Screening, Brief Intervention and Referral to

Treatment 1

Roy E. Smith, MDAddiction Medicine

1

Disclosure

• Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity.

• My content will not include discussion/ reference to commercial products or services.

• I do not intend to discuss unapproved/ investigational use of commercial products or services.

2

Module I: Introduction to SBIRT

Prevalence And Population Estimates Of Past Year Substance Use And Dependence : US Adults 18 Years And Older (200 Million)

USERS ADDICTED USERS

2001-2002 Wave I NESARC

3

Substance % Number % Number

Alcohol 65.44 136,035,000 5.82 7,911,000

Tobacco 26.66 57,503,000 46.13 26,525,000

Illicit Drugs 9.81 20,422,000 8.6 1,625,000

Marijuana 4.07 8,468,000 7.96 674,000

Opiates 1.81 3,756,000 6.3 237,000

Sedatives 1.24 2,583,000 5.42 140,000

Tranquilizers 0.93 1,940,000 5.04 98,000

Cocaine 0.56 1,169,000 23.91 279,000

Amphetamines 0.49 1,019 14.34 146,000

Inhalants/Solvents 0.11 220,000 1.04 2,400

Heroin 0.03 64,000 26.96 17,000

What is SBIRT?

SBIRT is a comprehensive, integrated, health approach to the delivery of early intervention and treatment services for:

For persons with substance use disordersThose who are at risk of developing these disorders

Primary care, mental health, ER and other community settings provide opportunities for intervention with at-risk substance usersBefore more severe consequences occur

SBIRT: Core Clinical Components

Screening: Very brief screening that identifies substance related problems

Brief Intervention: Raises awareness of risks and motivates patients to acknowledge & address problem. 1- 2 sessions of 5-8 minutes.

Brief Treatment: Cognitive Behavioral Therapy/MET with patients with higher risk or early dependence. 2-6 sessions of 30 minutes.

Referral: Referral of those with more serious addictions to specialized treatment services.

SBIRT Method

+ positive

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 primary and behavioral services

Improve linkages between health care services and alcohol/drug treatment services

19.7Any Illicit Drug

9.014.6

Any Illicit Drug, not marijuana

Marijuana

0.7

2.46.4

Crack

Psychotherapeutics (non-medical use)Cocaine

(in millions)0.5

0.50.6Inhalants

Meth

Ecstasy

0.10.1LSD

Heroin*past month users

0 5 10 15 20

Substance Abuse Challenges: 19.7 Million Americans Are Current* Users of Illicit Drugs

Conclusion: Increase in non-medical use of prescription drugs among 18 – 25 year olds since 2002.

Non-medical use of opioid analgesics is most significant contributor to the problem.

Substance Abuse Challenge:Non-Medical Use of Psychotherapeutics

Sources of Opioid Pain Relievers Used Non-Medically

(Accounts for 73% of prescription drug abuse)

Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006

Substance Abuse Challenge:Prescription Drug Sources: Primarily Friends or Family

Who are targets for

SBI?

Note: represents the general adult population in the US. The % ofhigh-risk drinkers is likely to be much higher in certain settings such as emergency or trauma departments.

Use of SBIRT Among At-Risk Patients

Severe Problem Drinkers

SBIRT

Hazardous & Harmful DrinkersSBIRT

Non-Drinkers or Low Risk Drinkers

SBI Could Have a Major Impact on Public Health

There are grounds for thinking SBI may:

stem progression to dependence.

improve medical conditions exacerbated by substance abuse.

prevent medical conditions resulting from substance abuse or dependence.

reduce drug-related infections and infectious diseases. identify

those at higher risk of abusing prescription drugs. identify

abusers of prescription drugs or OTC drugs.

have positive influence on social function.

Effectiveness of SBIRT

Meta analyses of 29 controlled trials in >7000 patients found BI superior to controls in ↓ drinking ( -38 gm/wk) at 12 months (Kaner et al, 2011)

Meta analyses of 19 controlled trials in 5639 patients found BI is effective (20% > controls) in ↓ alcohol use at 6 &12 months (Bertholet et al, 2005)

SAMHSA study: 459,000 patients in 6 states treated with SBIRT: 68% ↓ in drug use and 38% ↓ in heavy drinking at 6 months ( Madras et al, 2009)

Medical Outcomes for SBIRT

BI reduce mortality rates among problem drinkers by 23% to 26% (Cuijpers et al, 2004).

