Integrating Care through the Use of Screening and Brief Intervention in HIV Settings

1. Integrating Care through the Use of Screening and Brief Intervention in HIV Settings TRAINER’S NAME TRAINING DATE TRAINING LOCATION

2. Training Collaborators Pacific AIDS Education and Training Center Charles R. Drew University of Medicine and Science University of California, Los Angeles Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs

3. Test Your Knowledge

4. Test Your Knowledge 1.What is the maximum number of standard drinks that are within the low-risk drinking range for a healthy, non-pregnant 35 year-old woman? No more than 1 drink per occasion No more than 2 drinks per occasion No more than 3 drinks per occasion No more than 4 drinks per occasion

5. Test Your Knowledge 2. Please identify what the 5-letters in the AUDIT acronym stand for: Alcohol Use Disease Inventory Test Alcohol Use Disorders Identification Test Alcohol Use Disorders Inventory Test Alcohol Use Disease Inventory Training

6. Test Your Knowledge 3. Because of the linkage between substance use and HIV, screening and brief intervention protocols have been adopted throughout the United States. True False

7. Test Your Knowledge 4. Brief interventions often include: Feedback about the patient’s drug and/or alcohol use Advice on how to cut down on one’s alcohol and/or drug use Motivational techniques A and B only All of the above

8. Introductions Briefly tell us: What is your name? Where do you work and what you do there? Who is your favorite musician or performer? What is one reason you decided to attend this training session?

9. What Will You Learn Today? This brief training course will teach you how to: Administer substance use screening Deliver a brief intervention Employ a motivational approach Make referrals to specialized treatment, if needed

10. 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?

11. 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.

12. Benefits of SBIRT Substance abuse SBI may reduce alcohol and drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency department visits, depression, drug-related infections and infectious diseases 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 DUIs, and improve neonatal outcomes

13. Benefits of SBIRT for Practice Increases clinicians’ awareness of substance use issues. Offers clinicians more systematic approach to addressing substance use (less of a “judgment call”).

14. The Key to Successful Interventions Brief interventions are successful when clinicians relate patients’ risky substance use to improvement in patients’ overall health and wellbeing.

15. Candidates for Routine Screening College students Primary care patients Mental health patients Patients in infectious disease clinics People with alcohol- or drug-related legal offenses (e.g., DUI)

16. Rationale for Conducting SBIRT in an HIV Care Setting

17. HIV in 2013 HIV is now considered a manageable, chronic illness HIV patients are living longer and facing multiple health issues in addition to their HIV disease Homelessness Disease progression Mental illness Substance abuse Engagement, retention, and adherence among HIV patients continues to present challenges to HIV care providers SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012).

18. Risks of Untreated Mental Health and Substance Use Problems Poorer adherence to treatment and medication regimens Higher hospitalization rates for medical complications Greater likelihood of treatment drop-out or being lost to follow-up Greater risk for opportunistic (re-) infection Greater risk of psychosocial problems Greater risk of suicide or accidental death SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012).

19. SBIRT in HIV Settings SBIRT in primary care settings is effective in changing behavior and preventing adverse outcomes attributable to alcohol and other drugs. People living with HIV are more likely than the general population to experience substance abuse problems. SBI protocols have not been readily implemented in HIV care settings. SOURCE: Fischer, L. (2012). Addiction Science & Clinical Practice, 7(Suppl1): A73.

20. SBIRT in HIV Settings SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012).

21. Impact of a Computer-Assisted SBIRT Program in an HIV Setting Implemented in San Francisco General Hospital’s Positive Health Program (PHP) in 2010-11: Most common substances reported were: tobacco (68%), alcohol (64%), cannabis (58%), cocaine (39%), amphetamines (37%), nonmedical sedative use (32%), and nonmedical opioid use (26%). SBI for unhealthy substance use is acceptable to patients in HIV primary care settings Significant decreases observed with amphetamines and sedatives; significant increase in number of patients with HIV viral suppression. SOURCE: Dawson Rose et al. (2012). IAC Poster.

22. Colorado's Ryan White Collaborative SBIRT Project Of 2,500 patients screened: 31% (n=775) received a BI for risky alcohol, tobacco, or drug use 23% (n=575) were referred for therapy or specialized treatment Recommendations for standardizing SBIRT in HIV settings include: Apply a systematic screening approach Train providers to conduct BI Establish a referral network Integrate SBIRT with adherence and retention efforts SOURCE: Fischer, L. (2012). Addiction Science & Clinical Practice, 7(Suppl1): A73.

23. Activity: Adoption of SBIRT 3 minutes Can SBIRT work in your setting? End

24. Screening to Identify Patients At-Risk for Substance Use Problems

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

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

27. 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”

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

29. 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)

31. What is a Standard Drink?

32. 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

33. 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

34. 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: Smith, P.C. et al. (2009). Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine, 24(7), 787-780 .

35. Pre-Screening Example NIDA 1-item for 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: Smith, P.C. et al. (2010). A single question screening test for drug use in primary care. Archives of Internal Medicine, 170, 1155-160.

36. Alcohol: Women = 0 – 2 Men = 0 – 4 Alcohol: Women = 4+ Men = 5+ Other Drugs: Any Yes Other Drugs: All Nos Alcohol Screen Complete Other Drug Screen Complete Administer the AUDIT Administer the DAST Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT SBI Decision Tree Complete Pre-Screen

37. Review of the AUDIT 10-question alcohol use screening instrument Original target groups included: Medical patients Accident victims DWI offenders Mental health clients Designed for primary health care workers

38. Domains of the AUDIT Hazardous Alcohol Use Question 1: Frequency of Drinking Question 2: Typical quantity Question 3: Frequency of heavy drinking

39. Domains of the AUDIT (cont.) Dependence Symptoms Question 4: Impaired control over drinking Question 5: Failure to meet expectations because of drinking Question 6: Morning drinking

40. Domains of the AUDIT (cont.) Harmful Consequences of Alcohol Use Question 7: Guilt after drinking Question 8: Blackouts Question 9: Alcohol-related injuries Question 10: Others’ concerns about drinking

41. Scoring the Audit

42. Activity: AUDIT Practice I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients. Your responses will be confidential. These questions help me to provide the best possible care. You do not have to answer them if you are uncomfortable.

43. Activity: AUDIT Practice (cont.) Feedback? Reactions?

44. Alcohol Screen Complete Other Drug Screen Complete Administer the AUDIT Administer the DAST Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT SBI Decision Tree

45. What about Screening for Oral Health? Start by asking two simple questions: Do you have a dentist? Do you have any mouth/oral pain or discomfort that interferes with your eating or speaking? SOURCE: Dr. Fariba Younai, UCLA School of Dentistry (personal communication, May 24, 2013.

46. Brief Interventions for Patients At-Risk for Substance Use Problems

47. What are Brief Interventions? “Brief…interventions are short, face-to-face conversations regarding drinking, motivation to change, and options for change which are provided during a window of opportunity or potentially teachable moment occasioned by a medical event.” SOURCE: Dr. Craig Field, University of Texas.

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

49. 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. A randomized study with cocaine and heroin users found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls. SOURCE: Bernstein et al. (2005). Drug and Alcohol Dependence, 77, 49-59.

50. Where Do I Start? What you dodepends on where the patient isin the process of changing. The first step is to be able to identify where the patient is coming from.