-Cocaine Vaccine)

Myth One: Everyone Who Takes Crack Is An Addict

On Monday, during a radio interview with the sports-talk "Dan Patrick Show," Sheen mentioned that some crack users can "manage it socially." (He said his own attempts to be a social crack user "kind of blew up in my face. Like an exploding crack pipe, Dan.")

Although crack cocaine is indeed one of the most addictive drugs, Sheen's statement about social use is true of most people who have tried the drug, if by "social" you mean use that does not qualify you for a diagnosis of substance dependence. Far from being universally addictive, crack is actually unattractive to the majority of people who've tried it: only about 15%-20% of initial users become hooked. (More on Bonus: 4 Tips for Staying on the Wagon)

Indeed, according to data from the National Survey on Drug Use and Health, about 75.6% of those who tried crack between 2004 and 2006 were not using it at all two years later. Another 15% were still hitting the pipe occasionally, but not at levels that would qualify them as addicts. About 9.2% were addicted.

So, although Sheen's terminology may be inexact, he's correct about the existence of non-addicted crack users. He's also correct to note that drinking chocolate milk is much, much safer.

Myth Two: Residential Treatment Works Better than Outpatient Treatment, and Must Be Done in Groups

People magazine recently reported that Sheen would go into treatment for substance abuse for the third time, this time at home: "Surrounded by a team of professionals, the Two and Half Men star will attend no meetings with other patients, check into no center. He could do it all at home or in some other private setting." (More on Does Suffering From Withdrawal Really Mean You're Addicted?)

Commenting on Sheen's rehab plan, Dr. Drew told the magazine that "treatment of addiction is a group process when done properly — not an individual thing at all." Yet actual addiction research shows this is not the case. For example, the largest study ever done on alcoholism treatment, Project Match, was conducted mainly through individual therapy sessions (though one arm did focus on improving 12-step group participation): its aim was not to compare individual to group treatment, but overall, it found individual treatment just as successful.

Further, studies that have directly compared inpatient treatment to outpatient therapy have found that there is little difference in outcomes for most addicts, except for very severe cases, particularly amongst the homeless and jobless — these people lack social and family support, or other important goals to work toward, things that have been found to aid recovery. For employed professionals — like Sheen — outpatient and inpatient treatment tend to be equally effective. (More on 'i-Dosing': Can You Download a Drug High?)

Myth Three: 12-Step Programs are Required for Recovery

Although celebrities, including Sheen's own father, swear by them, 12-step programs like Alcoholics Anonymous are not the only way to recover from addiction. Project Match, in fact, found that on most measures, cognitive behavioral therapy and motivational enhancement therapy were as effective as 12-step facilitation (TSF), a program that worked to enhance 12-step attendance. When patients received these therapies as after-care following inpatient treatment, all three groups did equally well. However, in outpatient-treated addicts, those in the TSF group had slightly better rates of complete abstinence in the year following treatment. (More on Study: Do Energy Drinks Lead to Alcohol Abuse?)

So, although Sheen may not exactly be a model citizen — or rehab patient — his distaste for 12-step programs does not mean that he's untreatable. Maybe he just needs to find a rehab or addiction "professional" who is familiar with the scientific literature.
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Monday, February 7, 2011

Addiction Treatment Parity Doesn't Add Costs

Contrary to the hysterical warnings issued by the insurance industry and the Chamber of Commerce, it turns out that parity for addiction treatment does not add significantly to costs. One key reason is underutilization. Replacing the expensive and minimally effective rehab approach with a fully professional, scientifically based approach will not only make treatment even more cost effective, it will increase access to and utilization of treatment.


From Medscape Medical News > Psychiatry
No Increase in Substance Abuse Treatment Due to Mental Health Parity Law
Findings Should Squelch Fears That Controversial Legislation Will Cause Health Costs to Skyrocket
Deborah Brauser

February 4, 2011 — Parity in insurance coverage of substance abuse treatment has not led to increased use of this service or an increase in costs. It has done what it was designed to do — lower out-of-pocket expenses for covered individuals, new research suggests.

Employers who provide health insurance plans for mental and substance use disorders are now required by the Federal Mental Health Parity Act of 2008 to provide benefits that are equal to those given for general medical care.

