MGH to screen all patients for substance abuse
Querying part of effort to treat addiction
Massachusetts General Hospital will take the unusual step of questioning all patients about their use of alcohol and illegal drugs beginning this fall, whether they are checking in for knee surgery or visiting the emergency department with the flu.
How often have you had six or more drinks on one occasion, caregivers will ask, or used an illegal drug in the past year? If the battery of four questions reveals a possible addiction, doctors can summon a special team to conduct a “bedside intervention” and, if needed, arrange treatment.
The mandatory screening program is part of a broad plan to improve addiction treatment at the Boston teaching hospital and its community health centers and is an example of an expanding national and statewide effort to reach substance abusers earlier and in mainstream medical settings.
Nearly one-quarter of patients in the hospital for routine medical problems have active substance abuse disorders, according to national data — and that was before the recent epidemic of opioid abuse and overdoses in Massachusetts and other states.
Dr. Sarah Wakeman, medical director for substance use disorders at Mass. General’s Center for Community Health Improvement, called being in the hospital “a reachable moment,’’ when social workers and psychiatrists can bring initial treatment right to a patient’s bedside.
“We make it incredibly hard for people to access care for addiction,’’ she said. “Part of our goal is shifting the culture.’’
Standardized hospital-wide substance-abuse screening of all patients — not just those in the emergency room — is uncommon; just how uncommon is not known, since such hospital policies are not tracked.
Mass. General has long asked some patients about their drinking and drug use, but departments have varied in their efforts and often have not used specific questions proven to uncover problems.
Many medical centers are adopting universal screening in their emergency departments, along with follow-up care — an approach pioneered by Boston Medical Center 20 years ago.
Beth Israel Deaconess Medical Center in Boston began screening all emergency room patients for drinking and illegal drug use in January, while Brigham and Women’s Hospital, also in Boston, and Lahey Clinic’s Addison Gilbert Hospital in Gloucester adopted similar programs in the last several years. The American College of Surgeons has required hospitals to ask all trauma patients about their alcohol use since 2006 and will add screening for use of illegal drugs in July 2015.
In these cases, questions about drug and alcohol use are part of a wide range of information sought from hospital patients, including their medications, allergies, and health history, and patients have generally not objected. At Addison Gilbert, “almost 100 percent of patients’’ agree to meet with the social worker, who also screens them for mental illness.
As the Affordable Care Act pushes hospitals and physicians to better coordinate care and lower costs, they are realizing that tackling substance abuse in traditional medical settings can further both these goals.
Mass. General recently studied 2,583 patients with identified substance abuse disorders who were in the hospital for various medical problems — some related to addiction — and found they had longer stays and higher readmission rates than other patients. The cost of their care averaged nearly $10,000 per admission, 40 to 50 percent higher than the cost of treating patients with other chronic conditions such as congestive heart failure and pneumonia.
At the Brigham, caregivers are identifying more patients with serious addiction problems, often discovered because they have had accidents while under the influence or suffered withdrawal symptoms while hospitalized.
Screening programs are intended to reach patients before their illness gets this serious.
Despite the toll substance abuse takes on individuals and families, only about 10 percent of addicts are in treatment in any given year, in part because they are ashamed, said Dr. Joji Suzuki, director of addiction psychiatry at the Brigham.
“Lots of patients would seek treatment if it was in more traditional settings,’’ he said. For that to happen, he added, nurses and doctors must be trained how to question patients without sounding judgmental.
“Experts alone cannot handle this,’’ he said. “We need our regular medical colleagues to become comfortable with this. We need the entire health system to start taking responsibility.’’
As part of a 10-year strategic plan, Mass. General plans to spend at least $1.4 million a year on a new addiction screening and treatment program. It was prompted in part by a 2012 study of health needs in Chelsea, Charlestown, and Revere, which identified substance abuse as the number one concern. The hospital runs health centers in those communities.
Nurses will ask patients who are admitted to the emergency department and inpatient units questions recommended by the National Institutes of Health to gauge overuse of alcohol and use of illegal drugs or prescription medication for nonmedical reasons.
For certain patients who score high, a member of a new hospital addiction team will come to their hospital rooms and encourage them to talk about their drinking and drug-taking habits and how their lives are affected.
Dr. Timothy Wilens, director of addiction medicine at Mass. General, said a patient with high blood pressure who reports drinking four bourbons a night, for example, may not think his or her alcohol use is an issue. “I would say, ‘Let me tell you that when you drink at that level, it starts to affect you liver and cardiovascular health,’ ” Wilens said. “‘Let’s see if you can cut back to two drinks.’ You try to motivate the person.’’
Mass. General will hire five “recovery coaches” — former substance abusers who are certified by the state — to work at the hospital and in the three community health centers. Coaches will accompany people needing longer-term care to Alcoholics Anonymous meetings and encourage them to stick to treatment plans.
The hospital also plans to phase in screening for outpatients and establish an addiction discharge clinic to provide temporary treatment for patients who do not have immediate access to a primary care provider or therapist.
Wilens said that most hospitals believe screening patients is a good idea. “The problem is if you ask someone and find out there’s a problem, what are you going to do? Some of the hospitals have inadequate resources. That puts them in a bind.’’
Boston Medical Center, a pioneer in drug and alcohol screening and treatment, recently found itself in this position. The hospital, which serves many of Boston’s poorest residents, got a five-year $10 million federal grant in 2006 for drug and alcohol screening of all patients. The program included three hospitals and five community health centers, which screened 143,000 patients, of which 17 percent reported substance abuse.
Six months after a brief intervention and referral to treatment, a sample of 657 of these patients reported that their unhealthy substance use had dropped from 94 percent in the preceding month to 68 percent.
When the money ran out, the hospital did not have the funds to continue the program — though it got an additional grant to screen patients for substance abuse and depression in two outpatient departments and track the results.
Instead of hospital-wide screening, Boston Medical Center is focusing its resources on looking for substance abuse problems among — and providing treatment to — emergency room and trauma patients, who have a particularly high rate of drug and alcohol abuse, said Dr. Peter Burke, chief of trauma.
“You have to put your money where you can do the most good,’’ he said.