SBIRT TRAINING: FIELD SUPERVISORS APPRECIATION R. Lyle Cooper, Ph.D.Assistant Clinical ProfessorUniversity of Tennessee College of Social WorkProject Director SBIRT Training GrantMeharry Medical CollegeDepartment of Family and Community Medicine

WH

AT IS SBIRT?

An intervention based on “motivational interviewing” strategies • Screening: Universal screening for quickly assessing use

and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse

• Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users

• Referral to Treatment: Referrals to specialty care for patients with substance use disorders

Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment.

An Example of an SBIRT Intervention

http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/

MED

ICAL AND

PSYCHIATRIC H

ARM O

F HIG

H-RISK D

RINKIN

G

Historic Response and Public Health Response to Substance Abuse• Previously, substance use intervention and treatment

focused primarily on substance abuse universal prevention strategies and on specialized treatment services for those who met the abuse and dependence criteria.

• There was a significant gap in service systems for at-risk populations.

POLICY AN

D SBIRT

In the Public Health Paradigm, Services are Aligned and Integrated

Affordable Care Act: • Calls for the integration of mental and physical health care.• Mandates prevention, early intervention, and treatment.• Includes mental health and substance abuse treatment as “an

essential health benefit.”Mental Health Parity and Addiction Equity Act:• Health insurers and group health plans must provide the same

level of benefits for behavioral health as they do for primary care.

In Summary, mental and behavioral health must be considered in providing health care, and providers can be reimbursed for it!* *See sbirttn.org for more information on billing in Tennessee.

GOAL

The primary goal of SBIRT is to identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance abuse.

SEVERITY OF U

SEBased on Findings from Screening

Dependent Use

Harmful Use

At-Risk Use

Low Risk

SBIRT SCREENIN

G FLO

W

Client is given a screen with single question pre-screens

Social Worker reviews pre-screen prior to taking

the client to the office

Positive Screen

Social worker reviews screen

results and delivers brief intervention

Client asked to complete (is

administered) AUDIT and/or DAST

Client in need of

TX

Referral to TX made

at that time

Follow-up appointment scheduled

Client session documented in

recordNo further screening

75% Screen

Negative

This means more

assessment

Yes

NoNo

Yes

Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages?

NO YES

AUDIT C: How often do you have a drink containing alcohol? How many standard

drinks containing alcohol do you have on a typical day? 3. How often do you have six

or more drinks on one occasion?

Male score of 4 or more, Female score 2 or more, complete full

screen.

Sensitivity/Specificity: Male: 86%/89%

Female: 73%/91%

Source: www.integration.samhsa.gov/images/res/tool_auditc.pdf

ALCOHOL PRESCREENING

HOW MUCH IS “ONE DRINK”?

12-oz glass of beer (one can) 5-oz glass of wine

(5 glasses in one bottle)

1.5-oz spirits 80-proof

1 jigger

Equivalent to 14 grams pure alcohol

Determine the average drinks per day and

average drinks per week—ask:

On average, how many days a week do you have an alcoholic drink?

On a typical drinking day, how many drinks do you have? (Daily

average)

Weekly average = days X drinks

Recommended Limits

Men = 2 per day/14 per weekWomen/anyone 65+ = 1 per day or 7

drinks per week

> Regular limits = at-risk drinker

PRESCREENING DRINKING LIMITS

A POSITIVE ALCOHOL SCREEN

= AT-RISK DRINKER

Binge drink (5 for men or 4 for women/anyone 65+)

Or patient exceeds regular limits? (Men: 2/day or 14/week

Women/anyone 65+: 1/day or 7/week)

YESPatient is at risk. Screen for maladaptive pattern of use and clinically significant

alcohol impairment using AUDIT.

NOPatient is at low risk.

Alcohol Use Disorders Identification Test

AUDIT

What is it?Ten questions, self-administered or through an interview;

addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems

Developed by World Health Organization (WHO)

AUDIT QUESTIONNAIRE

WHO, 1992

AUDIT DOMAINS

WHO, 1992

SCORING THE AUDIT

Dependent Use (20+)

Harmful Use (16‒19)

At-Risk Use (8‒15)

Low Risk (0‒7)

SBI TRAININ

GOutline

• Motivational Interviewing Skills (Miller, Benefield, & Tonigan; r=.65)

• Responding to Change Talk• Role Play

RESISTANCE AN

D AM

BIVALENCE

Ambivalence

Problems with Status

quo

Hopes for change

CHANGE STATUS QUO

Desired effects of

status quo

Fear of Change

Counselor Behavior Counselor Behavior

Ambivalence Maintains the

Balance

Counselor Behavior Assists in Resolving Ambivalence, OR Assists in Maintaining

It!!!!!

