SBIRT

1. SBIRT

2. Learning Objectives At the end of the session, participants will be able to: • Understand SBIRT’s role in preventing the effect of substance abuse on individual and public health • Identify substance use risk limits • Identify how screening is conducted in a practice setting • Practice how to use two screening tools • IdentifyMIbasicsteps and core skills for the brief intervention • Demonstrateand practiceMIusingcore skills

3. What Is SBIRT? An intervention based on “motivational interviewing” strategies • Screening: Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse • Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users • Referral to Treatment: Referrals to specialty care for patients with substance use disorders Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment.

4. Leading Off: Defining the problem • Substance use: Inappropriate consumption of medicines, drugs. Alcohol, over the counter and prescription drugs. • Substance Misuse: consuming enough of a substance to put one’s physical or mental health at risk. • Substance Abuse: using a substance in a maladaptive pattern resulting in significant impairment or distress (e.g. significant negative impact with Family, school/work or legal status) • Substance Dependence: clinically significant impairment or distress as manifested by 3 or more of the following clinical criteria: Tolerance, withdrawal symptoms, substance taken in larger amounts than intended, unsuccessful attempts at decreasing use, disproportionate amount of time is spent on accessing and taking substance, important activities (social, occupational) are sacrificed to engage in use and continued use despite the person’s knowledge of the negative physiological and psychological effects the substance is having on their life.

5. Leading Off: Difference Between Abuse and Dependence • Abuse is too much, too often. Using substance at unsafe levels, but the person still able to avoid using when they need or want to. • Once a month binge drinking, and or drug use • Using is having an impact on one of these aspects of the person’s life: family/social, legal status, education/ employment. • Dependence is the inability to stop. The substance has become an integral, if not all encompassing, part of the person life. • Person to use or drink everyday or else they will experience withdrawal symptoms. • Person uses in the morning when they first wake up, or when they are at work. • Increased tolerance for substance of choice.

6. Alcohol vs Drug use: Key differences • Alcoholism tends to be insidious. Drug use can explode after several instances of using the substances • Drugs give a quicker, more intense high. • Increased risk of legal consequences for drug users. • More of a social stigma for drug users. • People with Alcohol Use Disorders can conceal their issues with more acceptable social rationale.

7. Detecting Risk Factors Early Screening can be a significant step toward effective intervention: • The clinician is often the first point of contact. • Early identification and intervention lead to better outcomes. • Patients are often seen by a clinician because of a related physical problem. Source: Treatnet. (2008). Screening, assessment and treatment planning.Retrieved from http://www.unodc.org/ddt-training/treatment/a.html

8. Based on Findings of Screening Dependent Use Harmful Use At-Risk Use Low Risk

9. Effectiveness of SBIRT • Data from SAMSHA grant programs demonstrate the impact of SBIRT on patient health: • Reduction in alcohol and drug use 6 months after receiving the intervention (41% of respondents reported abstinence from drugs and/or alcohol at follow-up, compared to 16% at baseline • Improvement in quality of life measures, including employment/education status, housing stability and 30-day past arrest rates (95% of respondents reported no arrests in the past 30 days at follow-up, compared to 88% at baseline) • Reduction in risky behaviors, including fewer unprotected sexual encounters (injection drug use decreased from 3.2% at baseline to 1.5% at follow-up)

10. A Positive Alcohol Screen= At-Risk Drinker Binge drink (5 for men or 4 for women/anyone 65+) Or patient exceeds regular limits? (Men: 2/day or 14/week Women/anyone 65+: 1/day or 7/week) YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT. NO Patient is at low risk.

11. How Much Is “One Drink”? 5-oz glass of wine (5 glasses in one bottle) 12-oz glass of beer (one can) 1.5-oz spirits 80-proof 1 jigger Equivalent to 14 grams pure alcohol

12. AUDITAlcohol Use Disorders Identification Test • What is it? • Ten questions, self-administered or through an interview; addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems • Developed by World Health Organization (WHO)

13. AUDITAlcohol Use Disorders Identification Test • What are the strengths? • Public domain—test and manual are free • Validated in multiple settings, including primary care • Brief, flexible • Focuses on recent alcohol use • Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use • Limitations? • Does not screen for drug use or abuse, only alcohol

