Grant helps St. Luke’s nip substance use issues in the bud

Jul. 16--Anna Peterson has a simple explanation for why drinking is more of a problem in the Upper Midwest than in other parts of the country.

"Long, cold winters," she said.

Whatever the reason, excess alcohol consumption in the region is a concern for Peterson in her role as director of case management for St. Luke's. It's one of the factors, she said, that drove St. Luke's to seek and insurer UCare to award $100,000 to expand an already existing program to identify and immediately begin addressing behavioral health issues.

The program goes by the unappealing acronym of SBIRT, which stands for Screening, Brief Intervention and Referral to Treatment. What it means is that a patient entering a clinic or hospital is asked questions regarding substance use. If the answers point to excess drinking or drug use, the patient can immediately be seen on site and given corrective guidance -- that's the brief intervention. If a more urgent problem is identified, the patient can be referred for behavioral health treatment.

The concept is simple, but it's evidence-tested as a powerful tool to reduce the consequences of excess use of alcohol and drugs, Peterson said. She points to a 1999 study reported in the Journal of the American Medical Association on the use of brief interventions for alcohol use. For those who received the interventions, according to the study, injuries and emergency department visits went down by 20 percent, hospitalizations by 36 percent, arrests by 46 percent and motor vehicle crashes by 50 percent.

"The evidence out there is phenomenal for SBIRT as far as creating a positive impact on patients," Peterson said.

The evidence also shows, she said, that about 75 percent of the U.S. population is at low risk for excess substance use, either because of abstinence or moderation. At the other end of the spectrum, 5 percent have a substance use disorder and need to be referred for treatment.

But the SBIRT method shines with the other 20 percent, Peterson said, people who may drink or use drugs excessively without normally being seen as having a problem.

"Historically that portion of the population has been almost ignored in a sense, and that's where our everyday people in society that still have jobs, still have good relationships -- they fall into that category," Peterson said. "But they are at risk of impacting their health ... of losing their job, of ending up divorced."

The economic toll is enormous.

Peterson points to a study on the economic impacts of excessive drinking in Wisconsin, including $750 million for health care, $2 billion in premature deaths, nearly $3 billion in additional productivity lost and $649 million for the criminal justice system. Add to that the cost of vehicular crashes and other expenses, and the total annual cost in Wisconsin alone is $6.8 billion. That's equivalent to nearly 20 percent of the state's budget in 2016. Put another way, it's $1,200 for every adult and child in Wisconsin.

Determining when use is excessive is a simple numbers game when it comes to alcohol, Peterson said. To be considered at low risk, healthy men under the age of 65 must have no more than four standard drinks per day and no more than 14 in a week. For healthy women and men 65 and older, the numbers are a maximum of three drinks per day and seven per week.

What's considered a standard drink varies by the drink -- a 12-ounce can of beer, a 5-ounce glass of wine or a shot of whiskey.

Many in the Northland pass those limits, at least on occasion, without giving it a thought, Peterson said.

"The focus isn't on those who are using hard drugs every day," she said. "It's those who are going to a barbecue on the weekend and ... oops, having one too many."

She told of one patient who went on vacation in a country where drinking heavily is accepted. The individual drank quite a bit of wine without ever really becoming drunk, she said. When he returned home, he developed pancreatitis.

The patient answered the screening questions and was told the amount of drinking he'd been doing had placed him at risk.

"They said, 'Wow, I had no idea,'" Peterson related. "It's an everyday person, has a job, has a family, does well on a day-to-day basis. But they were drinking in a very risky way."

Peterson and St. Luke's program trauma manager have been certified as SBIRT trainers and now have a team in place to intervene with trauma patients who are flagged for alcohol use, she said. With the grant money, that's being expanded to the hospital's obstetrics and gastrointestinal teams.

The program also is being introduced in St. Luke's clinics, said Joe Drexler, the health provider's director for population health and strategy. Nearly a year ago, two therapists were installed at St. Luke's Internal Medicine to be available for brief interventions and ongoing psychotherapy. More recently, a therapist was put in place for the same purpose at P.S. Rudie Medical Clinic downtown. Both serve "complex populations," Drexler said.

The grant money was intended to provide a therapist at St. Luke's Hibbing Family Medical Clinic, Drexler said.

"There's a great need," he said. "There's a lack of mental health (providers) there in general. ... We have a very busy clinic."

But there have been few responses to the posting for the position, he said, and if it can't be filled the position will be shifted to meet another need for an inpatient mental health therapist at the hospital.

Ideally, there would be a therapist at every clinic, Drexler said. But the screening process takes place regardless.

"These kinds of models where you integrate it into primary care allow us to be more creative with supporting the population," he said. "But those startup funds are really crucial. All of Minnesota needs it, but our area in particular. Coming from the Cities, it feels more desperate up here."

Dr. Julia Joseph-Di Caprio, chief medical officer for UCare, said the insurer targeted its grants to Greater Minnesota.

"We know that outside of the seven-county metro area, there are significant issues with substance use disorder and behavioral health, and really limited access to services," she said.

UCare sees the grants as beneficial to its members and as a good investment, Joseph-Di Caprio said.

"In terms of the evidence, we know that it can reduce health care costs," she said. "And the savings can range anywhere from a three or four or five to one return. And I'm not saying that it happens right away. But if you look over time, we know that this type of intervention, if it's done in an (emergency department) or a hospital or a primary care clinic, can result in fewer emergency department visits, fewer injuries, fewer hospitalizations ... fewer arrests and fewer motor vehicle crashes."

It works in part, Drexler suggested, because it meets people where they are without necessarily sending patients to a mental health clinic.

"'I don't want to go.' 'I'm not depressed or crazy,' We've heard it all," Drexler said. "They're a lot more comfortable if they're at their own doctor's office.

"With this kind of model, we break down a lot of barriers."

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