Screening, Brief Screening, Brief Intervention, Referral, and Intervention, Referral, and

Treatment (SBIRT) Treatment (SBIRT) Training SessionTraining Session

OB/GYNOB/GYN1.1. Review of the scope of problems due to Review of the scope of problems due to

alcoholalcohol

2.2. Review of screening and Review of screening and effective effective interventionsinterventions

3.3. BreakBreak

4.4. Video demonstration of Video demonstration of brief negotiated brief negotiated interventionintervention (BNI) (BNI)

5.5. Role playing sessions (small group) and Role playing sessions (small group) and discussiondiscussion

6.6. Complete post-program quiz Complete post-program quiz

Several TruthsSeveral Truths

Practitioners are reluctant to screen Practitioners are reluctant to screen and interveneand intervene

The primary care visit is an The primary care visit is an opportunity for interventionopportunity for intervention

Treatment works!Treatment works! Timely referral is effectiveTimely referral is effective

Alcohol: Scope of Alcohol: Scope of the Problem the Problem Why should Why should wewe care? care?

Alcohol is the most commonly used Alcohol is the most commonly used drug in the United Statesdrug in the United States

Alcohol Fast FactsAlcohol Fast Facts

Alcohol related deaths Alcohol related deaths 75,000/year75,000/year

Annual economic costAnnual economic cost $185 billion$185 billion Homicides (alcohol involved)Homicides (alcohol involved) 60-70%60-70% Suicides (alcohol involved)Suicides (alcohol involved) 40%40% Fatal motor vehicle accidentFatal motor vehicle accident 50%50% A risk factor for medical conditionsA risk factor for medical conditions

Hypertension, stroke, diabetes, liver, GI Hypertension, stroke, diabetes, liver, GI diseasedisease

Alcohol Fast FactsAlcohol Fast Facts

Major risk factor for all categories of Major risk factor for all categories of injuryinjury Problem drinkersProblem drinkers

Injuries per yearInjuries per year 2x 2x Hospitalizations for injuriesHospitalizations for injuries 4x 4x hospitalizations for injuryhospitalizations for injury

Even one alcohol-related visit Even one alcohol-related visit predicts continued problem drinkingpredicts continued problem drinking

Young AdultsYoung Adults Alcohol use in the past monthAlcohol use in the past month

88thth grade grade 17% 17% 1010thth grade grade 33%33% 1212thth grade grade 47% 47%

Binge drinking (>5drinks in a row) in last 2 weeksBinge drinking (>5drinks in a row) in last 2 weeks 8th grade8th grade 11% 11% 1010thth grade grade 21%21% 12th grader 12th grader 28%28%

Drivers between the ages of 16-25 account Drivers between the ages of 16-25 account for 30% of alcohol-related fatalitiesfor 30% of alcohol-related fatalities

Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org

Adults over 18 yearsAdults over 18 years

10 million (5%) 10 million (5%) dependent dependent drinkersdrinkers

40 million (20%) 40 million (20%) high risk drinkershigh risk drinkers 70 million (35%) 70 million (35%) moderate moderate

drinkersdrinkers 80 million (40%) 80 million (40%) abstainabstain

National Longitudinal Alcohol Epidemiologic Survey, 1992National Longitudinal Alcohol Epidemiologic Survey, 1992

High risk “At-risk” High risk “At-risk” drinkersdrinkers

Issues unique to Issues unique to pregnancypregnancy

Prevalence of alcohol usePrevalence of alcohol use 11%11% Binge drinking in a previous monthBinge drinking in a previous month 2% 2%

Prevalence of use (age 18-44)-non pregnantPrevalence of use (age 18-44)-non pregnant55%55%

Binge drinking in a previous monthBinge drinking in a previous month 13%13% Many not using contraception Many not using contraception

>50%>50%

Pregnancy is a unique time, where motivation to Pregnancy is a unique time, where motivation to reduce alcohol use may be higher.reduce alcohol use may be higher. 74% of women stop drinking during pregnancy.74% of women stop drinking during pregnancy.

