Screening, Brief Intervention & Referral to Treatment

1. Screening, Brief Intervention & Referral to Treatment Thomas E. Freese, PhD, & Beth Rutkowski, MPH UCLA Integrated Substance Abuse Programs UCLA David Geffen School of Medicine, Dept. of Psychiatry Pacific Southwest Addiction Technology Transfer Center www.uclaisap.org www.psattc.org

2. Training Goals Increase knowledge of screening and brief intervention concepts and techniques Introduce and practice screening and identification skills Review Motivational Interviewing Skills needed for doing Brief Interventions Develop skills to deliver the F.L.O. Brief Intervention

3. Quick Activity: Reflection Take some time to think about the most difficult change that you had to make in your life. How much time did it take you to move from considering that change to actually taking action?

4. We Don't Ask and We Don't Know What to Do Substance use problems are often unidentified In one study of 241 trauma surgeons, only 29% reported screening most patients for alcohol problems* In another study of 1,082 primary care physicians and psychiatrists, 68% routinely screened for drug use** 55% reported making formal referrals when drug abuse was found 15% reported doing nothing

5. Medical Consequences of Substance Abuse Substance abuse is a leading cause of illness and death. It can: Lead to unintentional injuries and violence. Exacerbate medical conditions (e.g. diabetes, hypertension, sleep disorders). Exacerbate neuropsychiatric disorders (e.g. depression, sleep disorders). Induce medical diseases(e.g. stroke, dementia, cancers). Result in infectious diseases and infections (e.g. HIV, Hepatitis C). Affect the efficacy of prescribed medications. Be associated with abuse of prescription medications. Result in low birth weight, premature deliveries, and developmentaldisorders. Result in dependence, which may require multiple treatment services. Conclusion: Substance abuse has a major impact on public health

6. 51.8% → Alcohol • Substance Abuse Challenges: • 22.5 Million Americans Are Current* Users of Illicit Drugs SOURCE: SAMHSA, 2011 National Survey on Drug Use and Health (released in 2012).

7. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services • For persons with substance use disorders • Those who are at risk of developing these disorders Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur

8. SBIRT Goals Increase access to care for persons with substance use disorders and those at risk of substance use disorders. Foster a continuum of care by integrating prevention, intervention, and treatment services. Improve linkages between health care services and alcohol/drug treatment services.

9. SBIRT: Review of Key Terms Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that raises awareness of risks and motivates client toward acknowledgement of problem. Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help. Referral:Procedures to help patients access specialized care.

10. Brief Intervention Effect Brief interventions trigger change. A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min. Research is less extensive for illicit drugs, but promising.

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

12. Substance Use Problems among Mental Health and/or Primary Care Populations SBIRT SBIRT

13. Rationale for Screening and Brief Intervention

14. Rationale for Screening and Brief Intervention Substance abuse problems are widespread worldwide. Substance use problems are associated with significant morbidity and mortality. Early identification and intervention can help reduce substance use problems.

15. Top 10 Risk Factors for Disease Globally Underweight Unsafe sex High blood pressure Tobacco consumption Alcohol consumption Unsafe water, sanitation, and hygiene Iron deficiency Indoor smoke from solid fuels High cholesterol Obesity

16. Injection Drug Use and HIV Injection drug use (IDU) has played a role in the global diffusion of HIV infection. Globally, between 5% and 10% of HIV infections result from IDU In Asia and Europe, over 70% due to IDU IDU is the dominant mode of transmission of hepatitis C virus SOURCE: UNODC, 2004.

17. Problems Related to Substance Use Acute intoxication (immediate effects from use): Physical Overdose Fever, vomiting Behavioral Accidents and injury Aggression and violence Unintended sex and unsafe sexual practices Reduced work performance

18. Problems Related to Substance Use Effects of regular use include: Specific physical and mental health problems Increased risk for infectious diseases Psychiatric symptoms Sleep problems Financial difficulties Legal, relationship, or work problems Risk of dependence Withdrawal symptoms when use is reduced or stopped

19. Benefits of Screening and Brief Intervention

20. Benefits of Screening and Brief Intervention

21. Benefits of Screening and Brief Intervention $1 Spent Saves $2-4

22. Benefits of Screening and Brief Intervention Neonatal Outcomes Work Performance

23. SBIRT for Alcohol: Major Impact of SBI on Morbidity and Mortality

24. SBIRT for Alcohol: Saves Healthcare Costs

25. The Key to Successful Interventions Brief interventions are successful when clinicians relate patients’ risky substance use to improvement in patients’ overall health andwell-being.

