1 / 49

SBIRT Training

SBIRT Training. The BNI-ART Institute Boston University School of Public Health Boston Medical Center, Dept. of Emergency Medicine Project Assert. BMC Emergency Department’s Health Promotion Advocates : provide comprehensive care & prevention

chione
Télécharger la présentation

SBIRT Training

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. SBIRT Training The BNI-ART Institute Boston University School of Public Health Boston Medical Center, Dept. of Emergency Medicine Project Assert

  2. BMC Emergency Department’s • Health Promotion Advocates : • provide comprehensive care & prevention • focus on substance abuse in context of other health and safety issues • offer info & health resources with emotional support & advocacy; • collaborates with staff to serve 5,000 + pts/yr Funded in 1993 SAMHSA/CSAT; 1998 line item in BMC ED Budget; a model for SBIRT in 2003 Lead HPA: Ludy Young., HPAs: John Cromwell, Dan Heenen, Brent Stevenson,, & Moses Williams AdmDir, Emma Riley; Med Dir., Dr. Edward Bernstein,

  3. What is SBIRT? • SBIRT is a comprehensive, integrated public health approach to the delivery of early intervention and treatment services to persons with at-risk and substance use disorders • The primary goal of SBIRT is to identify and effectively intervene with those who are high risk for psycho-social or health care problems related to their substance use. • Primary care centers, hospitals, EDs and other community settings provide excellent opportunity for early intervention

  4. The S-BI-RT • Screeningto identify patients with high-risk or dependent drinking and drug use • Brief Intervention:Conversation to motivate patients who screen positive to consider healthier decisions (e.g. cutting back, quitting, or seeking further assessment) • Referral to Treatment:Actively link patients to resources when needed

  5. Outline • Why people use alcohol and drugs • Different frameworks for viewing substance use • Moral failing • Biomedical model • Public health model • How SBIRT fits in • Evidence for SBIRT • Logistics of SBIRT in health care settings

  6. Why do people use alcohol & drugs? • Feels good/ not feel bad • Socialize, hang out • Feel outgoing, less shy • Have fun, relax • Celebrate • Stay alert • Tastes good

  7. Why do people use alcohol & drugs? • Environmental norms • Work place • Family, home • Friends • Peer pressure

  8. Why do people use alcohol & drugs? • Cope with stress • Self-medicate • Response to life trauma • ACEs: Adverse Childhood Events • Emotional, physical, sexual abuse; neglect; household dysfunction

  9. How does society view… …Alcohol and drug use / users? • In the past? • Currently? • In your community?

  10. A Moral Failing • Character flaw • Sign of personal weakness • Lacks values, strength • Menace, danger to society • Lazy, not contributing to society • Drugs are bad, deviant, criminal • Alcohol is acceptable up to a certain point • To be avoided; “Just say no” • Chose wrong path

  11. Traditional Approaches • War on Drugs, Just Say No • Jail, prison, department of corrections • Shame and blame confrontation • Treat and street in medical encounter • Stigmatization

  12. Dr. Nora Volkow: NIDA Director “STIGMA” In years past, science discovered the causes of epilepsy and leprosy and helped free the afflicted of stigma. “We are witnessing another instance of one of the great moral achievements of science: establishing the right of people who have been regarded as hopeless or untouchable to full consideration as human beings.” Addiction Science & Clinical Practice 2007; 4:1

  13. Reward and Craving Pathways

  14. Drugs can be “Imposters” of Brain Messages

  15. Cocaine increases dopamine levels by blocking re-uptake into cells dopamine

  16. Natural Rewards Elevate Dopamine Levels 1 2 3 4 5 6 7 8 Sex Food 200 200 NAc shell 150 150 DA Concentration (% Baseline) % of Basal DA Output 100 100 Empty 50 Box Feeding Female Present 0 Sample Number 0 60 120 180 Time (min) Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

  17. Functionally… Dopamine D2 Receptors are Decreased by Addiction Cocaine Meth DA D2 Receptor Availability Alcohol Heroin Control Addicted

  18. Dopamine is only part of the story Scientific research has shown that other neurotransmitter systems are also affected: Serotonin Regulates mood, sleep, etc. Glutamate Regulates learning and memory, etc.

