Screening, Brief Intervention, Referral, and Treatment (SBIRT) Training Session OB/GYN

1. Screening, Brief Intervention, Referral, and Treatment (SBIRT) Training SessionOB/GYN • Review of the scope of problems due to alcohol • Review of screening and effective interventions • Break • Video demonstration of brief negotiated intervention (BNI) • Role playing sessions (small group) and discussion • Complete post-program quiz

2. Several Truths • Practitioners are reluctant to screen and intervene • The primary care visit is an opportunity for intervention • Treatment works! • Timely referral is effective

3. Alcohol: Scope of the Problem Why should we care?

4. Alcohol is the most commonly used drug in the United States

5. Alcohol Fast Facts • Alcohol related deaths 75,000/year • Annual economic cost $185 billion • Homicides (alcohol involved) 60-70% • Suicides (alcohol involved) 40% • Fatal motor vehicle accident 50% • A risk factor for medical conditions • Hypertension, stroke, diabetes, liver, GI disease

6. Alcohol Fast Facts • Major risk factor for all categories of injury • Problem drinkers • Injuries per year 2x • Hospitalizations for injuries 4x hospitalizations for injury • Even one alcohol-related visit predicts continued problem drinking

7. Young Adults • Alcohol use in the past month • 8th grade 17% • 10th grade 33% • 12th grade 47% • Binge drinking (>5drinks in a row) in last 2 weeks • 8th grade 11% • 10th grade 21% • 12th grader 28% • Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org

8. Adults over 18 years • 10 million (5%) dependent drinkers • 40 million (20%) high risk drinkers • 70 million (35%) moderate drinkers • 80 million (40%) abstain National Longitudinal Alcohol Epidemiologic Survey, 1992

9. High risk “At-risk” drinkers

10. Issues unique to pregnancy • Prevalence of alcohol use 11% • Binge drinking in a previous month 2% • Prevalence of use (age 18-44)-non pregnant 55% • Binge drinking in a previous month 13% • Many not using contraception >50% • Pregnancy is a unique time, where motivation to reduce alcohol use may be higher. • 74% of women stop drinking during pregnancy.

11. Issues unique to pregnancy • No known safe levels of alcohol intake • No exact dose-response relationship • Binge drinking may be more concerning than similar volumes over time. • Increased stillbirth rate • <1 drink per week 1.37 per 1000 births • >/=1 drink per week 8.83 per 1000 births • Current U.S. recommendation: abstinence

12. Fetal alcohol syndrome (most severe) • Prevalence with heavy drinkers 10-50% • Offspring issues: • Leading cause of developmental delay in the US. • Growth problems (<10% at any point in time) • Facial dysmorphia • Microcephaly • Smooth philtrum, thin vermillion border, small palpebral fissures • Maxillary hypoplasia • Central nervous system abnormalities • Average IQ 63 • Fine motor dysfunction

13. Nation’s Public Health Agenda:Healthy People 2010 • Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department Ambulatory medical care survey

14. SCREENING

15. Screening for Alcohol use and abuse • ACOG Committee Opinion: Dec 2008 • “Obstetrician-gynecologists have an ethical obligation to learn and use a protocol of universal screening questions, brief intervention, and referral to treatment in order to provide patients with medical care that is state-of-the-art, comprehensive and effective. • Screening allows for early and effective treatment • Screening is cost-effective (saves $7 for every $ spent) • Primary care visit is an ideal opportunity to screen and intervene as necessary

16. UNIVERSAL SCREENING WIDENS THE NET ABSTAINERS & MILD DRINKERS (70%) MODERATE (20%) at risk drinkers SEVERE (10%) Specialized Treatment Brief Intervention Primary Prevention

18. ASK Current Drinkers • On average, how many days per week do you drink alcohol? • On a typical day when you drink, how many drinks do you have? • What is the maximum number of drinks you had on a given occasion last month?

19. Remember that a “standard drink” consists of:

20. Screen Positive: NIAAA Guidelines • Pregnant women 0 drinks

21. ASK Current Drinkers CAGE CCut Down A Annoyed G Guilty E Eye Opener

22. Detectionand Referral Does it matter?

23. What do we do? ABSTAINERS & MILD DRINKERS (70%) MODERATE (20%) at risk drinkers SEVERE (10%) Specialized Treatment Brief Intervention Primary Prevention

24. Brief negotiated intervention (BNI):A motivational interviewFor the “At-risk drinker”

25. Principles of Motivational Interviewing • Ask for permission to discuss problems • Express empathy and avoid arguments • Develop discrepancies • Help patients understand the differences between their behavior and their goals • Roll with resistance and provide personalized feedback • “Reflective listening” • Support self-motivation

26. Motivational Interviewing: A Tool for Behavior Change • ACOG Committee Opinion: Jan 2009 • The goal is to “help patients identify and change behaviors that place them at risk” • “motivational interviewing to everyday patient interactions has been proved effective in eliciting “behavior change” • “ACOG encourages the use of motivational interviewing as one approach to elicit behavior change.”