Compared to controls, BI group had significantly fewer alcohol related accidents, and hospital visits (Fleming et al, 2002).

NIAAA multisite controlled trial of BI in ER settings found BI was effective in reducing drinks per week at 3-months but not 6 & 12 months (Aseltine et al, 2010)

SBIRT in Texas: Insight project

8500 patients in Texas received BI. At 6-month follow up:

71% ↓ the number of days they drank alcohol

85% of binge drinkers ↓ number of heavy drinking days

68% reported no heavy drinking days in the past 30 days

89% of drug users ↓ the number of days they used drugs

80% of drug users reported no usage in the past 30 days

www.insightforhealth.com

Effectiveness of SBIRT

68-98% of patients with alcohol abuse are not detected in primary care.

4-8 of With SBIRT, 1-3 patientspatients

every week

patients are at risk

(10-20%)will lower their risk

Wilson et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005

If you see 40

Cost-Effectiveness of SBIRT

In a trauma center analysis (Gentillo et al, 2005) Every $$ spent on SBI saved $3.81 in direct injury costs Potential net savings of offering SBIRT to eligible trauma

patients would approach $1.82 billion/year

In community clinic analysis (Fleming, 2000) SBIRT cost/patient=$177, Cost savings/patient=$1170 Benefit /cost ratio= 5.6:1 Generated ~ $5630 in savings for every $1000 invested In medical costs alone, the benefit-to-cost ratio of brief

intervention was 3.2:1 over a 12-month period.

Role of the Healthcare Professional in SBIRT

1. Identification of misuse through screens

2. Present Screen results and feedback

3. Advice on Consumption reduction

4. Conduct or refer for Brief Intervention

5. Referral for formal assessment and specialised addiction services

Barriers to Screening & Intervention

Not having enough time to carry the out interventions.

No reimbursement for the screening.

Discomfort with initiating discussion about substance use.

Lack of training about substance misuse or treatment.

Inadequate referralresources for treatment

Fear of losing oralienating patients.

SBIRT module 2

Roy E. Smith, MDAddiction Medicine

22

Disclosure

Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity.

My content will not include discussion/ reference to commercial products or services. I do not intend to discuss unapproved/ investigational use of commercial products or services.

23

Module II: Screening in SBIRT

Most often they don’t

Focus on symptoms not the behaviors

Wrong questions – “do you drink too much?”

ConfrontationalShame and Blame

Tell the patient to quit

SBIRT facilitates doctor-patient communication using Motivational Interviewing techniques to promote change in behavior.

Usual Ways physicians talk to patients about alcohol and drug use

Paradigm Shift in SBIRT

Substance use disorders range on a continuum of no use to dependence

Earliest possible intervention

Target at-risk as well as dependent populations

“Meeting patients where they are”: Stage of Change model.

Basic Steps in Screening

Introduce the screen

Be specific in screen questions

Make sure screen questions reflect the same language as the patient

Convey non-judgmental attitude presenting screen results no matter what the answers are

Clinician barriers to screening for substances

57.7% Belief that patients lie

35.1% Time constraints

29.5% Fear that it will question patient’s integrity

25% Fear of frightening/angering patient

15.7% Uncertainty about treatments

12.6% Personally uncomfortable with subject

11%

May encourage patient to see other MD

10.6% Insurance doesn’t reimburse PCP time

CASA: Missed Opportunity: National Survey of Primary Care Physicians andPatients on Substance Abuse, April 2000

Agree/Strongly Agree

“If my doctor asked me how much I drink, Iwould give an honest answer.”

92%“If my drinking is affecting my health, my doctor should advise me to cut down on alcohol.”

96%“As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.”

93%Disagree/Strongly Disagree

how much alcohol I drink.” 86%

78%

Miller, PM, et al. Alcohol & Alcoholism; 2006

Overcoming barriers to screening: survey on patient attitudes to screening

“I would be annoyed if my doctor asked me“I would be embarrassed if my doctor asked me how much alcohol I drink.”

Screening

Use brief, validated instruments Universal and routine Goal to detect & assess severity of substance use AUDIT: Alcohol Use Disorders Identification Test DAST: Drug Abuse Screening Test Other tests: CAGE, ASSIST, CAGE-AID Urine Drug Screens, Blood tests (LFT, CDT) Self reports are reliable and valid screening tools 70% of patients comfortable with alcohol screens

Drinking Patterns

Abstinent

Moderate :

men: up to 2 drinks/day A typical serving of alcohol in the United States is any drink

that contains 14grams (0.6 fluid ounces) of pure alcohol. (14 g

ethanol yields 98 Calories). Different brands and types of

beverages vary in alcohol concentration.