14. Scoring the AUDIT Dependent Use (20+) Harmful Use (16‒19) At-Risk Use (8‒15) Low Risk (0‒7)

15. Prescription Drug Misuse Although many people take medications that are not prescribed to them, we are primarily concerned with— • Opioids (oxycodone, hydrocodone, fentanyl, methadone) • Benzodiazepines (clonazepam, alprazolam, diazepam) • Stimulants (amphetamine, dextroamphetamine, methylphenidate • Sleep aids (zolpidem, zaleplon, eszopicione) • Other assorted (clonidine, carisoprodol)

16. Common Illicit Drugs • Marijuana (Cannabinoids): psychological dependence. • Crack/Cocaine (Stimulants): short half-life, fast withdrawal. • Heroin (Opioids): effects similar to prescription opioids. • Crystal Methamphetamine (Stimulants : Fast addiction, MSM. • Ecstasy (Club Drug) • LSD, Shrooms (Hallucinogens): small chance of dependence.

17. Common Illicit Drugs • Marijuana: psychological dependence. • Crack/Cocaine: short half-life, fast withdrawal. • Heroin: effects similar to prescription opioids. • Crystal Methamphetamine: Fast addiction, MSM. • Ecstasy: Club Drug • LSD, Shrooms: small chance of dependence.

18. Prescreening for Drugs • “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” • (…for instance because of the feeling it caused or experiences you have…) • If response is, “None,” screening is complete. • If response contains suspicious clues, inquire further. • Sensitivity/Specificity: 100%/74% • Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Arch Intern Med ,170(13), 1155−1160.

19. A Positive Drug Screen • ANY positive on the drug prescreen question puts the patient in an “at-risk” category. The followup questions are to assess impact and whether substance use is serious enough to warrant a substance use disorder diagnosis. • Ask which drugs the patient has been using, such as • cocaine, meth, heroin, ecstasy, marijuana, opioids, etc. • Determine frequency and quantity. • Ask about negative impacts.

20. Scoring the DAST(10)Drug Abuse Screening Test High Risk (6+) Harmful Use (3‒5) Hazardous Use (1‒2) Abstainers (0)

21. TOLERANCE – HOW MANY DRINKS DOES IT TAKE TO MAKE YOU FEEL HIGH? 2 OR MORE = 2 POINTS WORRY – HAVE CLOSE FRIENDS WORRIED OR COMPLAINED ABOUT YOUR DRINKING IN THE PAST YEAR? YES = 1 POINT EYE – OPENER – HAVE YOU EVER HAD A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR GET RID OF A HANGOVER? YES = 1 POINT AMNESIA – HAS ANYONE EVER TOLD YOU ABOUT THINGS THAT YOU SAID OR DID WHILE DRINKING THAT YOU DO NOT REMEMBER? YES = 1 POINT KUT DOWN – HAVE YOU FELT YOU OUGHT TO CUTDOWN ON YOUR DRINKING? YES = 1 POINT TWEAK Screening Tool

22. CRAFFT- Adolescent Screening tool • Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? • Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? • Do you ever use alcohol or drugs while you are by yourself ALONE? • Do you ever FORGET things you did while using alcohol or drugs? • Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? • Have yo ever gotten into TROUBLE while you were using alcohol or drugs?

23. Key Points for Screening • Screen everyone. • Screen both alcohol and drug use including prescription drug abuse and tobacco. • Use a validated tool. • Prescreening is usually part of another health and wellness survey. • Explore each substance; many patients use more than one. • Follow up positives or "red flags" by assessing details and consequences of use. • Use your MI skills and show nonjudgmental, empathic verbal and nonverbal behaviors during screening.

24. MotivationalInterviewing StepsandCoreskills

25. Definition of Motivational Interviewing “Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

26. Applications of MotivationalInterviewing • MI enhances change for a range of behaviors: • Diet • Exercise • Reduction of alcohol and illicit drugs • Safer sex practices • Medication adherence • (Burke et al., 2003; Hettema et al., 2005; Rubak et al., 2005).

