Screening, Brief Intervention, and Referral to Treatment (SBIRT )

1. Screening, Brief Intervention, and Referral to Treatment (SBIRT)

2. Training Overview Our goal for this training is to instruct providers in specific SBIRT procedures and to develop participants’ skills to deliver SBIRT in their practices. Resources Activities Outcomes • Didactic learning • Role plays • Group discussions • Brief assessment • Links to additional training • Develop skills to deliver SBIRT • Discuss implementation challenges and possible solutions • Integrate SBIRT in practice (long-term outcome) • Participants • Educational materials from ATTCs and other centers • Trainers

3. Pre-test Please complete the pre-test. Thank you!!

4. This course will teach you how to: Administer screening Deliver a brief intervention Employ a motivational approach Make referrals to specialized treatment

5. Activity 1: 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?

6. 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.

7. Benefits of SBIRT Substance abuse SBI may reduce alcohol and drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency departmentvisits, 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

8. 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”).

9. Benefits of SBIRT for Practice “I had a vague idea on how to assess substance use, but now I think I have a lot more knowledge in these other areas. I know what to look for and it is a way to give me a gauge to see if the person is at risk and how to approach them [about that risk].” Mental health clinician, UCLA Counseling and Psychological Services

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

11. The Key to Successful Interventions “I just kind of relate it by saying…there’s just a big connection with mood and substance use, so I talk about that more as they could be someone who is anxious and they’re drinking or smoking pot. The drug use could be intensifying as a problem even if they are not identifying their use as a problem. So just pointing that out to them in a motivational interviewing way by saying, why don’t you track this and see what’s happening with your depression. And it just opens another way of talking about it. Sometimes you can see them glaze over and think, ‘‘Oh here we go with the alcohol and drug part.’’ But when you start linking it with mood and anxiety then they are like ‘Oh OK’.” Mental health clinician, UCLA Counseling and Psychological Services

12. 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)

13. Activity 2: Adoption of SBIRT Can SBIRT work in your setting?

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

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

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

17. 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”

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

20. How do we define risk? See reference list

21. How do we define risk?What’s a “drink”? See reference list

22. 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

23. 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 See reference list

24. 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 See reference list

25. 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

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

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

28. 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

29. 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

30. Activity #3: 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. See reference list

31. Activity #3: AUDIT Practice Feedback? Reactions?

32. Scoring the Audit

33. 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) See reference list

34. 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

35. Brief Interventions for Patients at Risk for Substance Use Problems

36. What Are Brief Interventions? “Brief opportunistic 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.” See reference list

37. Common Elements FRAMES Personalized Feedback Responsibility Advice Menu of options Empathy Self-efficacy

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

39. 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. See reference list

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

41. 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences and determine what to do next 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change Stages of Change:Primary Tasks 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills for maintaining recovery 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate change strategies 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses

42. 1. Pre-contemplation 2. Contemplation 3. Determination 4. Action 5. Maintenance 6. Recurrence

43. “People are better persuaded by the reasons they themselves discovered than those that come into the minds of others”Blaise Pascal

44. Ambivalence All change contains an element of ambivalence. We “want to change and don’t want to change” Patients’ ambivalence about change is the “meat” of the brief intervention.

45. Motivational Interviewing Strategies Use reflective listening and empathy Avoid confrontation Explore ambivalence Elicit “change talk”

46. Activity 4: Video Example (1) Young man is treated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video? See reference list

47. Activity 4: Video Example (2) Same scenario, but different doctor. What does this doctor do that is different? Does it work? See reference list

48. Reflective Listening Listen to both what the patient says and to what the person means Show empathy and don’t judge what patient says You do not have to agree Be aware of intonation Reflect what patient says with statement not a question, e.g., “You couldn’t get up for work in the morning.”

49. Levels of Reflection Repeating – Repeating what was just said. Rephrasing – Substituting a few words that may slightly change the emphasis. Paraphrasing – Major restatement of what the person said. Listener infers meaning of what was said. Can be thought of as continuing the thought. Reflecting Feeling – Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

50. Avoid Confrontation • Challenging • “What do you think you are doing?” • Warning • “You will damage your liver if you don’t stop drinking.” • Finger-wagging • “If you want to be a good student, you must stop drinking on school nights.”