There is always a fear that for substance abuse and for mental health, every time a plan is more generous, utilization will skyrocket...But this is not true.
"There is always a fear that for substance abuse and for mental health, every time a plan is more generous, the utilization will skyrocket, the costs will be so high, and all the insurance companies will start complaining that they won't be able to afford these services. But this is not true," lead study author Vanessa Azzone, PhD, researcher and biostatistician in the Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.

"I think these findings, along with those found in other studies, clear the air for all the people who have been criticizing parity law for mental health treatment," said Dr. Azzone.

The investigators note that the extensive use of managed care organizations (MCOs) within employer-based health insurance may be the reason for costs not rising.

"These MCOs administer behavioral health benefits and contain costs by managing the delivery of care — for example, through negotiated reduction in fees with a network of preferred providers and review of appropriateness of services to eliminate unnecessary use," they explain.

"Still, it's always a balance between getting more for the patient but also, from the plan side, controlling that services are only provided as needed," added Dr. Azzone.

The study is published in the February issue of Psychiatric Services.

Paucity of Research

Although previous research on the impact of mental health parity mandates "has undoubtedly helped to pave the way for passage of comprehensive federal legislation," there have been few studies on the effects of parity mandates for substance abuse treatment benefits, write the study authors.

"This is a group that is not studied as much. They're pretty sick and their services are very expensive. So there's been fear that the parity law could have a real impact," said Dr. Azzone.

Insurance plans for federal workers have been required to provide parity coverage since 2001. Because of this, the investigators decided to evaluate claims data on substance abuse treatment in 6 Federal Employees Health Benefit (FEHB) preferred provider organization plans between 1999 and 2001 (before parity was implemented) and between 2001 and 2002 (after implementation).

The use and costs of these plans were then compared with those found in a matched set of health plans without parity coverage.

Results showed no statistically significant differences in the use of substance abuse treatment services between the 2 plan types and no significant differences in probability rates of initiation and engagement.

Those enrolled in the FEHB plans had a significantly larger reduction in average out-of-pocket spending for these services (mean difference per user, −$101.09; P < .05) compared with those in the non-FEHB plans.

Although the FEHB group also had smaller increases in total substance abuse spending compared with the non-FEHB group, these differences were not significant.

Finally, more of the patients with parity were identified by their care providers as having a substance use disorder (difference-in-difference risk, 0.10; 95% confidence interval, 0.02 to 0.19; P < .05).

"Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care," write the researchers.

Clinicians' 'Biggest Stress'

According to Dr. Azzone clinicians' biggest stress is trying to get paid for services because insurance companies erect so many barriers to reimbursement.

"Still, there is this law, and I think clinicians should push more for their patients, even if it is hard for them to promote services when they have so many obstacles. This is already a population that finds it very hard to engage in and continue to get services," she said.

She added that her team is conducting other studies looking at the possibility of parity coverage differences for other groups.

"This includes patients with bipolar disorder or major depression that usually are more expensive and require more services. These patient populations could have a differential effect. We're also concentrating on children to see if the effect we found in adults overall is the same or not," she explained.

"I think this study is significant and an important step in the analysis of overall healthcare costs," Anita S. Everett, MD, director of Community Psychiatry Services at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, told Medscape Medical News.

Dr. Anita Everett
"Providing parity for substance abuse services didn't increase the overall costs. And that is the big fear that everyone has — open the floodgates and all these people will want these very expensive services," said Dr. Everett, who was not involved with this study.

"Also, the number of individuals who actually sought the services didn't go up that much. I think that that is important, although not shocking, and consistent with what we already know: a lot of people with a substance abuse disorder don't recognize their need for treatment or are unwilling to seek treatment. Offering parity is not all of a sudden going to break down their resistance."

Dr. Everett pointed out that a big part of "substance abuse disease" is to be in denial about the magnitude of the problem.

Parity Law Won't 'Break the Bank'

"The clinical significance of parity is that it enables a clinician to be able to help patients and to 'strike while the iron is hot,' so to speak. If they're at a point where they're ready, then hopefully we'll be able to immediately meet that readiness," she said.

Dr. Everett, who is also chair of the American Psychiatric Association's Council on Healthcare Systems and Finance, said that some primary care physicians might not be aware that the parity law has passed.