27. Four Stepsof theMIProcess 1.Engage (Express Empathy, Ask Open-Ended Questions) 2.Focus (Reflecting, Summarizing) 3.Evoke (Motivations, Concerns) 4.Plan (Raise Subject, Support Self-Efficacy)

28. Spirit of Motivational Interviewing • Collaborative (not confrontation) • - Developing a partnership in which the patient’s expertise, perspectives, and input are central to the consultation • - Fostering and encouraging power sharing in the interaction • Evocative • - Motivation for change resides within the patient • - Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals

29. Spirit of Motivational Interviewing • Respectful of autonomy (not authority) • - Respecting the patient’s right to make informed choices facilitates change • - The patient is in charge of his/her choices and responsible for the outcomes • - Emphasize patient control and choice • Compassionate • - Empathy for the experience of others • - Desire to alleviate the suffering of others • - Belief and commitment to act in the best interests of the patient

30. Stages of Change Prochaska & DiClemente (1984)

32. MotivationalInterviewing Coreskills

33. Core MI Skills • Open-Ended Questions • Affirmations • Reflections • Summaries

34. Open-EndedQuestions • Using open-endedquestions— • Enablesthe patienttoconveymore information • Encouragesengagement • Opensthe doorfor exploration

35. Open-EndedQuestions • Whatareopen-endedquestions? • Gatherbroaddescriptiveinformation • Requiremoreofa responsethana simple yes/noor fill intheblank • Oftenstartwithwordssuchas— • “How…” • “What…” • “Tell meabout…” • Usually gofromgeneral tospecific

36. Closed-EndedQuestions PresentConversationalDead Ends • Closed-endedquestions • typically— • Are for gatheringvery specific information • Tendtosolicityes-or-noanswers • Convey impression that the agenda is not focusedonthe patient

37. Closed-EndedQuestions • Avoid “Why?” Questions • Putspatientin a passive, or defensive,role • No opportunityfor patient toexploreambivalence

38. Learning Exercise Turningclosed-endedquestionintoan open-endedone. Doyoufeeldepressed oranxious?

39. Affirmations • What is anaffirmation? • Complimentsorstatementsof appreciationandunderstanding • Praisepositivebehaviors • Supportthe personastheydescribe difficult situations

40. Affirmations • Why affirm? • Supportandpromoteself-efficacy,prevent • discouragement • Buildrapport • Reinforce openexploration • (patienttalk) • Caveat • Mustbedonesincerely

41. AffirmationsMayInclude: • Commentingpositivelyonanattribute: • "Youare determinedtogetyourhealth back.” • A statement ofappreciation: • "Iappreciate youreffortsdespitethediscomfort • you’rein." • A compliment: • "Thankyouforall yourhardwork today."

42. Learning Exercise Provide an affirmation for each given patient scenario.

43. Reflective Listening Reflectivelisteningis oneofthe hardestskillstolearn. “Reflectivelisteningis away of checkingratherthanassumingthat you know whatismeant.” (MillerandRollnick, 2002)

44. Reflective Listening • Why listenreflectively? • Encouragesfurtherexplorationofproblemsand feelings • Demonstratesthatyou have accurately heard andunderstoodthe patient • Strengthensthe • empathicrelationship • Canbeusedstrategicallytofacilitate change

45. Levels ofReflection • SimpleReflection—staysclose • Rephrasing(substitutessynonyms) • Example • Patient: Ihear whatyouare sayingabout my drinking,butIdon’tthinkit’ssucha bigdeal. • Clinician:So,atthismomentyouare nottooconcernedaboutyourdrinking.

46. Levels ofReflection • Complex Reflection—makes a guess • – Paraphrasing—majorrestatement,infersmeaning, “continuingtheparagraph” • Examples • Patient:“Whoareyouto begivingmeadvice?Whatdoyouknowabout drugs?You’veprobablyneverevensmokedajoint! • Clinician:“It’shard to imaginehowIcouldpossiblyunderstand.” • *** • Patient:“Ijustdon’twanttotakepills. Ioughtto beableto handlethison my • own.” • Clinician:“Youdon’twantto rely onadrug.Itseemsto youlike acrutch.”

47. Levels ofReflection • ComplexReflection • – Reflection offeeling—deepest • Example • Patient:My wifedecidednottocometoday.Shesaysthisis my problem,andI needto solveit orfindanewwife.After alltheseyearsof my usingaround her,nowshewantsimmediatechangeanddoesn’twantto helpme! • Clinician:Herchoosingnottoattendtoday’smeetingwasabig • disappointmentforyou.

48. Learning Exercise Turningpatient statements into reflections Ex: Work has been hectic and some wine helps me relax.

49. Summaries • Periodicallysummarizewhat has • occurredinthevisit. • Summaryusages • Beginasession • End a session • Transition

50. Summaries • Strategicsummary—selectwhat information shouldbe includedandwhat can be minimized or leftout. • Additionalinformationcan also be incorporated intosummaries—for example,past conversations, assessment results, collateral reports, etc.