Low Risk:

men: up to 4 drinks/day, ≤14/wk

women: up to 3 drinks/day, ≤ 7/wk

High Risk (for harm)

Exceed low risk levels

binge - 5+/4+ drinks in two hours

heavy - frequent 5+/4+ drinks per day

women: up to 1drink/day

Drinking patterns in US

Annual Screen: Alcohol

• Single question recommended by NIAAA

• Sensitivity 82% and specificity 79% for risky drinking

(Smith et al, 2009)

Annual Screen: Drugs

• Single question recommended by NIAAA.

• Sensitivity 93% and specificity 94% for self reported drug use

(Smith et al, 2010)

Full Screen

• Full screen stratifies patients into zones of misuse

• Zones aid in diagnosis and inform interventionAUDIT: Alcohol DAST: Drugs

AUDIT zonesI II IIIIV 0 8 16 20DAST zonesI II

IIIIV 0

1

3

6

Stratification based on Screening

Recommendations for AUDIT score

AUDIT score RecommendationsZone I: 0-7 Alcohol Education &

adviceZone II: 8-15 Riskyuse

Brief Intervention

Zone III 16-19 Brief Treatment, possible ReferralHarmful use

Zone IV ≥ 20 abuse or dependence

Referral for specialized assessment and Treatment

For illicit drug use recommendation is Abstinence irrespective of DAST score.

Recommendations for DAST score

Zone I: 0: No problems

Encouragement

Zone II:1-2 Risky use Brief Intervention or Brief Treatment

≥ 6 abuse or dependence

Referral for specialized assessment and Treatment

For illicit drug use recommendation is Abstinence irrespective of DAST score.

Zone III Harmful use Brief Treatment, possible Referral

RecommendationsDAST score

SBIRT module 3

Roy E. Smith, MDAddiction Medicine

39

Module III: Conducting the Brief Intervention

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

Brief Intervention

Based on Motivational Interviewing (MI) Approach

People are ambivalent about change

People continue their drug use because of this ambivalence

Resolving ambivalence in the direction of change is key element of motivational interviewing

Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

“People are better persuaded by the reasonsthey themselves discovered than those that come into the minds of others”

Blaise Pascal

MI: Principles

1. Empathy May be the most crucial principle

Creates environment conducive to change, instills sense of safety, of being understood and accepted, and reduces defensiveness

Sets the tone within which the entire communication occurs. Without it, other components may sound like mechanical techniques

MI: Principles

2.Develop Discrepancy Help patient to become more aware of the

discrepancy between their addictive behaviors and their more deeply-held values and goals

Part of this is helping patient to recognize and articulate negative consequences of use. More effective if the patient does this, not the clinician

Explore values andgoals and then ask client to reflect on how their addictive behavior fits into them

MI: Principles

3. Roll with resistance In general, it is unhelpful to argue with clients.

Confrontation elicits defensiveness, which predicts a lack of change

Particularly counter therapeutic for clinician to argue that there is a problem while client argues that there isn’t one

Client does not need to accept diagnostic label (e.g. addict or alcoholic ) for change to occur

“ ” “ ”

MI: Principles

4. Support self-efficacy Can be conceptualized as a specific form of

optimism, a “can-do” belief in one’s ability to accomplish a particular task or change.

Crucial to help client see and experience their own ability to make positive changes.

Part of this is the clinician believing in the client’s ability to change.

FRAMES

Feedback: how their use may impact their current and future health

Responsibility: patient’s responsibility to change their behavior

Advice: based on medical concern

Menu: variety of options for change

Empathy: attitude Self-efficacy: reinforce patient’s belief in their own

ability to change

Feedback

Ask permission to share results

Screening results and interpretation

Score in relation to: norms

low-risk limits

consequences that others with similar results often experience

Responsibility

Responsibility for change is on patient, not provider.

Patient’s task to articulate and resolve ambivalence about change.

Giving Advice-Without Telling What to Do

Ask for permission:“There is something that concerns me. Would it be

ok if I shared my concerns with you?”

