The ASOC Training Series (draft)

1. Los Angeles County Department of Mental Healthwith support from SAMHSA/CSAT Presents:Screening, Brief Intervention, and Referral to Treatment (SBIRT): How to Identify and Motivate for Change Patients with Substance Use Disorders

2. The ASOC Training Series (draft) • On-site SBIRT training at DMH directly operated ASOC programs • Encourage clinical supervisors and/or SBIRT champions to walk through their agency to determine implementation issues • Follow-up with clinical supervisors/ champions via webinar/telehealth network to consult on implementation

3. Why SBIRT and Why now? • The service population will be increasing greatly. Therefore efficiency of service is critical • ACA is expanding SUD benefit and there will be more specialty care services available • SBIRT can help to incorporate screening, intervention and referral for treatment for substance use into the overall clinic redesign plan for your clinic • Help in engaging in referring people more efficiently into appropriate EBPs • Screening will help with overall treatment planning and treating to target

4. Objectives Describe the background and rationale for conducting SBI in medical settings Describe screening procedures for identifying patients engaged in at-risk drinking Review brief intervention strategies and techniques

5. Consider the patients that you treat What are the characteristics of the ones …who are the most difficult? …who you see the most often?

6. 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, mental health clinics and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur

7. SBIRT: Core Clinical Components • Screening: Very brief screening that identifies substance related problems • Brief Intervention: 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: Referral of those with more serious addictions

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 mental health services, health care services and alcohol/drug treatment services

9. Screening in medical settings… Substance abuse problems are often unidentified • In one study of 241 trauma surgeons, only 29% reported screening most patients for alcohol problems.* • In a health study of 7,371 primary care patients, only 29% of the patients reported being asked about their use of alcohol or drugs in the past year.** (Sources: *Danielsson et al., 1999; **D’Amico et al., 2005)

10. What is a standard drink?

11. 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

12. Is it really a problem? Prevalence of problematic alcohol and other drug use

13. 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 *NSUDH, 2008

14. 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% *Los Angeles County Data

15. 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

16. 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 vicodin to help with pain

17. SBI Procedures:Follow-up Action Depends on Score Screening Score Negative Screen Positive screen Positive Reinforcement Moderate Use Moderate/High Use Abuse/Dependence Brief Intervention Brief Treatment Referral to Treatment

18. Screening and Brief Interventions in Healthcare Settings Work Substance abuse SBI may reduce alcohol and other drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency dept visits, depression Health care costs Studies have indicated that SBI for alcohol saves $2 - $4 for each $1.00 expended Other outcomes SBI may reduce work-impairment, reduce DUI, and improve neonatal outcomes, decrease mental health symptoms, improve quality of life References provided in subsequent slides

19. SBI Could Have a Major Impact on Public Health There are grounds for thinking SBI may: • stem progressionto dependence. • Prevent/improve mental health conditions exacerbated by substance abuse. • Prevent/improve medical conditions resulting from substance abuse or dependence. • reduce drug-related infections and infectious diseases. • improve response to medications. • have positive influence on social function.

20. Screening to Identify Patients at risk for Alcohol Problems How do we conduct the screening?

21. Alcohol Problems Among Trauma Patients SBIRT SBIRT

22. Coding for Screening andBrief Intervention Reimbursement

23. Coding for Screening andBrief Intervention Reimbursement

24. What is screening? • A range of evaluation procedures and techniques to capture indicators of risk • A preliminary assessment that indicates probability that a specific condition is present • A single event that informs subsequent diagnosis and treatment (Source: SAMHSA, 1994)

25. Brief Intervention Effect • Brief interventions can trigger change • 1 or 2 sessions can yield much greater change than no counseling • A little counseling can lead to significant change • Brief interventions can yield outcomes that are similar to those of longer treatments

26. The Concept of Motivation • Motivation is influenced by the clinician’s style • Motivation can be modified • The clinician’s task is to elicit and enhance motivation • “Lack of motivation” is a challenge for the clinician’s therapeutic skills, not a fault for which to blame our clients

27. The Concept of Ambivalence • Ambivalence is normal • Clients usually enter treatment with fluctuating and conflicting motivations • They “want to change and don’t want to change” • “Working with ambivalence is working with the heart of the problem”

28. So…What is the best way to ask?

29. Single-Item alcohol screener • Primary care setting Validated single item • Single item recommended by NIAAA • “How many times in the past year have you had 5/4 or more drinks in a single setting?” • Smith, P., Schmidt, S., Allensworth-Davies, D., & Saitz, R. (2009)

30. Single-Item drug screener • "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?" • A response of at least 1 time was considered positive for drug use • Smith, PC, Schmidt, SM, Allensworth-Davies, D, & Saitz, R. (2010)

32. Review: LAC DMH Assessment

34. Conducting the Brief Intervention

35. Example of the Directing Style

36. The 3 Tasks of a BI F L O W Avoid Warnings! Warn Feedback Options Explored Listen & Understand (that’s it)

37. How does it all fit together?

38. Example of the Guiding Style

39. The 3 Tasks of a BI F L O Feedback Options Explored Listen & Understand

40. The First Task: Feedback • Your job in F is only to deliver the feedback! • Let the patient decide where to go with it. • Ask for Permission explicitly • There’s something that concerns me. • Would it be ok if I shared my concerns with you? • Provide direct feedback • The results of your screening form suggest that…

41. SUD Chronic Anxiety Anxiety Family SUD Pain Medical Issues

42. Providing Feedback Elicit (ask for permission) Give feedback Elicit again (the person’s view of how the advice will work for him/her)

43. Ambivalence is Normal The 2nd Task: Listen & Understand

44. The Second Task: Listen and Understand • Change Talk • DESIRE: I want to do it. • ABILITY: I can do it. • REASON: I can’t afford to lose my job. • NEED: I have to do it. • COMMITMENT!!! I WILL DO IT.

45. The Second Task: Listen and Understand • Tools for Change Talk • Pros and Cons • Importance & Confidence Scales • Readiness Ruler

46. Avoid questions that inspire a yes/no answer. How to Explore Ambivalence Summarize both pros and cons… “On the one hand you said.., and on the other you said….

47. The Second Task: Listen and Understand • Importance/Confidence/Readiness • On a scale of 1–10… • How important is it for you to change your drinking? • How confident are you that you can change your drinking? • How ready are you to change your drinking? • For each ask… • Why didn’t you give it a lower number? • What would it take to raise that number? 1 2 3 4 5 6 7 8 9 10

48. SUD SUD Sadness Physical Problem Family Social Isolation Mental Health Social Isolation

49. The Third Task: Options for Change Offer a Menu of Options Manage your drinking (cut down to low-risk limits) Eliminate your drinking (quit) Never drink and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment)

50. The Third Task: Options for Change The Advice Sandwich Ask permission Give Advice Ask for Response