Effective Implementation of SBIRT: Screening, Brief Intervention, and Referral to Therapy3/18/2021
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SBIRT GOALS
Primary goal is to identify and effectively intervene with those who are at moderate to high risk for psychosocial or medical problems
related to substance use
Objectives of this training
• Reflect on our own biases associate with substance use and abuse • Orient to SBIRT intervention • Review standardized screening tools • Primer on Motivational Interviewing (MI) and Stages of Change • Introduce a model of brief intervention • Practice SBIRT/MI skills
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Objectives of this training
Screening: Universal, efficient. Assesses level of risk: at risk use, abuse, dependence
Brief Intervention: MI for at risk or problematic substance use
Referral to Treatment: Counseling or other specialty care
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What do you experience when you encounter a person who uses substances?
What do you bring to the interaction?
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What do you experience when you encounter a person who uses substances?
A Social Failing?
A Disease?
Disease Defined
• A departure from health of the body and it’s function • Identifiable risk factors • Known pathophysiology • Recognizable group of signs and Sxs • Predictable morbidity ,mortality ,natural Hx • Responds to Tx
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• The impaired model • The Dry Moral Model • The Wet Model • The Wet Moral Model
• The Chronic Disease Model
• Pts with SUDs are easily recognizable….
• 90% function in society and have normal jobs, family, pay taxes…
• 12-15% of Americans who try drugs or alcohol socially will develop SUD
• Treatment for opioid SUD doesn’t work…
• Reduces drug use 40-60% • Decreases criminal behavior up to 50% • Reduces risk of HIV, Hep C, Hep B by X6. • Increases employment rates by 40% • More effective than DM, HTN, or asthma Tx
• Treatment not worth it…
• 1 year methadone $4,700 • 1 year Buprenorphine $3,300-$7,500 • 1 year prison $30-$40,000+ • $1.00 in treatment $12.00 savings in crime and health
care costs
Disease- Definitions
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Defined Re-defined
• A departure from health of the body and it’s function
• Identifiable risk factors • Known pathophysiology • Recognizable group of signs and Sxs • Predictable morbidity ,mortality ,natural
Hx • Responds to Tx
• A disorder of the body and it’s function • Identifiable risk factors • Known pathophysiology • Recognizable group of signs and Sxs • Predictable morbidity ,mortality ,natural
Hx • Responds to Tx
Adverse Childhood Experiences (ACES)
Felliti et al 1998
Family Hx prevalence studies
Neuropathophysiological: “Hijacked Reward System”
Causal Pathways
Neurophysiology 101
1. Rewards…modulates obsessive thought and impulsivity in the cortex and limbic systems
2. Permanent changes seen in activated MRI/PET scan
cognitive impairment
Neurochemistry 101
1. All major classes of addictive drugs work at the same point on these pathways: the reward pathways-eating, love, sex, fight or flight
• Mu receptor: opiates, alcohol indirectly • GABA: alcohol, benzodiazepines, barbiturates • 5 HT: alcohol • Dopamine receptors: amphetamines, cocaine , alcohol
Not just a disease….
Disease
Show Unwavering Compassion and Regard for the Patient With This Disease
• Your patient is not immoral. • Your patient is not weak. • Your patient is not a loser. • Your patient is sick and afraid that you will find out and dislike
them/fire them.
• Primary care/ER/hospital settings provide opportunity for early intervention with at risk substance users…..
BEFORE MORE SEVERE CONSEQUENCES OCCUR
SBIRT Goals
Increase access to care for persons with current or future risk for substance use disorders
Foster continuum of care by integrating prevention, intervention, and Tx services
Improve linkages between health care services and alcohol/drug Tx services
Stages of Change MI: To Move Patient to Next Step
RelapseMaintenanceActionPreparationContemplationPre- contemplation
Process can happen in above order or revert back and forth stage to stage
Transtheoretical Model
MI Evidence Base
• Using MI techniques shown to improve patient’s medical and mental health in long term studies
• Numerous studies have shown 5 min discussion with PCP as effective as 20 min counseling session to achieve change
Screening in a Practice Setting
When you ask, it implies: 1) The issue is important 2) You can hear it and won’t be upset with it
What you don’t ask implies: 1) You don’t think its important! 2) You may be upset about it if you hear it.
Thus, you have joined the conspiracy of silence!!