Preface advice with permission to disagree:This may or may not be helpful to you…“ ”

Patients have Options

Your patient has options that they can decide what works best for them. These include: Cutting down on their use Reducing harm associated with use Quitting all use Getting help Absolutely nothing

You provide the options, let them make the choice

Express Empathy

Open

Nonjudgmental

Reflective

Understand patient’s frame of reference

Acceptance and affirmation

No “authoritative/expert” tone

Self-Efficacy

What positive changes has patient made before?

Remind patient of their previous successes

Draw parallels to substance use

Assure patient that he/she can be successful and that you will assist

The 4 Tasks of a BI

Feedback

Enhance Motivation

Negotiate a Plan

Give Screen res

Warn

Avoid Warnings!

’(that s it)

S F M P W

Present Screening results

Screening results act as conversation starter

Ask permission to raise the subject of substance use.

‘Thanks for filling out the form. Would you mind taking a few minutes to talk to me about your alcohol use and how it might relate to your health’

How you talk to the patient matters

You are singing off key if you find yourself…

•Challenging• Shaming

•Warning • Labeling

•Finger-wagging • Confronting

•Moralizing • Being Sarcastic

•Giving unwanted • Playing expert advice

Provide Feedback

Provide information about zone of misuse.

Explore connection with health and express concern.

Educate about NIAAA guidelines for low risk drinking.

Elicit patient reaction to feedback.

Providing Feedback

The Feedback Sandwich

Ask permission Give Feedback Ask for

Response

Feedback

Your job is only to deliver the feedback!

Let the patient decide where to go with it.

Feedback

Give Patient Feedback: An Example

Range: “BAC can range from 0 (sober) to .4 (lethal)”

Level: “.08 defines drunk driving (heavy drinking)”

Give score: “Your level was …”

Elicit reaction: “What do you make of that?”

Feedback

Finding a HookAsk the client about their concernsProvide non-judgmental feedback/informationWatch for signs of discomfort with status quo or interest in or ability to change

Always ask this question: “What role, if any, do you think alcohol/drugs played in any problems you have?”Let the patient decideJust asking the question is helpful

Non confrontational style…I’m not going to push you to change anything you don’t want to changeI’m not here to convince you that you’re an alcoholic.I’d just like to give you some information..I’d really like to hear your thoughts about…What you do is up to you.

Feedback

Responding to Resistance

“Look, I don’t have an alcohol problem.”

“My dad was an alcoholic and I’m not like him.”

“I can quit anytime I want to.”

“This isn’t what I came for.”

“Everybody drinks during the Steelers game.”

“I’m not going to push you to change anything you don’t want

“I’d like to give you information, what you do is up to you.”

“I’d like to hear your opinions

“What are some things that bother you about your use?”

to.”

about…”

Enhance motivation

Ambivalence isNormal

Enhance motivation

‘On a scale of 0-10, how ready are you to change any aspect of your drinking?’

Explore pros and cons. ‘What are some things you like (& don’t like) about your drinking?’

Enquire and listen for change talk

Enhance motivation

Importance/Confidence/Readiness rulerOn a scale of 1–10…•How important is it for you to change your drinking/use?•How confident are you that you can change your drinking/use?•How ready are you to change your drinking/use?

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 8 910

Enhance motivation

Strategies for weighing the pros and cons…

•“What do you like about drinking/using?”•What do you see as the downside of drinking/using?•“What Else?”

Summarize both pros and cons…“On the one hand you said.., and on the other you said….

Enhance motivation

Listen for the change talk…•Maybe drinking did play a role in what happened

•If I wasn’t drinking this would never have happened

•It’s not really much fun anymore

•I can’t afford to be in this mess again

•The last thing I want to do is hurt someone else

•I know I can quit because I’ve stopped before

Summarize, so they hear it twice!

Enhance Motivation

Change Talk is Happening When the Client Makes Statements that Indicate:

Recognition of a problem

A concern about the problem

Statements indicating an intention to change

Expressions of optimism about change

Enhance motivation

Change TalkDESIRE: 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.

Enhance motivation

Dig for change talk…

I’d like to hear your opinions about…

What are some things that bother you about your drinking/use?

What role do you think alcohol/drugs played?

How would you like your drinking/use to be 5 years from now?

Negotiate a plan

Help patient to set goals.

Provide clear advice and express your concerns.

Secure agreement about changes patient is willing to make. This includes steps to reduce use, abstain or seek referral.

Schedule follow up as needed

Negotiate a Plan

What now?

What do you think you will do?

What changes are you thinking about making?

What do you see as your options?

Where do we go from here?

