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Northwell Begins Screening Children for Substance Abuse

News  |  By Christopher Cheney  
   January 17, 2018

Stepping up efforts to address the opioid crisis, Northwell Health expanded 'universal' drug screening to its children's hospital.

As part of efforts for early detection and diagnosis of opioid addiction, Northwell Health has expanded alcohol and substance abuse screening beyond adults to include patients aged 12 to 18 at Cohen Children's Medical Center.

Expansion of the addiction screening last week is part of the New Hyde Park, NY-based health system's commitment to help all patients address substance-abuse disorders, says Sandeep Kapoor, MD, director of the health system’s Screening, Brief Intervention and Referral Treatment program (SBIRT).

Northwell conducts SBIRT screening for every patient at all of the health system's emergency rooms and primary care practices, he says. "It's been a universal approach."

SBIRT is a key component of Northwell's response to the opioid addiction crisis because of the importance of early detection and diagnosis, says Joseph Conigliaro, MD, chief of general internal medicine at the health system. "The whole idea behind SBIRT is you can get at addiction early as opposed to getting it late, when the horse is out of the barn."

SBIRT, which Northwell launched in December 2013, features self-reported screening for alcohol and substance abuse with evidence-based tools. Northwell clinicians have been using two SBIRT evidence-based tools at primary care practices and emergency rooms for adults, and they are using one screening tool for children.

Self-reported screening features patients responding to screening-tool questions. For example, adults are screened for opioid and other illicit drug use with the Drug Abuse Screening Test, which qualifies and quantifies prescription and illicit drug use, then risk-stratifies patients.

At Northwell, Kapoor says brief interventions are the primary focus of SBIRT for patients detected with possible opioid addiction:

  • The essential element of the brief intervention is a conversation that engages the patient about their opioid use. The conversation features four pillars of motivational interviewing: compassion, acceptance, partnership, and evocation.
  • The interviewer seeks to build rapport and trust, then provides feedback on the screening with the patient's permission.
  • The conversation serves as a starting point to help the patient gain insight and self-identify any consequences related to their opioid use.
  • At the end of the conversation, the interviewer determines whether the patient is ready and willing to make a change, then helps the patient formulate a plan that could include referral to specialty care.

"It's a nonconfrontational conversation during a clinical visit—either in an emergency room or a primary care office," Kapoor says. “Even though it is busy, you pause and speak with the patient to better understand where they are at with their substance use."

The key to implementing SBIRT at Northwell primary care practices has been integrating the program into clinical workflows, Conigliaro says, noting that efforts with medical assistants and nurses helped screening for addiction become essentially another vital sign.

Northwell's effort to implement SBIRT in both the ER setting and at primary care practices is a significant achievement, Conigliaro says. "This in itself is a measure of success, demonstrating organizational awareness and acceptance that substance use needs to be handled as any other disease process."

The universal nature of SBIRT screening at Northwell's primary care practices and ERs is also crucial, he says.

"We screen everybody. We don't try to pick out people who are more likely to be addicted. So, if you are a 75-year-old nun, you are going to get screened for alcohol and drugs."

Opioid Crisis Task Force

Another addiction initiative at Northwell is starting to roll out new programs.

Launched in 2016 with six members drawn from interdisciplinary fields, Northwell's Opioid Management Steering Committee is developing a "battery of solutions" to help address the opioid crisis in New York, Kapoor says.

The steering committee has four focal points:

  • Limiting the supply of opioids
  • Raising awareness of opioid addiction
  • Identifying and managing the dependent population
  • Treating the opioid-addicted population

Several steering committee work groups have been formed:

  • Community and school-based outreach
  • Pain management
  • Data mining to help monitor and evaluate Northwell's opioid-addiction programs
  • Addiction protocols for standardizing inpatient treatment
  • Practice guidelines for opioid-medication prescriptions
  • Emergency medicine not only to identify patients who are addicted to opioids but also to start treatment in the ER before handing off patients for specialty care

Currently, two of the steering committee's pilot programs that focus on the safe disposal of opioid medications are being expanded.

One pilot program started with a safe-disposal receptacle for medications being installed in the main lobby at Southside Hospital in Bay Shore, NY. A contract was recently signed to have the receptacles installed at other Northwell hospitals, Kapoor says.

The other medication-disposal pilot program features Northwell's commercial pharmacy partner, Vivo Health Pharmacy.

Starting in November, all Northwell opioid medication prescriptions filled at a Vivo Health Pharmacy have gotten a special sticker on the bottle cap. The sticker has a message for patients, advising them that if they have any unused medication they can call the pharmacy, which will mail a safe-disposal pouch.

The pouches, which contain a neutralizing agent, can be used to dispose as many as 15 pills. Patients place pills in the pouch, add a few drops of water, then throw the pouch in the trash.

The safe-disposal pouches have been popular with patients and the program is expected to expand when new Vivo Health Pharmacies open, Kapoor says.

Opioid Addiction Treatment

In 2016, Northwell provided substance-abuse disorder services to 6,000 inpatients and 90,000 people in outpatient settings, says Jonathan Morgenstern, PhD, assistant vice president for addiction services.

At Northwell, which has five tertiary hospitals, 10 community hospitals, three specialty hospitals, and four affiliated hospitals, Morgenstern says most opioid-addicted patients follow a three-step trajectory:

  • Inpatient detoxification for three to seven days to withdraw from physical dependence on opioids, usually with the assistance of medication such as Suboxone.
  • Inpatient rehabilitation for 10 to 14 days. "Typically, when a patient comes out of detox, they are not experiencing withdrawal, but they are in a vulnerable and somewhat shaky state. … They need a protected environment and therapy," Morgenstern says.
  • Outpatient services for three to six months, including medication and a combination of individual therapies to help patients transition from a protected environment back into their communities.

Even though treatment for opioid addiction can take months, most insurance plans cover the treatment and there is funding for uninsured patients, Morgenstern says. Under the Patient Protection and Affordable Care Act, substance use disorders treatment, including opioid addiction care, is considered an essential benefit that commercial plans must cover. Also, many states provide direct subsidies to SUD treatment programs to fund treatment for uninsured patients.

Christopher Cheney is the CMO editor at HealthLeaders.


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