  19. Genetic, Developmental and Environmental Interaction Non addicted unrelated Non addicted sibling Addicted sibling Precuneus Striatum Amygdala Orbitofrontal cortex Risk factors Protective factors Risk factors Protective factors Risk factors Protective factors Stop impulse response Stop impulse response Stop impulse response VolkowND, Baler RD. Science 2012; 335:546.

  20. Ability to stop an impulse to act is determined by the overall balance of risk factors and protective factors • Maladaptive risk factors • high impulsivity, stress reactivity • novelty seeking, conditioning/habits • negative emotionality • poor reality awareness • Adaptive protective factors • positive emotionality • robust inhibitory control and executive function • strong coping skills and good frustration management temper cues for potential reward

  21. SAMHSA CSAT Jack B. Stein, MSW, PhD

  22. Drug overdose deaths were second only to motor vehicle crash deaths among leading causes of unintentional injury death in 2007 in the United States. (27,658)

  23. Addiction similar to other Chronic Illnesses <30% of patients adhere to prescribed medications & diet or behavioral changes 50% recurrence rate Substance abuse should be insured, monitored, treated and evaluated like other chronic diseases Hypertension Diabetes Asthma Addiction McLellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

  24. Paradigm Shift = Innovative Approaches Shift from moral failing to addiction as a chronic and recurrent condition: • Chronic disease management • Integration with behavioral health • Expanding treatment options • Medication assistance : suboxone, methadone, naltrexate • Intensive outpatient services • Sober housing • Drug court and treatment in prison

  25. Treatment success depends on: A comprehensive model that considers • Interpersonal relationships • Employment options • Housing options • Mental health services • Safety and support • Human rights, dignity …and more

  26. Learning from Successful Examples: The Cardiac Care Chain of Survival ? • Saving lives & promoting recovery, cardiac & addiction require: • community involvement, screening and access • structural changes informed by evidence • $ and monitoring of access & quality • workforce development • an integrated, coordinated, collaborative system • public education, and advocacy & de-stigmatization

  27. Biomedical Model Isn’t Enough • Chronic illness model doesn’t take high-risk use into account • Many people who use alcohol and drugs do not meet criteria for dependence • Intervention still needed for preventing future injury, illness, or possible dependence • Substance use doesn’t happen in a vacuum • cost society over $600 billion annually • have far-reaching implications for family, workplace, community, and health care system

  28. SBIRT Addresses Both • Continuum of Use • Low-risk use • High-risk / unhealthy use • Abuse and dependence (substance use disorders) • Continuum of Care • Brief intervention, action plan • Wrap-around services • Detox, treatment types

  29. SBIRT: Part of a Public Health Solution • It attempts to identify those who are high-risk for psycho-social or health care problems related to their substance use • It attempts to effectively intervene in a nonjudgmental, empathic, and motivational way • It offers an opportunity for finding and connecting to additional services • It’s a holistic way of addressing the many ways the individual affects and is affected by its environment/society

  30. Does SBIRT work? Evidence

  31. Research Demonstrates Effectiveness • A growing body of evidence about SBIRT’s effectiveness, including cost-effectiveness, has demonstrated its positive outcomes. • The research shows that SBIRT is an effective way to reduce alcohol and drug related health and social/ legal problems.

  32. Making a Measurable Difference • Since 2003, SAMHSA has supported SBIRT programs with over 1.5 million persons screened. • Outcome data confirm a 40% reduction in harmful use of alcohol by those drinking at risky levels and a 55% reduction in negative social consequences. • Outcome data also demonstrate positive benefits for reduced illicit substance use. Based on review of SBIRT GPRA data (2003-2011).