27. Fleming et al JAMA 1997 “Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices” • Randomized controlled trial 723 patients • 17 practices with 64 physicians • Intervention included: • Educational workbook, • 15 minute visits one month apart x 2 • Nurse follow-up calls x 2 (2 weeks after the visit)

28. Fleming et al JAMA 1997 • Results at 12 months (n=723) Alcohol consumption reduced with intervention: • Intervention group 19.1 drinks/wk  11.5 • Control group 18.9 drinks/wk  15.2 Episodes of binge drinking during prior 30 days: • Intervention group 5.7  3.1 • Control group 5.3  4.2

30. Brief Interventions are Effective…How do we do it?

31. Video: Scenario 1

32. Components of the Brief Negotiated Intervention • Raise the Subject • Provide Feedback • Enhance Motivation • Negotiate and Advise

34. Step 1: Raise the Subject • Establish Rapport • Raise the subject of alcohol use

35. Step 1: Establish Rapport • To understand the patient’s concerns and circumstances • “That car accident must have been scary” • “Having your boyfriend hurt you must be awful” • To explain the providers concern/role • I am concerned regarding the effect alcohol may be having on you. • To avoid a judgmental stance

36. Step 1: Raise the subject • Get the patient’s agreement to talk about the alcohol or drug use • Do you mind if we just take a few minutes to talk about your alcohol/drug use? • Talk about the pros and cons of their use/abuse • What is it that alcohol does for you? • Re-state what they have said regarding the pros and cons

37. Troubleshooting:What if the patient does not want to talk about their use/abuse ? “ Okay, I see you aren’t ready to talk about this today. Remember that we are here 24 / 7 if you change your mind”

38. Step 2: Provide Feedback • Review patient’s drinking patterns • “From what I understand you are drinking…”

39. Step 2: Provide Feedback • Make connection to the visit if possible • “What connection (if any) do you see between your drinking and this visit?” • If the patient sees a connection: • Reflect what they have just said. • If the patient does not see a connection: • Help make a connection with facts • “Alcohol can slow your reflexes and predispose you to accidents” • “Alcohol may impair your judgment and …..

40. Step 2: Provide Feedback • Compare to National Norms and offer NIAAA guidelines (show them)

41. Step 3: Enhance Motivation:Assess the readiness for change “On a scale of 1-10 (1 being not ready and 10 being very ready) how ready are you to change any aspect your drinking patterns?” 1 2 3 4 5 6 7 8 9 10

42. Step 3: Enhance MotivationDevelop Discrepancies • If patient indicates she is ready for change: > 2 : “Why did you choose that number and not a lower one? What are some reasons that you are so motivated to change.” • If patient indicates she is not ready for change: < 1: “Have you ever done anything that you wish you hadn’t while drinking: What would make this a problem for you.” Discuss pros and cons

43. Step 3: Enhance Motivation Develop DiscrepancyExplore Pros and Cons • Help the patient identify the discrepancy between present behavior and important goals • Use the discrepancy as a change motivator • Let the patient name the problem and offer solutions

44. The Ready Patient • Help the patient to: • Name a solution for themselves • Choose a course of action • Decide how to achieve it • Encourage patient choice

45. Don’t Use shame or blame Preach Label Stereotype Confront Do Offer information, support and further contact Present feedback and concerns, if permitted Negotiate: “What would it take you to consider a change ?” Not Ready for Change

46. Not Ready for Change Avoid arguments • Counter productive • Defending breeds defensiveness • Perceptions can be shifted • Labeling is unnecessary • Resistance is a signal to change strategies • Rolling with resistance

47. Don’t Jump ahead Give advice Expect argument about change Do Explore pros & cons “help me to understand what alcohol does for you” “Are there things you don’t like about your alcohol use?” Unsure patients

48. Step 4: Negotiate and Advise • Reinforce what the patient has stated are her goals. • “So… you would like to reduce your drinking to prevent….” • Negotiate the goal/Elicit a response • “What is the next step?” • Give advice • “If you can stay within the limits you just mentioned you will be less likely to have a car accident..” • Summarize • “This is what I heard you say..

49. Step 4: Negotiate and Advise • Provide handouts • Drinking agreements • Other support sources

50. Step 4: Negotiate and Advise • Suggest primary care follow up or referral • Social worker • Psychiatric services • Discharge sheet of possible centers and / or programs and information • Thank patient for their time