Screen everyone for tobacco, alcohol, prescription and street drug use Use validated tools, incorporate into Wellness Screening Tools For positive screens explore each substance used, assess details of use and consequences of use Consistent verbal/nonverbal cues that are non-judgmental, empathetic. Utilize MI skills
Screening in a Practice Setting
Assuring Cross-cultural Efficacy: RESPECT
R espect - Demonstrate respect E xplanatory model - Understand how the
patient makes sense of the world (including this visit)
S ocio-cultural context (avoid stereotyping) P ower - Mitigate status differences E mpathy - Make sure the patient feels heard and understood C oncern - Elicit concerns about drinking T rust - These practices establish a trusting and therapeutic alliance
Let go of our prejudices!
No one chooses to be an addict!!!
• Treat patients who suffer with substance abuse issues with respect they deserve.
• It’s a disease where our intervention has greater impact on morbidity, extended length of life, and social costs than our intervention in coronary artery disease
• Act like we care and mean it.
SBIRT: Screening Low Risk Drinking
• Women and Men>65 or comorbidities • 7 or less drinks/week: Ave 1/day • 3 or less drinks per occasion
• Men • 14 or less drinks/week: Ave 2/day • 4 or less drinks per occasion
• Drugs: Anything but zero is at least at risk use?
What’s a drink?
Motivational Interviewing
Screening for Dependence
• CAGE (Men) • T-ACE or TWEAK (Women) • AUDIT (All) • DAST 10 (All) • CRAFFT (Teens) • 4 Ps, 4 Ps plus, 5 Ps (Pregnancy)
TWEAK
• Tolerance: How many drinks does it take to feel a buzz? >3=2 points • Worried: Have you ever felt worried about your use of alcohol (or drugs)? 2
points • Eye opener? 1 point • Amnesia: Have you ever experienced a blackout? 1 point • Kut back? 1 point
> 2 points=harmful drinking
Four Ps
The 4 P’s has been tested and validated and effectively identifies pregnant women at highest risk for substance use during pregnancy. Now in public domain. Administration Time: 3 to 5 min.
Ewing H. A practical guide to intervention in health and social services with pregnant and
postpartum addicts and alcoholics: theoretical framework, brief screening tool, key interview
questions, and strategies for referral to recovery resources. Martinez (CA): The Born Free Project,
Contra Costa County Department of Health Services; 1990
Four Ps
• Parents: Did any of your parents have a problem with alcohol or other drug use?
• Partner: Does your partner have a problem with alcohol or other drug use?
• Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
• Present: In the past month have you drunk any alcohol or used other drugs? -Some have changed this to “Before you were aware you were pregnant did you drink alcohol or use other drugs?”
Scoring: Any “yes” should trigger further questions
AUDIT: Alcohol Use Disorders Identification Test
• How often do you have a drink containing alcohol? (never, monthly, 2-4X/mos, 2-3X/wk, 4 or more X/wk)
• How many drinks containing alcohol do you have on a typical day when drinking? (1-2, 3-4, 5-6, 7-9, >10)
• How often do you have 4 or more drinks on one occasion? (never, <monthly, monthly, weekly, daily)
• How often during the last year have you found that you were unable to stop drinking once you had started?
• How often have you failed to do what is expected of you because of your drinking?
• How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?
• How often in the last year have you had a feeling of guilt or remorse after drinking?
• How often in the last year have you been unable to remember what you did the night before because of your drinking?
• Have you or someone else been injured because of your drinking? (no, yes>1 year ago, yes in last year)
• Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down?
Drug Abuse Screening Test: DAST 10
• Have you used drugs other than those required for medical reasons? Yes No • Do you use more than one drug at a time? • Are you unable to stop using drugs when you want to? • Have you ever had blackouts or flashbacks as a result of drug use? • Do you ever feel bad or guilty about your drug use? • Does your spouse (or parents) ever complain about your involvement with drugs? • Have you ever neglected your family because of your use of drugs? • Have you engaged in illegal activities in order to obtain drugs? • Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking
drugs? • Have you had medical problems as a result of your drug use (e.g. memory loss,
hepatitis, convulsions, bleeding)?
CRAFFT Adolescent Screen (Car, Relax, Alone, Family/Friends, Trouble)
• 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 you Family or Friends tell you that you should cut down on your drinking or drug
use? • Have you ever gotten into Trouble while you were using alcohol or drugs?
SBIRT At Risk Use to Addiction: Brief Intervention
Brief Intervention
• Evidence based, cost and time effective tool designed to target pt’s with mild to moderate risk of alcohol/drug related problems and/or harm of developing them.