"I know that the American Psychiatric Association, along with a number of other organizations, is actively working to promote awareness for healthcare providers, patients, and their families that parity for substance abuse and for mental health services does exist," she said.

"I also think that resources such as referral services should be collected and offered in primary care offices."

I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank.
She noted that, although these findings are important, the study population might not be representative of all groups in the United States.

"These were people who were fairly motivated and are probably comparable to other private pay insurance groups — but maybe not to the Medicare or Medicaid populations. We know it can give us some ideas about applicability to the general public, but it may or may not be predictive of the other 300 million Americans who are not federal employees," explained Dr. Everett.

"However, I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank."

The study was funded by a grant from the National Institute on Drug Abuse through the Brandeis-Harvard Center for Managed Care and Drug Abuse Treatment. Its data were originally collected in a study funded by the Department of Health and Human Services. The study authors and Dr. Everett have disclosed no relevant financial relationships.

Psychiatr Serv. 2011;62:129-134.

Medscape Medical News © 2011 WebMD, LLC
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Tuesday, February 1, 2011

ALLTYR™ Is Born!

Over the past year, I have blogged and spoken about the need for transformational change in the addiction treatment system. This week, we took a major step towards stimulating that change, by forming a corporate structure for clinical, educational, advocacy and research efforts. ALLTYR™, the name of the organization, has now been incorporated in Minnesota!

There are two major areas of activity. The first is to develop a model for 21st Century specialty addition treatment. Built on a foundation of science, compassion and common sense, the ALLTYR™ Clinic will provide medically based, multidisciplinary evaluation and treatment for the entire spectrum of substance use disorders. The Clinic will use the ASSET™ Model of care. ASSET™ stands for Alcohol and Substance Use Screening, Evaluation and Treatment. We will provide comprehensive evaluations with recommendations for any indicated treatment. The ASSET Clinic will have several areas of specific expertise, including impaired professionals and executives, managing patients with brain injuries, complex chronic pain management, patients with serious medical problems such as cirrhosis and pancreatitis, patients with treatment-resistant alcohol or drug addiction and patients with complex mixes of psychiatric, medical and addictive disorders. The planned opening for the ASSET Clinic is Fall 2011, although we may be able to start accepting patients sooner.

The second focus for ALLTYR will be to help existing healthcare organizations address substance use throughout their system of care. Most people who drink too much or use other psychoactive drugs are not addicted, but are “at-risk” users. That is, they are using at a level that places them at elevated risk for developing problems later. They are currently not symptomatic. For example, someone drinking 4 or 5 drinks several days a week, or using marijuana several times a week, but who does not endorse any criteria for substance dependence. For this group, who do not have a diagnosable disorder, the goal is to counsel them about their use, so as to reduce the risk. They are similar to people with high cholesterol before a heart attack, or high blood pressure before a stroke. Treatment is not appropriate for them. This group is quite responsive to brief counseling, either by health care clinicians or on the internet, by workplace health initiatives, and so forth. When I was at NIH, we developed a product specifically for at-risk drinkers called Rethinking Drinking.

The second group are people who have some symptoms of alcohol addiction (or dependence, these are interchangeable terms) but who are functional. This group primarily endorses symptoms such as repeatedly going over limits, a persistent desire to quit or cut down, and use despite physical or psychological problems caused or exacerbated by their use, such as hangover, nausea, or insomnia. They do not have the kind of problems we usually associate with addiction such as major life disruptions involving employment, parenting, school performance, or serious interpersonal or legal problems. This group, called functional alcohol dependents, are not appropriate for specialty addiction treatment, but respond well to medications and brief support, much like mild to moderate depression is treated in primary care. Both of these groups are best dealt with in non-addiction specialty settings such as primary care or mental health care (general psychiatry).

For these groups, ALLTYR will provide consultation and training for existing health care systems. The goal is to help them address substance use throughout their healthcare system. For too long it has been considered forbidden for anyone but an addiction counselor to address substance use, which is why so few people now receive any risk reduction or treatment. Attending to substance use needs to be brought back into the mainstream of health care, including mental health care.

I am very excited about this next step in my new venture: making scientifically based addiction treatment available to the public in ways that are attractive, accessible, affordable and effective.