Integrating Care through the Use of Screening and Brief

Intervention in HIV Settings

TRAINERrsquoS NAMETRAINING DATE

TRAINING LOCATION

Training Collaborators

bull Pacific AIDS Education and Training Center Charles R Drew University of Medicine and

Science University of California Los Angeles

bull Pacific Southwest Addiction Technology Transfer Center

bull UCLA Integrated Substance Abuse Programs

2

Test Your Knowledge

3

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

4

Test Your Knowledge

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

5

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Training Collaborators

bull Pacific AIDS Education and Training Center Charles R Drew University of Medicine and

Science University of California Los Angeles

bull Pacific Southwest Addiction Technology Transfer Center

bull UCLA Integrated Substance Abuse Programs

2

Test Your Knowledge

3

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

4

Test Your Knowledge

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

5

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Test Your Knowledge

3

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

4

Test Your Knowledge

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

5

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

4

Test Your Knowledge

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

5

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Test Your Knowledge

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

5

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Test Your Knowledge

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

6

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Test Your Knowledge

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

7

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Introductions

Briefly tell usWhat is your nameWhere do you work and what you do thereWho is your favorite musician or performerWhat is one reason you decided to attend this training session

8

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

This brief training course will teach you how to

bull Administer substance use screening

bull Deliver a brief intervention

bull Employ a motivational approach

bull Make referrals to specialized treatment if needed

What Will You Learn Today

9

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

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

10

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBIRT Review of Key TermsScreening 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

11

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Benefits of SBIRTSubstance 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 costsStudies have indicated that SBI for alcohol saves $2 - $4 for each $100 expended

Other outcomes SBI may reduce work-impairment reduce DUIs and improve neonatal outcomes

12

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Benefits of SBIRT for Practice

bull Increases cliniciansrsquo awareness of substance use issues

bull Offers clinicians more systematic approach to addressing substance use (less of a ldquojudgment callrdquo)

13

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The Key to Successful Interventions

Brief interventions are successful when clinicians relate patientsrsquo risky substance use to improvement in patientsrsquo overall health and wellbeing

14

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Candidates for Routine Screening

bull College students bull Primary care patientsbull Mental health patientsbull Patients in infectious disease clinicsbull People with alcohol- or drug-related

legal offenses (eg DUI)

15

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Rationale for Conducting SBIRT in an HIV Care Setting

16

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

HIV in 2013bull HIV is now considered a manageable chronic

illnessbull HIV patients are living longer and facing

multiple health issues in addition to their HIV diseasebull Homelessness bull Disease progressionbull Mental illnessbull Substance abuse

bull Engagement retention and adherence among HIV patients continues to present challenges to HIV care providers

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 17

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Risks of Untreated Mental Health and Substance Use Problems

bull Poorer adherence to treatment and medication regimens

bull Higher hospitalization rates for medical complications

bull Greater likelihood of treatment drop-out or being lost to follow-up

bull Greater risk for opportunistic (re-) infectionbull Greater risk of psychosocial problemsbull Greater risk of suicide or accidental death

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 18

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBIRT in HIV Settingsbull SBIRT in primary care settings is effective in

changing behavior and preventing adverse outcomes attributable to alcohol and other drugs

bull People living with HIV are more likely than the general population to experience substance abuse problems

bull SBI protocols have not been readily implemented in HIV care settings

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 19

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBIRT in HIV Settings

SOURCE Center for Community Collaboration UMBC Psychology Department (2012) 20

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Impact of a Computer-Assisted SBIRT Program in an HIV Setting

bull Implemented in San Francisco General Hospitalrsquos Positive Health Program (PHP) in 2010-11bull Most common substances reported were tobacco

(68) alcohol (64) cannabis (58) cocaine (39) amphetamines (37) nonmedical sedative use (32) and nonmedical opioid use (26)

bull SBI for unhealthy substance use is acceptable to patients in HIV primary care settings

bull 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 21

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Colorados Ryan White Collaborative SBIRT Project

bull Of 2500 patients screenedbull 31 (n=775) received a BI for risky alcohol tobacco

or drug usebull 23 (n=575) were referred for therapy or specialized

treatment

bull Recommendations for standardizing SBIRT in HIV settings include

bull Apply a systematic screening approachbull Train providers to conduct BIbull Establish a referral networkbull Integrate SBIRT with adherence and retention efforts