What happens next?

Negotiate a Plan

Offer a Menu of OptionsManage your use (cut down to low-risk limits)

Eliminate your use (quit)

Never drink/use and drive (reduce harm)

Utterly nothing (no change)

Seek help (refer to treatment)You provide the options, let patients make the choice

Negotiate a plan

During MENUS You can also explore previous strengths, resources and successes“Have you stopped drinking/using drugs before?”

“What personal strengths allowed you to do it?” “Who

helped you and what did you do?”

“Have you made other kinds of changes successfully in the past?”

How did you accomplish these things?“ ”

Advice

The Advice Sandwich

Ask permission Give Feedback

Ask for Response

Advice

Giving Advice Without Telling Someone What to Do

Ask for Permission explicitly There’s something that concerns me. Would it be ok if I shared my concerns with

you?

Preface advice with permission to disagree This may or may not be helpful to you.

Advice

Giving Advice Without Telling Someone What to Do

Provide Clear Information or Feedback “The results of your test suggest that…” “What happens to some people is that…” “My recommendation would be that…”

Elicit their reaction “What do you think?” “What are your thoughts?”

Advice-Integrated with Health Issues

Based on fact and medical concern…

“I will be prescribing medication for your pain. However it has a negative interaction with alcohol. I am concerned that your alcohol use will interfere or lead to additional problems if you drink while on medication.

“I appreciate your honesty in reporting your marijuana use. I am concerned about your asthma and how marijuana use may lead to further complications.” “I would like for us to meet with our Healthcare Specialist to work on a plan to reduce or abstain your marijuana use.”

“You are having a hard time falling asleep at night, so you have 4 drinks to help. Let’s talk about other ways to help you sleep.”

”

Closing BI

Closing the ConversationSummarize patients views (especially the pro)

What agreement was reached (repeat it)

Remind about follow ups or referral

SBIRT Demonstration videos

http://www.sbirtnc.org/video-demonstrations/Acknowledgement: SBIRToregon.org

SBIRT Demonstration videos - NIAAA

https://webmeeting.nih.gov/case1

Referral to Treatment

Direct referrals for those with a diagnostic substance use disorder

Establish linkages with local and regional providers to expedite referrals

Give written name, address and telephone number of the provider

Important Internet Sites

www.sbirtnc.org

www.samhsa.gov/prevention/SBIRT/ www.nida.nih.gov/nidamed

www.sbirttraining.com www.uclaisap.org

http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf

Support Building for SBI

Reimbursed by Medicare and some State Medicaid programs.

Health plans that have committed to paying for screening and brief intervention (SBI), when covered under particular plan documents, include:

AETNA (nationwide) CIGNA (nationwide) Anthem Blue Cross and Blue Shield

(Colorado, Connecticut, Indiana, Kentucky, Ohio, Maine, Missouri, Nevada, New Hampshire, Virginia, and Wisconsin)

Blue Cross of California Blue Cross Blue Shield of Georgia Blue Cross Blue Shield of Minnesota Empire Blue Cross Blue Shield of New York Independence Blue Cross HealthPlus (Michigan) HealthPartners (Minnesota)

JCAHO recently called for input into what role if any it might play in developing standards for SBI in various medical settings.

Brief Intervention Videos

Videos from The BNI-ART Institutehttp://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/

Video Examples from the NIAAAhttp://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/

VideoCases.htm

Resources & Online Trainings

North Carolina websites: www.sbirtnc.org www.sa4docs.org SAMHSA SBIRT site: www.samhsa.gov/prevention/SBIRT/index.aspx NIAAA Helping Patients Who Drink Too Much:

www.niaaa.nih.gov/Publications/EducationTrainingMaterials/guide NIDA NIDAMed: www.drugabuse.gov/nidamed Boston University Alcohol Screening and BI Curriculum:

www.bu.edu/act/mdalcoholtraining/ ACOG Drinking and Reproductive Health FASD Prevention Tool Kit:

www.acog.org/departments/healthIssues/FASDToolKit.pdf Oregon SBIRT site: www.sbirtoregon.org PA SBIRT site: www.ireta.org/sbirt Alcohol Screening and Brief Intervention for Trauma Patients

www.facs.org/trauma/publications/sbirtguide.pdf

89

Roy E. Smith, MDRoy E. Smith, MDAddiction Medicine

Pavillon241 Pavillon Place

Mill Spring, NC 28756www.pavillon.org

(800) 392-4808