SBIRT Screening, Brief Intervention, & Referral to Treatment

1. SBIRTScreening, Brief Intervention, & Referral to Treatment Carrie Jankowski, MSSW, LCSW ANNE AND HENRY ZARROW SCHOOL OF SOCIAL WORK CENTER FOR SOCIAL WORK IN HEALTHCARE

2. Who is SAMHSA? • The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. • Since 2003, SAMHSA has supported SBIRT with more than 1.5 Million people screened

3. Screening, brief intervention, and referral to treatment IS : • a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services. • Persons with substance use disorders • Those whose use are at higher levels of risk • carried out at in primary care, hospitals, and other Health care and community settings. • based on Motivational Interviewing strategies , may result in Brief intervention or referral to Treatment

4. Goal of sbirt • to identify and effectively intervene with those who are at moderate or high risk for problems related to their Alcohol and other substance use.

5. Results of Hazardous alcohol and substance abuse • Injury/trauma • Contributes to many Acute and chronic diseases • Criminal justice involvement • Social problems • Mental health consequences (e.g. anxiety and depression) • Increased absenteeism and accidents in the workplace

6. Substance abuse: A Public Health Perspective

7. Screening Stratifies Risk

8. Making a Measurable Difference • Outcome data of SBIRT confirms a 40 percent reduction in harmful use of alcohol by those drinking at risky levels and a 55 percent reduction in negative social consequences. • Outcome data also demonstrate positive benefits for reduced illicit substance use. Based on review of SBIRT GPRA data (2003−2011)

9. SBIRT Is a Highly Flexible Intervention

10. Earlier Detection and Intervention are Key • By intervening early, SBIRT saves lives and money and is consistent with overall support for Patient wellness • Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed comorbid health conditions

11. Survey on medical patient Attitudes PATIENTS ARE OPEN TO DISCUSSING THEIR SUBSTANCE USE TO IMPROVE THEIR HEALTH

12. Why Is It Important to do SBIRT in Primary Care and Other Health Care Settings?

13. SBIRT Decreases the Frequency and Severity of Alcohol and Drug Use • Primary care is one of the most convenient points of contact for substance issues. Many patients are more likely to discuss this subject with their family physician than a relative, therapist, or rehab specialist.

14. SBIRT Reduces Short and Long Term Health Care Costs • By intervening early, SBIRT saves lives and money and is consistent with overall support for patient wellness • Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed comorbid health conditions

15. Step One: Screening • Universal Screening is the first step of the SBIRT process and determines the severity and risk level of the patient’s substance use. • The results allow the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient. • “a discussion aimed at raising an individual’s awareness of their risky behavior and motivating them to change their behavior” (Substance Abuse and Mental Health Services Administration, 2007). • Research shows that approximately 90% of substance use disorders go untreated • What are examples of common screens? Cholesterol, mammogram, gestational diabetes

16. Universal Screening • Results in earlier detection • Addresses the problem, which brings them to seek medical treatment • Reduces Risk of future injury or illness • Normalizes the Screening and subsequent discussion

17. Key Points for Screening • Screen everyone • Use validated tools and processes • Prescreening is usually part of another health, stress or wellness survey • Usually self administered in waiting room- paper or electronic • VERY brief (in contrast to assessment (which is more in-depth) • Any positives (“red flags”) can be addressed in assessment

18. Screening in a Practice Setting

19. Screening for Alcohol Use When Screening, It’s Useful To Clarify What One Drink Is!

20. What is a standard drink?

21. Screening, Brief Intervention, and Referral to Treatment CATEGORIES OF DRINKING LOW-RISK DRINKING LIMITS IV DEPENDENT: 5% III HARMFUL: 8% II RISKY: 9% I HEALTHY: 78%

22. Evidence Behind the Numbers (SEE SBIRT CARD) • analyses reveal significant and rapid increases in the risks of— • injuries and resulting death • Being a target of aggression or Being aggressive • Alcohol use disorders • Unfavorable medical Concerns • work-related, legal, and social consequences • The more the individual exceeds the guidelines, the Greater the likelihood of one or more of the above.

