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More patients or more competition?

July 1, 2010
by Larry M. Gentilello, MD, FACS
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A physician believes widespread substance use screening in primary care will boost specialty treatment

It wasn't too long ago that addiction treatment specialists were the only source of professional help to those suffering from problems with alcohol and drugs. But in recent years, screening, brief intervention and referral to treatment (SBIRT) of patients with potential alcohol- and drug-related problems has increasingly become a part of mainstream medicine.

First introduced in the late 1990s, SBIRT addresses the entire spectrum of substance use disorders, from early symptoms that are identified and addressed before the patient has exhibited signs of addiction to addicted patients who need long-term chronic treatment. The approach is evidence-based, and has demonstrated a small but proven impact on daily and weekly alcohol consumption, DUI arrests, injuries, car crashes and other complications associated with alcohol and drug misuse.

Now, physicians and healthcare providers of all stripes (those in trauma centers, emergency departments, primary care and college campus health clinics, general surgical and medical wards, and employee assistance programs) increasingly are using formal screening methods to detect the potential harmful use of alcohol, prescription drugs, or illicit drugs. And physicians and other hospital and clinic staff are also counseling patients who screen positive for substance use and are referring some on for treatment by addiction specialists.

There is a great deal of other evidence that the momentum for the SBIRT approach continues to grow:

  • A new medical specialty board, the American Board of Addiction Medicine, was established in 2007 and already has certified nearly 3,000 physicians from various disciplines as specialists in addiction medicine.

  • Medicare, and in some states Medicaid, is reimbursing clinicians for these services. New CPT codes for reimbursing brief intervention activities were adopted. Effective in January 2007, the Centers for Medicare and Medicaid Services (CMS) allowed reimbursement for alcohol- and drug-related screening and brief interventions.

  • Barriers to SBIRT are falling. For instance, many states have repealed insurance laws that discourage blood alcohol test screening in emergency departments. A widely adopted state insurance law recommended in 1947 by the National Association of Insurance Commissioners (NAIC) allowed health insurance companies to deny payment to physicians and healthcare providers for medical care to persons injured as a result of being under the influence of alcohol or a non-prescribed narcotic. As a result of these laws, one in four trauma surgeons were experiencing denials of reimbursement and only half of trauma surgeons surveyed were screening patients for blood alcohol content. Fortunately, progress has been made in repealing these laws. In 2001, the NAIC unanimously recommended that states repeal the laws, and since then 14 states and the District of Columbia have done so.

The leading question now for “traditional” addiction treatment professionals is how much this trend will affect public health and their livelihoods. Will there be fewer referrals to addiction treatment specialists? Will these specialty providers have to compete with doctors for patients? Or will they receive more referrals and develop closer ties and stronger relationships with physicians?

Those are legitimate questions, but first it might be helpful to place this trend into some historical perspective.

What's behind the SBIRT trend?

The mainstreaming of SBIRT reflects a growing acknowledgement that alcohol and drug use can endanger the health of people who do not have, by definition, an addiction.

Although alcohol and other drugs cause or complicate the treatment of at least 70 medical conditions for which patients frequently seek care, medical schools and residency training programs traditionally have provided very little practical training for doctors on how to screen for substance use and intervene when necessary.

As a result, in any given year, 22 million Americans are in need of substance use treatment, yet only two million patients each year receive it. Why is that? The main reason is 94 percent of patients simply don't know they need treatment. Four percent know they need treatment but don't want it, and two percent know they need help and are actively seeking it or wanting to engage in it.

When it comes to addressing alcohol or drug use problems, one of the most important developments in the past 20 years has been the recognition that only a relatively small fraction of the patients who use alcohol or drugs in quantities that can damage their health meet the criteria for having alcohol dependence syndrome or alcoholism, or are drug addicts.

This was shown by the largest study on SBIRT, a 2009 analysis that screened 459,599 patients in general medical settings (including emergency departments, family practice clinics, trauma centers and general medical surgical wards).

The study found that 22.7 percent of patients had a positive screen for some type of alcohol or drug problem. The two most commonly identified problems were binge drinking (getting drunk to the point of intoxication) and regular use of alcohol in amounts that might not lead to intoxication, but that over time can cause chronic health problems. These two types of drinking patterns were found in 15.9 percent of patients. However, the severity of the problem was at a level that most patients were judged to need only one skillfully delivered counseling session.