SOURCE Fischer L (2012) Addiction Science amp Clinical Practice 7(Suppl 1) A73 22

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Adoption of SBIRT Can SBIRT work in your setting

3 minutes

End

23

>

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Screening to Identify Patients At-Risk for

Substance Use Problems

24

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

ScreeningAssessment

Whatrsquos going on in these pictures

25

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Types of Screening ToolsSelf-report

bull Interviewbull Self-administered

questionnairesBiological markers

bull Breathalyzer testing

bull Blood alcohol levelsbull Saliva or urine

testingbull Serum drug testing

26

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Characteristics of a Good Screening Tool

bull Brief (10 or fewer questions)bull Flexiblebull Easy to administer easy for patientbull Addresses alcohol and other drugsbull Indicates need for further assessment or

interventionbull Has good ldquosensitivityrdquo and ldquospecificityrdquo

27

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Benefits of Self-Report Toolsbull Provide historical

picturebull Inexpensivebull Non-invasivebull Highly sensitive for

detecting potential problems or dependence

28

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are bull Alcohol- or drug-free when interviewedbull Told that their information is confidentialbull Asked clearly worded objective questionsbull Provided memory aides (calendars

response cards)

29

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Screen TargetPopulation

Items

Assessment [Type] Setting (most common)

URL

ASSIST(WHO)

-Adults-Validated in many cultures and languages

8 Hazardous harmful or dependent drug use (including injection drug use) [Interview]

Primary Care httpwwwwhointsubstance_abuseactivitiesassist_testenindexhtml

AUDIT(WHO)

-Adults and adolescents-Validated in many cultures and languages

10 Identifies alcohol problem use and dependence Can be used as a pre-screen to identify patients in need of full screenbrief intervention[Self-admin Interview or computerized]

-Different settings-AUDIT C- Primary Care (3 questions)

httpwhqlibdocwhointhq2001who_msd_msb_016apdf

DAST-10 Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different settings httpwwwintegrationsamhsagovclinical-practicescreening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse risky behavior amp consequences of use [Self-admin or Interview]

Different settings httpwwwceasar-bostonorgCRAFFT

CAGE Adults and youth gt16

4 -Signs of dependence not risky use[Self-admin or Interview]

Primary Care httpwwwintegrationsamhsagovclinical-practicesbirtCAGE_questionairepdf

TWEAK Pregnant women 5 -Risky drinking during pregnancy Based on CAGE-Asks about number of drinks one can tolerate alcohol dependence amp related problems [Self-admin Interview or computerized]

Primary Care Womenrsquos organizations etc

httpwwwsbirttrainingcomsitessbirttrainingcomfilesTWEAKpdf

30

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What is a Standard Drink

31

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

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 gt65 No more than 3 drinks on any day and 7 drinks per week NIAAA 2011

Drinking Guidelines

285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 35 oz 15 oz 32

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Pre-Screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief interventionbull Self-report 1-4 questionsbull Biological blood alcohol level test

33

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Pre-Screening ExampleNIAAA 1-item for alcohol use

ldquoHow many times in the past year have you had X or more drinks in a dayrdquo

5 for men

4 for women

bull Identifies unhealthy alcohol usebull Positive screen gt 1 or more

(provide BI)

SOURCE Smith PC et al (2009) Primary care validation of a single-question alcohol screening test Journal of General Internal Medicine 24(7) 787-780 34

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Pre-Screening ExampleNIDA 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 reasonsrdquo

bull Identifies overall drug usebull Positive screen = 1 or more

SOURCE Smith PC et al (2010) A single question screening test for drug use in primary care Archives of Internal Medicine 170 1155-160 35

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBI Decision Tree

AlcoholWomen = 0 ndash 2

Men = 0 ndash 4

AlcoholWomen = 4+

Men = 5+

Other DrugsAny Yes

Other DrugsAll Nos

Administer the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

Complete Pre-Screen

36

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Review of the AUDIT

bull 10-question alcohol use screening instrument

bull Original target groups included bull Medical patients

bull Accident victims

bull DWI offenders

bull Mental health clients

bull Designed for primary health care workers

37

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Domains of the AUDIT

Hazardous Alcohol UseQuestion 1 Frequency of DrinkingQuestion 2 Typical quantityQuestion 3 Frequency of heavy drinking