26. Specialized Treatment Distribution of Alcohol (or Drug) Problems Brief Intervention Prevention

27. 2M people (0.8%) receiving treatment* 21M people (7%) have problems needing treatment, but not receiving it* ≈ 60-80M people (≈20-25%) using at risky levels US Population: 307,006,550 US Census Bureau, Population Division July 2009 estimate 28 *NSUDH, 2008

28. In treatment (2 Million) • Diagnosable problem with substance use • Referred to treatment by:* • Self/Family 37% • Criminal Justice 25% Other SUD Program 8% • County Assessment Center 19% Healthcare 3% • Other 8% Healthcare 3% 29 *Los Angeles County Data

29. In need of treatment (21 Million) • Reported problems associated with use • Not in treatment currently • 1.1% Made an effort to get treatment • 3.7% Felt they needed treatment, but made no effort to get it. • 95.2% Did not feel that they needed treatment Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are unaware of the problem or do not feel they need help. 30

30. Using at risky levels (60-80 Million) • Do not meet diagnostic criteria • Level of use indicates risk of developing a problems. • Some examples… These people need services, but will never enter the treatment system Drinks 3-4 glasses of wine a few times per week Adolescent smokes marijuana with his friends on weekends Pregnant woman occasionally has a shot of vodka to relieve stress Occasionally takes one or two extra Vicodinto help with pain 31

31. Implications As long as specialty care programs (SUD treatment programs) are the only places which address SUD: Most people with severe problems will not receive treatment Virtually all people with risky use will not receive professional attention

32. Locations for Routine Screening Primary care settings Emergency rooms/trauma centers Prenatal clinics/OB-GYN offices Medical specialty settings for diabetes, liver, and kidney disease/transplant programs Pediatrician offices College health centers Mental health settings Infectious disease clinics Drinking driver programs

33. Activity: Adoption of SBIRT How will SBIRT work in your setting? Form a group of 2-3; Identify 1-2 barriers and 1-2 facilitators of SBIRT adoption within in your work setting

34. Screening to Identify Patients At Risk for Substance Use Problems

35. What is a Standard Drink?

36. Drinking Guidelines • Men: No more that 4 drinks on any day and 14 drinks per week • Women: No more than 3 drinks on any day and 7 drinks per week • Men and Women >65: No more than 3 drinks on any day and 7 drinks per week NIAAA, 2011 285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 3.5 oz 1.5 oz

37. What’s going on in these pictures? Assessment Screening

38. Types of Screening Tools Self-report Interview Self-administered questionnaires Biological markers Breathalyzer testing Blood alcohol levels Saliva or urine testing Serum drug testing

39. Characteristics of a Good Screening Tool Brief (10 or fewer questions) Flexible Easy to administer, easy for patient Addresses alcohol and other drugs Indicates need for further assessment or intervention Has good “sensitivity” and “specificity”

40. Sensitivity and Specificity Sensitivity refers to the ability of a test to correctly identify those people who actually have a problem, e.g., “true positives” Specificity is a test’s ability to identify people who do not have a problem, e.g., “true negatives” Good screening tools maximize sensitivity and reduce “false positives”

42. Menu of Screening Tools • BAC/Drug Screen (biological measures) • Pre-Screens (1 question) • CAGE(4 questions) • CRAFFT(6 questions) • DAST (10 questions) • AUDIT(10 questions) • AUDIT-C+ (5 questions) • ASSIST (8 questions for each substance used)

43. Screening Tools • BAC/Drug Screen • Pre-Screens • CAGE • CRAFFT • DAST • AUDIT • AUDIT-C+ • ASSIST

44. Benefits of Self-Report Tools Provide historical picture Inexpensive Non-invasive Highly sensitive for detecting potential problems or dependence

45. Enhancing Accuracy of Self-Report Self-reports are more accurate when people are: Alcohol- or drug-free when interviewed Told that their information is confidential Asked clearly worded, objective questions Provided memory aides (calendars, response cards)

46. Pre-screening Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief intervention. Self-report, 1-4 questions Biological, blood alcohol level test

47. Pre-screening Example NIAAA 1-item for alcohol use “How many times in the past year have you had X or more drinks in a day?” • Identifies unhealthy alcohol use • Positive screen > 1 or more (provide BI) 5 for men 4 for women SOURCE: Barclay, L. (2009). Single screening question may accurately identify unhealthy alcohol use. Journal of General Internal Medicine.

48. Pre-screening Example NIDA 1-item for illicit drug use "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Identifies overall drug use Positive screen = 1 or more SOURCE: Barclay, L. (2010). Single screening question may identify drug use in primary care. Archives of Internal Medicine, 170: 1155-160.

49. Screening Tools • BAC/Drug Screen • Pre-Screens • CAGE • CRAFFT • DAST • AUDIT • AUDIT-C+ • ASSIST

50. Screening Tools • BAC/Drug Screen • Pre-Screens • CAGE • CRAFFT • DAST • AUDIT • AUDIT-C+ • ASSIST