Issues unique to Issues unique to pregnancypregnancy

No known safe levels of alcohol intake No known safe levels of alcohol intake No exact dose-response relationshipNo exact dose-response relationship Binge drinking may be more concerning Binge drinking may be more concerning

than similar volumes over time.than similar volumes over time. Increased stillbirth rateIncreased stillbirth rate

<1 drink per week<1 drink per week 1.37 per 1000 births1.37 per 1000 births >/=1 drink per week>/=1 drink per week 8.83 per 1000 births8.83 per 1000 births

Current U.S. recommendation: Current U.S. recommendation: abstinenceabstinence

Fetal alcohol syndrome Fetal alcohol syndrome (most severe)(most severe)

Prevalence with heavy drinkersPrevalence with heavy drinkers 10-10-50%50%

Offspring issues:Offspring issues: Leading cause of developmental delay in the US.Leading cause of developmental delay in the US. Growth problems (<10% at any point in time)Growth problems (<10% at any point in time) Facial dysmorphia Facial dysmorphia

MicrocephalyMicrocephaly Smooth philtrum, thin vermillion border, small palpebral Smooth philtrum, thin vermillion border, small palpebral

fissuresfissures Maxillary hypoplasiaMaxillary hypoplasia

Central nervous system abnormalitiesCentral nervous system abnormalities Average IQ 63Average IQ 63 Fine motor dysfunctionFine motor dysfunction

Ambulatory medical care survey

Nation’s Public Health Nation’s Public Health Agenda:Agenda:

Healthy People 2010Healthy People 2010 Increase the proportion of persons Increase the proportion of persons

who are referred for follow-up care who are referred for follow-up care for alcohol problems, drug problems, for alcohol problems, drug problems, or suicide attempts after diagnosis or suicide attempts after diagnosis or treatment for one of these or treatment for one of these problems in the emergency problems in the emergency departmentdepartment

SCREENINGSCREENING

Screening for Alcohol use and abuse

ACOG Committee Opinion: Dec 2008ACOG Committee Opinion: Dec 2008 ““Obstetrician-gynecologists have an ethical obligation Obstetrician-gynecologists have an ethical obligation

to learn and use a protocol of universal screening to learn and use a protocol of universal screening questions, brief intervention, and referral to treatment questions, brief intervention, and referral to treatment in order to provide patients with medical care that is in order to provide patients with medical care that is state-of-the-art, comprehensive and effective. state-of-the-art, comprehensive and effective.

Screening allows for early and effective treatmentScreening allows for early and effective treatment Screening is cost-effective (saves $7 for every $ Screening is cost-effective (saves $7 for every $

spent)spent) Primary care visit is an ideal opportunity to Primary care visit is an ideal opportunity to

screen and intervene as necessaryscreen and intervene as necessary

UNIVERSAL SCREENING WIDENS THE NET

ABSTAINERS & MILD DRINKERS

(70%)

MODERATE(20%)

at risk drinkers

SEVERE (10%)

Primary Prevention

Brief Intervention

Specialized Treatment

ASK Current DrinkersASK Current Drinkers

On average, how many days per On average, how many days per week do you drink alcohol?week do you drink alcohol?

On a typical day when you drink, On a typical day when you drink, how many drinks do you have?how many drinks do you have?

What is the maximum number of What is the maximum number of drinks you had on a given occasion drinks you had on a given occasion last month?last month?

Remember that a Remember that a “standard drink” “standard drink”

consists of:consists of:

Screen Positive: NIAAA Screen Positive: NIAAA GuidelinesGuidelines

Pregnant womenPregnant women 0 drinks0 drinks

ASK Current DrinkersASK Current Drinkers

CAGE

C Cut DownA AnnoyedG GuiltyE Eye Opener

DetectionDetection and and ReferralReferral

Does it matter?Does it matter?

What do we do?

ABSTAINERS & MILD DRINKERS

(70%)

MODERATE(20%)

at risk drinkers

SEVERE (10%)

Primary Prevention

Brief Intervention

Specialized Treatment

Brief negotiated Brief negotiated intervention (BNI):intervention (BNI):

A motivational interviewA motivational interviewFor the “At-risk drinker”For the “At-risk drinker”

Principles of Motivational Principles of Motivational InterviewingInterviewing

Ask for permission to discuss problemsAsk for permission to discuss problems

Express empathy and avoid argumentsExpress empathy and avoid arguments

Develop discrepanciesDevelop discrepancies Help patients understand the differences between their Help patients understand the differences between their

behavior and their goalsbehavior and their goals

Roll with resistance and provide personalized Roll with resistance and provide personalized feedbackfeedback ““Reflective listening” Reflective listening”

Support self-motivationSupport self-motivation

Motivational Interviewing: Motivational Interviewing: A Tool for Behavior ChangeA Tool for Behavior Change

ACOG Committee Opinion: Jan 2009ACOG Committee Opinion: Jan 2009 The goal is to “help patients identify and The goal is to “help patients identify and

change behaviors that place them at risk”change behaviors that place them at risk”

““motivational interviewing to everyday patient motivational interviewing to everyday patient interactions has been proved effective in interactions has been proved effective in eliciting “behavior change”eliciting “behavior change”

““ACOG encourages the use of motivational ACOG encourages the use of motivational interviewing as one approach to elicit behavior interviewing as one approach to elicit behavior change.” change.”