38

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Domains of the AUDIT (cont)

Dependence SymptomsQuestion 4 Impaired control over drinkingQuestion 5 Failure to meet expectations

because of drinkingQuestion 6 Morning drinking

39

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Domains of the AUDIT (cont)

Harmful Consequences of Alcohol UseQuestion 7 Guilt after drinkingQuestion 8 BlackoutsQuestion 9 Alcohol-related injuriesQuestion 10 Othersrsquo concerns about drinking

40

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Scoring the Audit

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIRT

20+ High BTRT

41

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity AUDIT Practice

bull I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients

bull Your responses will be confidentialbull These questions help me to provide the best

possible carebull You do not have to answer them if you are

uncomfortable

42

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity AUDIT Practice (cont)

Feedback Reactions

43

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBI Decision TreeAdminister the AUDIT

Administer the DAST

Alcohol Screen Complete

Other DrugScreen Complete

LowNo RiskAlcohol = 0 ndash 7Other drugs = 0

At RiskAlcohol = 8 ndash 15

Other drugs = 1 ndash 2

ModHigh RiskAlcohol = 16 ndash 19

Other drugs = 3 ndash 5

HighSevere RiskAlcohol = 20 ndash 40

Other drugs = 6 ndash 10

Reinforce behavior Monitor

Brief Intervention Goal Lower Risk

Reduce use to acceptable levels

BIReferral to txBTGoal 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

44

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What about Screening for Oral Health

Start by asking two simple questionsbull Do you have a dentistbull Do you have any mouthoral pain or discomfort

that interferes with your eating or speaking

SOURCE Dr Fariba Younai UCLA School of Dentistry (personal communication May 24 2013 45

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Brief Interventions for Patients At-Risk for

Substance Use Problems

46

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What are Brief Interventions

ldquoBriefhellipinterventions 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 eventrdquo

SOURCE Dr Craig Field University of Texas 47

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Goal of Brief Interventions

Behavior change

Awareness of problem

Motivation

Presenting problem Screening

results

48

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Brief Intervention Effectbull Brief interventions trigger changebull A little counseling can lead to significant

change eg 5 min has same impact as 20 minbull Research is less extensive for illicit drugs but

promisingbull 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 49

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Where Do I Start

What you do depends 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

50

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Stages of Change

Primary Tasks

1 PrecontemplationDefinition

Not yet considering change or is unwilling or unable to change

Primary TaskRaising Awareness 2 Contemplation

Definition Sees the possibility of change but

is ambivalent and uncertain

Primary TaskResolving ambivalence

Helping to choose change

3 DeterminationDefinition

Committed to changingStill considering what to do

Primary TaskHelp identify appropriate

change strategies

4 ActionDefinition

Taking steps toward change but hasnrsquot stabilized in the process

Primary TaskHelp implement change strategies

and learn to eliminate potential relapses

5 MaintenanceDefinition

Has achieved the goals and is working to maintain change

Primary TaskDevelop new skills for maintaining recovery

6 RecurrenceDefinition

Experienced a recurrence of the symptoms

Primary TaskCope with consequences and

determine what to do next

51

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Stages of Change Intervention Matching Guide

bull Offer factual informationbull Explore the meaning of events that

brought the person to treatmentbull Explore results of previous effortsbull Explore pros and cons of targeted

behaviors

bull Explore the personrsquos sense of self-efficacy

bull Explore expectations regarding what the change will entail

bull Summarize self-motivational statements

bull Continue exploration of pros and cons

bull Offer a menu of options for changebull Help identify pros and cons of various

change optionsbull Identify and lower barriers to changebull Help person enlist social support bull Encourage person to publicly

announce plans to change

bull Support a realistic view of change through small steps

bull Help identify high-risk situations and develop coping strategies

bull Assist in finding new reinforcers of positive change

bull Help access family and social support

bull Help identify and try alternative behaviors (drug-free sources of pleasure)

bull Maintain supportive contact bull Help develop escape planbull Work to set new short and long term

goals

bull Frame recurrence as a learning opportunity

bull Explore possible behavioral psychological and social antecedents

bull Help to develop alternative coping strategies

bull Explain Stages of Change amp encourage person to stay in the process

bull Maintain supportive contact

1 Pre-contemplation

2Contemplation

3Determination

4Action

5Maintenance

6Recurrence

52

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

ldquoPeople are better persuaded by the reasons they themselves

discovered than those that come into the minds of othersrdquo

Blaise Pascal

53

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Ambivalence

All change contains an element of ambivalence

We ldquowant to change and donrsquot want to changerdquo

Patientsrsquo ambivalence about change is the ldquoheartrdquo of the brief intervention