OPEN

ING

STRATEGIES

Micro Skills

O A R S

PEN

QUESTIONS

FFIRMING

EFLECTIVE

UMMARIZING

AFFIRMATIO

NS

Affirmations are closely tied to our values. What feels affirming to one person can be irrelevant to another.Think of a compliment you received recently that was deeply meaningful to you. Write it down.What made this affirmation personally meaningful to you?

LEVELS OF REFLECTIO

NLEVELS OF REFLECTION

Simple Reflection—stays closeRepeatingRephrasing (substitutes synonyms)

Example

Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal.

Clinician: So, at this moment you are not too concerned about your drinking.

LEVELS OF REFLECTIO

N (CO

NTIN

UED

)LEVELS OF REFLECTION

Complex Reflection—makes a guessParaphrasing—major restatement, infers meaning, “continuing the paragraph”

Examples

Patient: “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!

Clinician: “It’s hard to imagine how I could possibly understand.”

***

Patient: “I just don’t want to take pills. I ought to be able to handle this on my own.”

Clinician: “You don’t want to rely on a drug. It seems to you like a crutch.”

LEVELS OF REFLECTIO

N (CO

NTIN

UED

)LEVELS OF REFLECTION

Complex Reflection

Reflection of feeling—deepest

Example

Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me!

Clinician: Her choosing not to attend today’s meeting was a big disappointment for you.

DO

UBLE-SID

ED REFLECTIO

NS

A double-sided reflection attempts to reflect back both sides of the ambivalence the patient experiences.

Patient: But I can't quit smoking. I mean, all my friends smoke!

Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you.

Patient: Yes. I guess I have mixed feelings.

SBI TRAININ

GChange Talk

Desire: wish, want, likeAbility: can, could, ableReasons: ct gives reasons for changeNeed: need, should, got to, mustCommitment LanguageCommitment: will, promise, intendTaking steps: ct expresses things they have done to change

SBI TRAININ

GDrumming for Change Talk

• I am going to read a series of statements

• You all listen, and if you hear change talk drum on your table or legs or something

• If you year commitment language, I want you to rub the pearl as it is precious in terms of change

BADG

E CARD

0 10

III

IV

Low risk or Abstain: 78%

Dependent: 5%

IIHarmful: 8%

Risky: 9%

Not at all

Very

Drinks Per week

DrinksPer day

Men 14 4 Women 7 3

All age >65 7 3 Pregnancy 0 0

Categories of drinking for patients

0 1 2 3 4 5 6 7 8 9 10

IIIIV

I Low risk or

Abstain: 78%

Dependent: 5%

IIHarmful: 8%

Risky: 9%

MEHARRY MEDICAL COLLEGELow-risk drinking limits

• “If it’s okay with you, let’s take a minute to talk about the annual screening form you’ve filled out today.”

Raise the subject

• “As your doctor, I can tell you that drinking (drug use) at this level can be harmful to your health and possibly responsible for the health problem you came in for today.”

Provide feedback

“On a scale of 0-10, how ready are you to cut back your use?”• If >0: “Why that number and not a ____ (lower one)?”

• If 0: “Have you ever done anything while drinking (using drugs) that you later regretted?”

Enhance motivation

• “What steps can you take to cut back your use?”• “How would your drinking (drug use) have to impact your life

in order for you to start thinking about cutting back?”

Negotiate plan

Zone of use: II - Risky III - Harmful IV - Dependent AUDIT score: Women: 4-12 Men: 5-14 Women: 13-19 Men: 15-19 Women and Men: 20+ DAST score: 0-2 3-5 6+

Not at all

Very

INSE

RT R

EFER

AL C

ONT

ACT

INFO

RMAT

ION

HERE

SBI TRAININ

GSBIRT Badge Card

Use the badge card to guide the conversation with the client in the

following exercise.

SBI TRAININ

GTry it Out

• In groups of 3 you will be given a case study. • One person will be the patient, one the social

worker, and the third the observer.• SW and observer, study the case study together

and identify areas of interest for the interview. • Patient, study your description.• Use the AUDIT and/or DAST responses you have to

start a motivational conversation about behavior change.

• Observer, use the BIOS to critique the work of the doc in your group.

References

Miller, W.R., Benefield, G.S., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.Burke, B.L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled drinking trials. Journal of Consulting and Clinical Psychology, 71, 843-861.Bertholet, N., Daeppen, J.B., Weitsbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: Systematic review and meta-analysis. Archives of Internal Medicine, 165(9), 986-985.