• Intended to be simple advice to reduce risk.
• Designed to provide a pt with information to promote health and prevent disease.
• Allows PCPs to provide quality care and reduce recidivism rates in ER and health centers.
• Meant to motivate the patients to change unwanted negative or unhealthy behaviors.
• A tool used to help patients decrease harmful and hazardous alcohol/drug use patterns.
Elements of BI
use •16-19 significant
dependence
DAST 10
• 1-2 indicates at risk use •3-5 Moderate risk •6-8 substantial use
CRAFFT
TWEAK
Eligibility scores for BI
Elements if BI (Cont)
Brief 3-5 min conversation between PCP and patient consists of: • Open ended questions re use patterns • Feedback (paraphrasing back medical, psych, social consequences) • Simple advice • Commitment to change • Set follow-up date • Supply “to go” literature
Motivational Interviewing (MI) 101 Miller and Rollnick 2010
Increases the patients natural desire to change: • Patient -centered, evidence-based, goal oriented
• The client tips the balance toward positive change: Enhances intrinsic motivation to change by exploring and resolving patient ambivalence
• Elicits pt’s own language of change.
• Collaborative, respectful, compassionate, maintains autonomy.
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Motivational Interviewing (MI): Native POV
• Honors the wisdom within the pt instead of forcing the provider/counselor wisdom upon the client.
• Patient seen as a person vs a problem. Pt identifies and processes own feelings about change. Some tribes respect pt by addressing clan relation: sister, uncle, etc
• Humble , respectful, and active guidance helps client examine and move forward with feelings about change.
• Persuasion not effective: Trying to convince pt to change invites resistance/argument.
• MI style is peaceful: Draws wisdom from inside the pt.
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Honor Body: Exercise,
Explore Own Faith
Feeding your Spirit
Honor Feelings Pay attention to feelings and emotions -leads to healing
Don’t harbor unhealthy feelings
-Makes you sick
-Letting things go
S Bear and L Thompson National American Indian and Alaska Native ATTC
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• Local knowledge unique to a given culture or society:
• - Has its own theory, philosophy, scientific and logical validity.
• Used as a basis is for decision-making for all life’s needs
S Bear and L Thompson National American Indian and Alaska Native ATTC
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Engage Focus Evoke Plan
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Artful MI
Connects possible behavior changes with what the patient cares about: • Goals • Aspirations • Dreams • Values • Concerns
Must LISTEN Be inquisitive Understand Pts Perspective Elicit patient’s reason for change
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Artful MI
You can influence motivation! Work with ambivalence and resistance
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MI - Ambivalence
• Ambivalence is normal
• All change associated with some ambivalence. Want to change… Don’t want to change
• MI Goal: Amplify discrepancy/cognitive dissonance: Current behavior vs Larger Life Goals
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MI Skills: OARS
Open questions • Provides the individual space to choose how they want to respond Affirmations • Brings to the forefront the individual’s strengths, positive attributes and efforts Reflections • Offers short summary about what the individual has said and makes a guess to it
meaning Summarize • Collect, link or transition the individual’s comments ensuring understanding and
moving the conversation forward
problem?”
Open: “Can you talk to me about your use of
alcohol?” “Can you talk to me about times it has caused any problems for you?”
• Open patient up- stimulates them to explain their thoughts
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OARS Framework
Open Questions
• 2 reflections for every question
Affirmations
• Comment positively on an attribute
• State appreciation of things patient may be doing right- ”catch them doing right”
• =Expression of hope, caring and support
• (Remember: It’s the relationship!!!!)
Reflective Listening
• When in doubt , listen and reflect
• Take a guess and reflect back:
• Reveals listening/attempt to understand
• Emphasizes pt’s change talk • Diffuses resistance • Frame as a statement, not a
question: “So, you are not interested in quitting smoking.”
Levels of Reflection
• Repeat: • Restate directly
synonym • Add New Meaning:
• Summarize: • Gather patient statements
and reflect underlying meaning
Double Sided Reflection Acknowledge both sides of patients’ ambivalence
“Smoking reduces my stress” “On the 1 hand smoking helps reduce your stress, on the other hand you said increased stress due to cough, smoke outside, $$ …
Metaphor Painting a clarifying picture
“Everyone tells me I have a drinking problem, but I don’t feel its that bad.”
“ its like everyone is harassing you about your drinking , like a cloud of mosquitoes that won’t stop.”