54

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Video ExampleYoung 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

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos

(INSERT ldquoBAD SBIRTrdquo VIDEO)

55

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Reflective Listening

bull Listen to both what the patient says and to what the person means

bull Show empathy and donrsquot judge what patient saysbull You do not have to agree

bull Be aware of intonationbull Reflect what patient says with statement not

a question eg ldquoYou couldnrsquot get up for work in the morningrdquo

56

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Levels of Reflection

bull Repeating ndash Repeating what was just saidbull RephrasingParaphrasing ndash Restatement of

what the person said Listener infers meaning of what was said Can be thought of as continuing the thought

bull Reflecting Feeling ndash Listener reflects not just the words but the feeling or emotion underneath what the person is saying

57

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Avoid Confrontationbull Challenging

ldquoWhat do you think you are doingrdquo

bull Warning

ldquoYou will damage your liver if you donrsquot stop drinkingrdquo

bull Finger-wagging

ldquoIf you want to be a good student you must stop drinking on school nightsrdquo

58

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Explore Ambivalence

Benefits of change

Costs of using drugs

Benefits of using drugs

Costs of change

59

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

How to Explore Ambivalence

Avoid questions that lead to a yesno response

The good things about

______

The not- so-good things

about ____

The good things about

changing

The not-so-good things

about changing

60

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Reflective Listening

bull What change are you wanting to makebull What makes you want to changebull What are the good things about making

this change Not-so-good things

61

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Elicit ldquoChange TalkrdquoChange talk consists of self-motivational statements that suggest

bull Recognition of a problem

bull Concern about staying the same

bull Intention to change

bull Optimism about change

62

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Video ExampleSame scenario but different doctor What does this doctor do that is different Does it work

(INSERT ldquoGOOD SBIRTrdquo VIDEO)

SOURCE The BNI-ART Institute Boston University School of Public Health Interactive Cases SBIRT in Action Accessed on September 26 2011 at httpwwwbuedubniartsbirt-in-health-caresbirt-educational-materialssbirt-videos 63

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Conducting a Brief Intervention

F L O

64

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

FLO The 3 tasks of a BI

Avoid Warnings

F L O WFeed

back

Listen

amp U

nd

erstand

Warn

Op

tion

s Exp

lored

(thatrsquos it)65

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

How Does It All Fit TogetherFeedback

Setting the stage

Tell screening results

Listen amp understand

Explore pros amp cons

Explain importance

Assess readiness to change

Options explored

Discuss change options

Follow up

66

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 3 Tasks of a BI

F L OFeed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

67

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task Feedback

The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

68

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task FeedbackWhat you need to cover1 Range of scores and context2 Screening results3 Substance use norms in population4 Interpretation of results (eg risk level)5 Patient feedback about results

69

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task FeedbackWhat do you say

1 Range of score and context - Scores on the AUDIT range from 0-40 Most people who are social drinkers score less than 8

2 Results - Your score was 18 on the alcohol screen

3 Norms - A score of 18 means that your drinking is higher than 75 of the US adult population

4 Interpretation of results - 18 puts you in the moderate-to-high risk range At this level your use is putting you at risk for a variety of health issues

5 Patient reactionfeedback - What do you make of this70

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Informational Brochures

71

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task FeedbackHandling Resistancebull Look I donrsquot have a drug problembull My dad was an alcoholic Irsquom not like himbull I can quit using anytime I want tobull I just like the tastebull Everybody drinks in college

What would you say72

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Neu

ropa

thy

SUD

HIV

Con-fusion Medical

Issues

Anxiety

SUD

ldquoThe Chaserdquo

73

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

To avoid thishellip

LET GO

The 1st Task Feedback

74

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task Feedback

Easy Ways to Let Gobull Irsquom not going to push you to change

anything you donrsquot want to changebull Irsquod just like to give you some informationbull What you do is up to you