23. Alcohol Prescreening • Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages? • YES • NO • NIAAA Single Screener: How many times in the past year have you had five (men) or four (women or patients over age 65) drinks or more in a day? Sensitivity/Specificity: 82%/79% • If one or more affirmative answers, move on to full screen. • Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. J Gen Intern Med 24(7), 783−788

24. Prescreening Drinking Limits Recommended Limits Men = 4 per day/14 per week Women/anyone 65+ = 3 per day/ 7 drinks per week > Regular limits = at-risk drinker • Determine the average drinks per day and average drinks per week—ask: • On average, how many days a week do you have an alcoholic drink? • On a typical drinking day, how many drinks do you have? (Daily average) • Weekly average = days X drinks

25. AUDIT • Alcohol Use Disorders Identification Test (AUDIT) [audit-C is shorter version] • 10-Item Alcohol Screen • Developed by World Health Organization (WHO) • Can be self-administered or through an interview • addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems

26. Becoming familiar with the Audit • Take a minute to and complete the audit screen supplied. • (you can take it as yourself or someone else that you know)

29. Scoring the Audit • Each question has a set of responses to choose from • Response Scores range from 0 to 4 • Add score for questions 1 through 10

30. Scoring and interpreting the audit

31. AUDIT Domain

32. PreScreening & Screening for Drugs

33. Prescreening for drugs

34. A Positive Drug Screen

35. Evidence Based Screening • Dast (10) • 10-item brief screening tool • Can be administered by clinician or self-administered • Yes or no responses • Can be used with adults and older youth

36. Using SBIRT and MI skills for other Behavioral Concerns • Depression, anxiety, and tobacco use are all common Behavioral issues that significantly impact health status • can Also be Addressed in an SBIRT format • PHQ-2 or PHq-9Depression • Gad-2 or gad-7anxiety • Also can address suicidality—high percentage of people had primary care visit within 30 days of death • Supported by public/private health fundors

37. Routine screener • Medical Practices are instituting electronic or paper screening tools that incorporate most or all of the above. • Often called a wellness-r stress screen • Medical Practices are adding mental health professionals in a collaborative integrated healthcare model. • Co-location or referrals not as effective-the vast majority of People do not make it to a Behavioral Health referral

38. Patient Stress Questionnaire

39. Based on Findings of Screening • The clinician has valid, patient self-reported information that is used in brief intervention. • Often the process of screening sets into motion patient reflection on their substance use behavior.

40. Linking Screening and Brief Intervention MI strategies facilitate— • Finding personal and compelling reasons to change • Building readiness to change • Making commitment to change

41. Step two: Brief intervention • Brief interventions are designed to: • Low cost, effective public health intervention for harmful drinking • motivate individuals to change their behavior • help them understand how their substance use puts them at risk • Ultimately reduce or give up their substance use • Or encourage those with dependence to accept more intensive Care or treatment

42. Goal of Brief Interventions Awareness of problem Behavior change Motivation Presenting problem Screening results

43. Brief intervention in primary care • Usually last from 5 to 15 minutes of brief “advice” • are not intended to treat people with serious substance dependence. • Evidence-based implementation of motivational interviewing skills are the underpinnings of the Brief intervention. 

44. In the Brief Intervention we use MI Skills to… • Assess where the patient is currently in the cycle of change and • Assist person to move through stages of change toward successful sustained change

45. Principles of Motivational Interviewing • MI is founded on five basic principles: • Express empathy • Develop discrepancy • Avoid argumentation • Roll with resistance • Support self-efficacy • Reference: Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism

46. MI: Tips for expressing empathy • Good eye contact • Responsive facial expression • Body orientation • Verbal and nonverbal “encouragers” • Reflective listening/asking clarifying questions • Avoid expressing doubt/passing judgment

47. Core MI • Open-ended questions • Affirmations • Reflections • Summaries

48. Reflective Listening • Reflective listening is one of the hardest skills to learn. • “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002) • Involves listening and understanding the meaning of what the patient says • Accurate empathy is a predictor of behavior change

49. Summaries • Periodically summarize what has occurred in the Brief Intervention • Summary usages • Begin a session • End a session • Transition

50. Summaries (continued) • Strategic summary—select what information should be included and what can be minimized or left out. • Additional information can also be incorporated into summaries—for example, past conversations, assessment results, collateral reports, etc.