Fleming et al JAMA Fleming et al JAMA 19971997

“Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices”

Randomized controlled trial 723 patients Randomized controlled trial 723 patients

17 practices with 64 physicians17 practices with 64 physicians

Intervention included: Intervention included: Educational workbook, Educational workbook, 15 minute visits one month apart x 215 minute visits one month apart x 2 Nurse follow-up calls x 2 (2 weeks after the visit)Nurse follow-up calls x 2 (2 weeks after the visit)

Fleming et al JAMA Fleming et al JAMA 19971997

Results at 12 months (n=723)Results at 12 months (n=723)

Alcohol consumption reduced with Alcohol consumption reduced with

intervention: intervention: Intervention group Intervention group 19.1 drinks/wk 19.1 drinks/wk

11.5 11.5

Control group Control group 18.9 drinks/wk 18.9 drinks/wk

15.215.2

Episodes of binge drinking during Episodes of binge drinking during

prior 30 days:prior 30 days: Intervention groupIntervention group 5.7 5.7 3.1 3.1

Control groupControl group 5.3 5.3 4.2 4.2

Brief Interventions are Effective…

How do we do it?How do we do it?

Video: Scenario 1Video: Scenario 1

Components of the Brief Components of the Brief Negotiated InterventionNegotiated Intervention

1.1. Raise the SubjectRaise the Subject

2.2. Provide FeedbackProvide Feedback

3.3. Enhance MotivationEnhance Motivation

4.4. Negotiate and AdviseNegotiate and Advise

Establish RapportEstablish Rapport Raise the subject of alcohol useRaise the subject of alcohol use

Step 1: Raise the SubjectStep 1: Raise the Subject

Step 1: Establish RapportStep 1: Establish Rapport

To understand the patient’s concerns To understand the patient’s concerns and circumstancesand circumstances ““That car accident must have been scary”That car accident must have been scary” ““Having your boyfriend hurt you must be Having your boyfriend hurt you must be

awful”awful” To explain the providers concern/roleTo explain the providers concern/role

I am concerned regarding the effect I am concerned regarding the effect alcohol may be having on you.alcohol may be having on you.

To avoid a judgmental stanceTo avoid a judgmental stance

Step 1: Raise the Step 1: Raise the subjectsubject

Get the patient’s agreement to talk about Get the patient’s agreement to talk about the alcohol or drug usethe alcohol or drug use Do you mind if we just take a few minutes to Do you mind if we just take a few minutes to

talk about your alcohol/drug use?talk about your alcohol/drug use?

Talk about the pros and cons of their Talk about the pros and cons of their use/abuseuse/abuse What is it that alcohol does for you?What is it that alcohol does for you?

Re-state what they have said regarding Re-state what they have said regarding the pros and consthe pros and cons

Troubleshooting:What if the patient does not want to talk about

their use/abuse ?

“ “ Okay, I see you aren’t ready to talk Okay, I see you aren’t ready to talk about this today. Remember that we are about this today. Remember that we are

here 24 / 7 if you change your mind”here 24 / 7 if you change your mind”

Step 2:Step 2: Provide Provide FeedbackFeedback

Review patient’s drinking patternsReview patient’s drinking patterns ““From what I understand you are From what I understand you are

drinking…”drinking…”

Step 2:Step 2: Provide Provide FeedbackFeedback

Make connection to the visit if possibleMake connection to the visit if possible ““What connection (if any) do you see What connection (if any) do you see

between your drinking and this visit?”between your drinking and this visit?” If the patient sees a connection:

Reflect what they have just said. If the patient does not see a connection:

Help make a connection with facts “Alcohol can slow your reflexes and

predispose you to accidents” “Alcohol may impair your judgment and …..

Step 2:Step 2: Provide Provide FeedbackFeedback

Compare to National Norms and Compare to National Norms and offer NIAAA guidelines (show them)offer NIAAA guidelines (show them)

Step 3: Enhance Step 3: Enhance Motivation:Motivation:

Assess the readiness for Assess the readiness for changechange

““On a scale of 1-10 On a scale of 1-10

(1 being not ready and 10 being very (1 being not ready and 10 being very ready) ready)

how ready are you to change any how ready are you to change any aspect your drinking patterns?”aspect your drinking patterns?”