75

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 1st Task FeedbackFinding a Hookbull Ask the patient about their concernsbull Provide non-judgmental feedbackinformationbull Watch for signs of discomfort with status quo or

interest or ability to changebull Always ask this question ldquoWhat role if any do

you think alcohol played in your (getting injured)bull Let the patient decidebull Just asking the question is helpful

76

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Role Play

Letrsquos practice F Role Play Giving Feedback Using Completed Screening Tools

bull Focus the conversationbull Get the ball rollingbull Gauge where the patient is bull Hear their side of the story

77

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

AUDIT Results

Score Level Action

0-7 Low Encouragement

8-19 LowModerate BI

16-19 Moderate BIBT

20+ High BTRT

78

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 3 Tasks of a BI

F L O

Feed

back

Listen

amp U

nd

erstand

Op

tion

s Exp

lored

79

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 2nd Task Listen amp Understand

Ambivalence is Normal

80

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 2nd Task Listen amp Understand

Tools for Change Talk

bull Pros and Cons

bull ImportanceReadiness Ruler

81

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 2nd Task Listen amp UnderstandStrategies for Weighing the Pros and Consbull What do you like about drinking

bull What do you see as the downside of drinking

bull What else

Summarize Both Pros and Cons

ldquoOn the one hand you said

and on the other you saidhelliprdquo

82

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 2nd Task Listen amp Understand

Listen for the Change Talkbull Maybe drinking did play a role in what happened

bull If I wasnrsquot drinking this would never have happened

bull Using is not really much fun anymore

bull I canrsquot afford to be in this mess again

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

bull I know I can quit because Irsquove stopped before

Summarize so they hear it twice

83

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 2nd Task Listen amp UnderstandImportanceConfidenceReadiness

On a scale of 1ndash10hellip

bull How important is it for you to change your drinking

bull How confident are you that you can change your drinking

bull How ready are you to change your drinking

For each ask

bull Why didnrsquot you give it a lower number

bull What would it take to raise that number

1 2 3 4 5 6 7 8 9 1084

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Role Play

Letrsquos practice L Role Play Listen amp Understand

Using Completed Screening Tool

bull Pros and Cons

bull ImportanceConfidenceReadiness Scales

bull Develop Discrepancy

bull Dig for Change

85

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

OOp

tion

s Exp

lored

The 3 Tasks of a BI

F L

Feed

back

Listen

amp U

nd

erstand

86

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What nowbull What do you think you will do

bull What changes are you thinking about making

bull What do you see as your options

bull Where do we go from here

bull What happens next

The 3rd Task Options for Change

87

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Offer a Menu of Options

bull Manage drinkinguse (cut down to low-risk limits)

bull Eliminate your drinkingdrug use (quit)

bull Never drink and drive (reduce harm)

bull Utterly nothing (no change)

bull Seek help (refer to treatment)

The 3rd Task Options for Change

88

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

During MENUS you can also explore previous strengths resources and successesbull Have you stopped drinkingusing drugs before

bull What personal strengths allowed you to do it

bull Who helped you and what did you do

bull Have you made other kinds of changes successfully in the past

bull How did you accomplish these things

The 3rd Task Options for Change

89

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 3rd Task Options for Change

Giving Advice Without Telling Someone What to Dobull Provide Clear Information (Advise or Feedback )

bull What happens to some people is thathellipbull My recommendation would be thathellip

bull Elicit their reactionbull What do you thinkbull What are your thoughts

90

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 3rd Task Options for Change

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

91

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

The 3rd Task Options for ChangeClosing the Conversation (ldquoSEWrdquo)

bull Summarize patients views (especially the pro)

bull Encourage them to share their views

bull What agreement was reached (repeat it)

92

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Role Play

Letrsquos practice O Role Play Options Explored

bull Ask about next steps offer menu of optionsbull Offer advice if relevantbull Summarize patientrsquos viewsbull Repeat what patient agrees to do

93

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Putting It All TogetherFeedbackbull Range

Listen and Understandbull Pros and Consbull ImportanceConfidenceReadiness Scalesbull Summary