  33. Brief Intervention in the Clinical Setting Reduces Cocaine and Heroin Use Testing the ASSERT Model- Randomized Control Trial in Heroin-Cocaine Users Intervention group more likely to be abstinent at 6 months(n=778 + hair at baseline) follow-up rate 82% cocaine alone (22.3% vs 16.9%) heroin alone (40.2% vs 30.6%) both drugs (17.4% v s 12.8%) adjusted OR of 1.51-1.57 Cocaine levels in hair reduced 29% intervention group vs 4% control group Bernstein et al. Drug & Alcohol Dependence, 2005;77:49-59

  34. Univ. of Michigan. Rhode Island Hospital Yale Univ. Denver Health Medical Cooper Health Univ. of Southern California Univ. of Virginia Charles Drew Univ. Howard Univ. Univ. of California Univ. of New Mexico Emory University New England Med. Boston Medical Academic Emergency Medicine SBIRT Collaborative 26% screened positive for at risk drinking

  35. Patient Response to SBIRT at 3 month F/U Summary (n=1173) At 3 months, controlling for baseline drinking levels, patients receiving the intervention • 2x as likely to drink within the NIAAA low risk guidelines as the controls (39% vs. 19%). • had 3 fewer ‘typical number of drinks per week’ than controls • providers reported greater utilization of SBIRT in their practice

  36. Meta-analyses of BI and MI Alcohol only Kaner et al. (Cochrane), 2007 I vs C ↓4 drinks/wk Vasilaki et al, 2006 aggregate .18, .60 at 3 months USPSTF, 2004 69% vs. 57% drinking risky amts; 38 grams/wk Alcohol/drugs Dunn et al, 2001 Hettema et al, 2005 (.30 at 1 yr)

  37. A Ten Minute Brief Negotiated Interview By Practitioners Reduces Hazardous and Harmful Drinking Among ED Patients ( Donofrio et al. Ann of Emerg Med. 2012) N=889 Mean # drinks/ past 7 days • BNI BL 19.8 12 mo 14.3 • SC BL 20.9 12 mo 17.6 # Binge drinking days/past 28 • BNI BL 7.5 12 mo 4.7 • SC BL 7.2 12 mo 5.8 Driving after >3 drinks • BNI BL 38% 12 mo 29% • SC BL 43% 12 mo 42%

  38. Recognizing the treatment gap and the need for prevention with a nationwide movement to a standard of care US Preventive Services Task Force Level I and II Trauma Centers Millions in federal SBIRT funding for state & residency training programs NIH funding Joint Commission hospital SBIRT standards reimbursement codes - Centers for Medicare & Medicaid Services; the AMA (CPT codes) and E&M codes

  39. What does SBIRT look like? Screening Brief Intervention Referral to Treatment

  40. Screening What • NIAAA Qs, NIDA Qs, DAST, AUDIT-C, AUDIT, CRAFFT , ASSIST, Health Needs History When • Triage, while patient awaits medical attention Who • Health promotion advocate (HPA), health educator, medical assistant, triage nurse, social worker, doctor Where • Triage, bedside, waiting room, private room/office

  41. Brief Intervention = the BNI What • BNI = Brief Negotiated Interview (5-steps) When • Patient screens positive for risky alcohol/drug use Who • Health promotion advocate (HPA), health educator, nurse, doctor, social worker, medical assistant Where • Bedside, private room/office

  42. 5 Steps of the BNI • Build rapport • Bringing up the topic, being nonjudgmental • Pros & Cons • Ask what is liked/disliked about the behavior • Information & Feedback • Give facts and feedback about the behavior, ask for thoughts • Readiness Ruler • Assess readiness to make any changes (to be healthier, safer) • Prescription for Change • Ask for action steps, create a plan together

  43. Referral to Treatment (or other services) What • Calling service providers, getting medical clearance (for detox), calling about insurance, arranging transportation, giving information: handouts, brochures, contact info., safety supplies When • Patient wants (and is good match for) additional services Who • Health promotion advocate (HPA), health educator, social worker, nurse, doctor, medical assistant Where • Bedside, private room/office

  44. Next, we'll break it down...

More Related