Reframing Helps think about the situation differently
“I have tried to quit and failed so many times.”
“Wow, you have been persistent, despite being discouraged a number of times. This change must be important to you.”
Shifting Focus Shows understanding:
Patient: “What do you know about…? You probably never…!”
Response: “It is hard to imagine how I could possibly understand.”
Feeling Reflection Emotional undertone
“Considering quitting for some time due to its bad for my health.”
“You are very worried about your health and how its affected by smoking.”
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Reflect Ambivalence
Accentuate Change Talk
When Patients Speak About Change, they Begin to See The Possibility Of Change.
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Desire: I want to.. like to... I wish…
Ability: I would.. I can.. I am able to.. I could…
Reason: There are good reasons to… This is important…
Need: I really need to…
Commitment: I intend to… I will… I plan to…
Activation: I am doing this today…
Taking Steps: I went to my first meeting…
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Sustain Talk Opposite of change talk
• I really enjoy cigs- (Desire) • Don’t think I can give up- (Ability) • Drinking is how I have fun.-(Reason) • I don’t need to quit(Need) • I am going to drink and nobody’s gonna stop me (Commitment) • I am not ready to quit(Activation) • I went back to the bar (Taking steps)
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Evoking Change Talk: Desire, Ability, Reason, Need, Commitment
Why have you been thinking of changing…? (Desire)
If you were to change …, How would you do it? (Ability)
What are the 3 most important reasons to make this change…?(Reasons)
How would things be different/better if you decided to make the change? (Need)
What’s the next step? Scale 1-10 how willing are you to change…..? (Commitment)
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Confidence: “How confident are you that you can change your …?”
Readiness: “How ready are you to change your ….now?”
The total “change” ie d/c substance may be overwhelming: Consider scale using “cutting back” vs “stopping”.
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SAD and Simple Reflections Amplified Reflections Double-sided Reflections
SCARED Shift Focus Come Alongside Agree w/ a Twist Reframe Emphasize Personal Control Disclose Feelings
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MI traps
Taste Stress reduction
OK if I give you feedback about
your …..?” “Can I give you
some advice about….?”
may or may not work for you, but…”
Menu of options:
which option would you like
to try?”
Emphasize personal
Ask for Response
Negotiate a Plan
• Invite active patient participation • Pt determines goals and priorities • Pt weighs options • Together work out details • SMART plan: • Specific, Measurable, Achievable, Relevant, Time-limited
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Finalize MI
• Review Commitment • Review the plan • Set up f/u date/appointment • Express encouragement but reality: • Plan is a trial. • Inoculate: “We will reevaluate on …If it isn’t working for you, it only
means that particular plan doesn’t work for you. We learn from it, modify it in a way that will work better for you.”
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Key Takeaways
•What we bring to the conversation… •Verbal and Nonverbal Cues 1. Reflected on our own biases
•Patients feel safe and pursue help. 2. Oriented to Unconditional acceptance as a key to a therapeutic relationship
•Why MAT works3. Reviewed “Hijacked” Reward System
•Introduced a model of brief intervention 4. Introduced Tools to identify and effectively intervene early in SUD course
5. Primer on Motivational Interviewing (MI) and Stages of Change
•OARS: Open Ended Questions, Affirmation, Reflective listening, SMART plan, Follow-up 6. Practiced SBIRT/MI skills
It Takes a Community: Connection is Key to Prevention and Recovery
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SBIRT: Goals and Objectives
Reflection
What do you experience when you encounter a person who uses substances?
Disease Defined
Factchecks
Neuropathophysiological: “Hijacked Reward System”
Not just a disease….A Chronic Disease
Show Unwavering Compassion and Regard for the Patient With This Disease
What’s SBIRT
Stages of ChangeMI: To Move Patient to Next Step
Slide Number 22
MI Evidence Base
Slide Number 25
What’s a drink?
CRAFFTAdolescent Screen(Car, Relax, Alone, Family/Friends, Trouble)
SBIRTAt Risk Use to Addiction:Brief Intervention
Brief Intervention
Motivational Interviewing (MI): Native POV
Motivational Interviewing (MI): Native POV
Motivational Interviewing (MI)Medicine Wheel
Motivational Interviewing (MI)
Artful MI
Artful MI
MI - Ambivalence
Evoking Change Talk: Desire, Ability, Reason, Need, Commitment
Scaling Questions-Listen
Finalize MI
Key Takeaways