Options Exploredbull Menu of Options

94

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Encourage Follow-Up Visits

At follow-up visitbull Inquire about usebull Review goals and progressbull Reinforce and motivatebull Review tips for progress

95

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Enhancing Motivation for Change Inservice TrainingBased Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatmentwwwsamhsagov

SOURCE SAMHSACSAT Treatment Improvement Protocol (TIP) Series Enhancing motivation for change in substance abuse treatment 35 Rockville (MD) US DHHS 96

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Referral to Treatment for Patients At-Risk for Substance Dependence

97

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Referral to Treatmentbull Approximately 5 of patients screened will

require referral to substance use evaluation and treatment

bull A patient may be appropriate for referral whenbull Assessment of the patientrsquos responses to the screening

reveals serious medical social legal or interpersonal consequences associated with their substance use

These high risk patients will receive a brief intervention followed by referral

98

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

ldquoWarm hand-offrdquo Approach to Referrals

bull Describe treatment options to patients based on available services

bull Develop relationships between health centers who do screening and local treatment centers

bull Facilitate hand-off bybull Calling to make appointment for patientstudent

bull Providing directions and clinic hours to patientstudent

bull Coordinating transportation when needed99

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Practice FLO ndash Dive Right In

bull Try screening and giving feedback only

bull After several practices with F add in L amp O

100

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Activity Wrap-Up

What I

learned

What Irsquod like

to work on

nexthellip

101

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

SBIRT Implementation Recommendations

bull Identify champions within primary care HIV and substance abuse settings

bull Promote SBI as a standard of care for all patients

bull Have an openness to new modalities such as brief intervention and brief treatment

bull Expand scope of focus to include high-risk alcohol and drug use not only dependence

SOURCE J Esquibel (2012) Colorado SBIRT wwwimprovinghealthcoloradoorg 102

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What did you learn

103

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

What did you learn

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 womanA No more than 1 drink per occasionB No more than 2 drinks per occasionC No more than 3 drinks per occasionD No more than 4 drinks per occasion

104

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

2 Please identify what the 5-letters in the AUDIT acronym stand for

A Alcohol Use Disease Inventory TestB Alcohol Use Disorders Identification TestC Alcohol Use Disorders Inventory TestD Alcohol Use Disease Inventory Training

What did you learn

105

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

3 Because of the linkage between substance use and HIV screening and brief intervention protocols have been adopted throughout the United StatesA TrueB False

What did you learn

106

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

4 Brief interventions often include A Feedback about the patientrsquos drug andor

alcohol useB Advice on how to cut down on onersquos alcohol

andor drug useC Motivational techniquesD A and B onlyE All of the above

What did you learn

107

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Take Home Points for Cliniciansbull Alcohol and drug problems are common

identifiable and treatable conditions in a variety of medical settings

bull Screening helps HIV providers to understand and address the consequences of untreated substance use disorders

bull Screening and brief intervention strategies can be used to maximize a ldquoteachable momentrdquo with your HIV patients

108

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Key SBIRT Resourcesbull Foundations of SBIRT Self-Paced Online Course

(wwwattcelearnorg) bull SBIRT Implementation Guide for HIV Care Service

Programs (wwwcenterforcommunitycollaborationorg )

bull NIAAA SBIRT Pocket Guide (httppubsniaaanihgovpublicationsPractitionerPocketGuidepocketpdf)

bull SAMHSA SBIRT White Paper (httpwwwsamhsagovpreventionsbirt)

109

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Key SBIRT Resourcesbull SAMHSA-HRSA Center for Integrated Health

Solutions ndash SBIRT Page (httpwwwintegrationsamhsagovclinical-practicesbirt)

bull Alcohol SBI Guide for Public Health Professionals (httpwwwaphaorgNRrdonlyresB03B4514-CCBA-47B9-82B0-5FEB4D2DC9830 SBImanualfinal4_16pdf)

bull National SBIRT ATTC (httpwwwattcnetworkorgregcentersindex_nfa_sbirtasp)

110

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg

Thank You

For more informationTom Freese tfreesemednetuclaedu

Beth Rutkowski brutkowskimednetuclaedu Maya Talisa Gil-Cantu mayaHIVtrainingCDUorg

Pacific Southwest ATTC wwwpsattcorg PAETC Training calendar wwwHIVtrainingCDUorg