1 2 3 4 5 6 7 8 9 10

Step 3: Enhance MotivationStep 3: Enhance MotivationDevelop DiscrepanciesDevelop Discrepancies

• If patient indicates she is ready for change:If patient indicates she is ready for change:

>> 2 : 2 : “Why did you choose that number and “Why did you choose that number and not a lower one? What are some reasons that not a lower one? What are some reasons that you are so motivated to change.”you are so motivated to change.”

• If patient indicates she is not ready for If patient indicates she is not ready for change:change:

<< 1: 1: “Have you ever done anything that you “Have you ever done anything that you wish you hadn’t while drinking: What would wish you hadn’t while drinking: What would make this a problem for you.” Discuss pros and make this a problem for you.” Discuss pros and conscons

Step 3: Enhance MotivationStep 3: Enhance Motivation Develop DiscrepancyDevelop Discrepancy

Explore Pros and ConsExplore Pros and Cons

Help the patient identify the Help the patient identify the discrepancy between present behavior discrepancy between present behavior and important goals and important goals

Use the discrepancy as a change Use the discrepancy as a change motivatormotivator

Let the patient name the problem and Let the patient name the problem and offer solutionsoffer solutions

The Ready PatientThe Ready Patient

Help the patient to:Help the patient to: Name a solution for themselvesName a solution for themselves Choose a course of actionChoose a course of action Decide how to achieve itDecide how to achieve it Encourage patient choiceEncourage patient choice

Not Ready for ChangeNot Ready for Change

Don’t Don’t Use shame or Use shame or

blameblame PreachPreach LabelLabel StereotypeStereotype ConfrontConfront

DoDo Offer information, Offer information,

support and further support and further contactcontact

Present feedback Present feedback and concerns, if and concerns, if permittedpermitted

Negotiate: “What Negotiate: “What would it take you to would it take you to consider a consider a change ?”change ?”

Not Ready for Change Not Ready for Change Avoid argumentsAvoid arguments

Counter productiveCounter productive Defending breeds defensivenessDefending breeds defensiveness Perceptions can be shiftedPerceptions can be shifted Labeling is unnecessaryLabeling is unnecessary Resistance is a signal to change Resistance is a signal to change

strategiesstrategies Rolling with resistanceRolling with resistance

Unsure patientsUnsure patients

Don’tDon’t Jump aheadJump ahead Give adviceGive advice Expect argument Expect argument

about change about change

DoDo Explore pros & Explore pros &

conscons ““help me to help me to

understand what understand what alcohol does for alcohol does for you”you”

““Are there things Are there things you don’t like about you don’t like about your alcohol use?”your alcohol use?”

Step 4:Step 4: Negotiate and Negotiate and AdviseAdvise

Reinforce what the patient has stated are Reinforce what the patient has stated are her goals.her goals. ““So… you would like to reduce your drinking to So… you would like to reduce your drinking to

prevent….”prevent….” Negotiate the goal/Elicit a responseNegotiate the goal/Elicit a response

““What is the next step?”What is the next step?” Give adviceGive advice

““If you can stay within the limits you just If you can stay within the limits you just mentioned you will be less likely to have a car mentioned you will be less likely to have a car accident..”accident..”

SummarizeSummarize ““This is what I heard you say..This is what I heard you say..

Step 4:Step 4: Negotiate and Negotiate and AdviseAdvise

Provide handoutsProvide handouts Drinking Drinking

agreementsagreements Other support Other support

sourcessources

Step 4:Step 4: Negotiate and Negotiate and AdviseAdvise

Suggest primary care follow up or Suggest primary care follow up or referralreferral Social workerSocial worker Psychiatric servicesPsychiatric services Discharge sheet of possible centers and Discharge sheet of possible centers and

/ or programs and information/ or programs and information

Thank patient for their timeThank patient for their time

SummarySummary

Alcohol problems are common, Alcohol problems are common,

identifiable and treatable disordersidentifiable and treatable disorders

Knowledge and skills for screening Knowledge and skills for screening

and intervention can be learnedand intervention can be learned

VIDEO 2VIDEO 2ndnd and 3 and 3rdrd scenarioscenario

DiscussionDiscussion

To what degree do you discuss alcohol use with your patients?

DiscussionDiscussion

Do you think you can incorporate SBIRT (Screening, Brief Negotiated Interview, and Referral to Treatment) into your practice?

If so, why? What parts seem to work well?

If not, why not? What barriers exist?

Small GroupsSmall Groups