SBIRT

1. SBIRT

2. Learning Objectives At the end of the session, participants will be able to: • Understand SBIRT’s role in preventing the effect of substance abuse on individual and public health • Identify substance use risk limits • Identify how screening is conducted in a practice setting • Practice how to use two screening tools • IdentifyMIbasicsteps and core skills for the brief intervention • Demonstrateand practiceMIusingcore skills

3. What 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.

4. Leading Off: Defining the problem • Substance use: Inappropriate consumption of medicines, drugs. Alcohol, over the counter and prescription drugs. • Substance Misuse: consuming enough of a substance to put one’s physical or mental health at risk. • Substance Abuse: using a substance in a maladaptive pattern resulting in significant impairment or distress (e.g. significant negative impact with Family, school/work or legal status) • Substance Dependence: clinically significant impairment or distress as manifested by 3 or more of the following clinical criteria: Tolerance, withdrawal symptoms, substance taken in larger amounts than intended, unsuccessful attempts at decreasing use, disproportionate amount of time is spent on accessing and taking substance, important activities (social, occupational) are sacrificed to engage in use and continued use despite the person’s knowledge of the negative physiological and psychological effects the substance is having on their life.

5. Leading Off: Difference Between Abuse and Dependence • Abuse is too much, too often. Using substance at unsafe levels, but the person still able to avoid using when they need or want to. • Once a month binge drinking, and or drug use • Using is having an impact on one of these aspects of the person’s life: family/social, legal status, education/ employment. • Dependence is the inability to stop. The substance has become an integral, if not all encompassing, part of the person life. • Person to use or drink everyday or else they will experience withdrawal symptoms. • Person uses in the morning when they first wake up, or when they are at work. • Increased tolerance for substance of choice.

6. Alcohol vs Drug use: Key differences • Alcoholism tends to be insidious. Drug use can explode after several instances of using the substances • Drugs give a quicker, more intense high. • Increased risk of legal consequences for drug users. • More of a social stigma for drug users. • People with Alcohol Use Disorders can conceal their issues with more acceptable social rationale.

7. Detecting Risk Factors Early Screening can be a significant step toward effective intervention: • The clinician is often the first point of contact. • Early identification and intervention lead to better outcomes. • Patients are often seen by a clinician because of a related physical problem. Source: Treatnet. (2008). Screening, assessment and treatment planning.Retrieved from http://www.unodc.org/ddt-training/treatment/a.html

8. Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption During Pregnancy • An estimated 9.4 % of pregnant women in the US drank in the past month in 2010 and 2011 • National Institute on Alcohol Abuse and Alcoholism (NIAAA), the American College of Obstetricians and Gynecologists (ACOG) , and the United States Preventive Services Task Force (USPSTF) support universal screening. ACOG has stated that ‘‘physicians have an ethical obligation to learn and use techniques for universal screening questions, brief intervention, and referral to treatment’’ • The medical community will not be able to address alcohol exposure during pregnancy while women with alcohol use disorders remain undiagnosed and providers feel comfortable discussing these issues. Peggy L. O’Brien, Matern Child Health J (2014) 18:1–9, March 2013

9. Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption During Pregnancy • The universal application of SBIRT is necessary if disparities in screening and consequences are to be avoided. Universal application will capture use by women whom, contrary to the evidence doctors may not consider at risk • All women of reproductive age should be routinely screened as part of their primary care visit, with intervention provided as needed. • SBIRT for pregnant women should include prenatal and postpartum care. • Once screening occurs, both brief intervention and referral to treatment must be meaningful. A thoughtful brief intervention with subsequent booster sessions and/or carefully coordinated referral and follow-up may make a significant difference. Peggy L. O’Brien, Matern Child Health J (2014) 18:1–9, March 2013

10. Based on Findings of Screening Dependent Use Harmful Use At-Risk Use Low Risk

11. How Much Is “One Drink”? 5-oz glass of wine (5 glasses in one bottle) 12-oz glass of beer (one can) 1.5-oz spirits 80-proof 1 jigger Equivalent to 14 grams pure alcohol

12. 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) YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT. NO Patient is at low risk.

13. AUDITAlcohol Use Disorders Identification Test • 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)

14. AUDITAlcohol Use Disorders Identification Test • What are the strengths? • Public domain—test and manual are free • Validated in multiple settings, including primary care • Brief, flexible • Focuses on recent alcohol use • Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use • Limitations? • Does not screen for drug use or abuse, only alcohol

15. 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) YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT. NO Patient is at low risk.

16. Experts now know that the effects of prenatal alcohol exposure extend beyond FAS "Fetal alcohol spectrum disorders“ (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis Alcohol and Pregnancy

17. TWEAK • T-Tolerance: How many drinks can you hold? • W-Worried: Have close friends or relatives Worried or complained about your drinking in the past year? • E-Eye opener: Do you sometimes take a drink in the morning when you get up? • A-Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? • K- Do you sometimes feel the need to Cut down on your drinking?

18. Prescription Drug Misuse Although many people take medications that are not prescribed to them, we are primarily concerned with— • Opioids (oxycodone, hydrocodone, fentanyl, methadone) • Benzodiazepines (clonazepam, alprazolam, diazepam) • Stimulants (amphetamine, dextroamphetamine, methylphenidate • Sleep aids (zolpidem, zaleplon, eszopicione) • Other assorted (clonidine, carisoprodol)

19. Common Illicit Drugs • Marijuana (Cannabinoids) • Crack/Cocaine (Stimulants) • Heroin (Opioids) • Crystal Methamphetamine (Stimulants) • Ecstasy (Club Drugs) • LSD, Shrooms (Hallucinogens)

20. Common Illicit Drugs • Marijuana (Cannabinoids): psychological dependence. • Crack/Cocaine (Stimulants): short half-life, fast withdrawal. • Heroin (Opioids): effects similar to prescription opioids. • Crystal Methamphetamine (Stimulants) : Fast addiction, MSM. • Ecstasy (Club Drug) • LSD, Shrooms (Hallucinogens): small chance of dependence.

21. Drug Abuse Screening Test (10) • What is it? • Shortened version of DAST 28, containing 10 items, completed as self-report or via interview. DAST(10) consists of screening questions for at-risk drug use that parallel the MAST (an alcohol screening instrument) • Developed by Addiction Research Foundation, now the Center for Addiction and Mental Health • Yields a quantitative index of problems related to drug misuse • What are the strengths? • Sensitive screening tool for at-risk drug use • What are the weaknesses? • Does not include alcohol use

22. Scoring the DAST(10)Drug Abuse Screening Test High Risk (6+) Harmful Use (3‒5) Hazardous Use (1‒2) Abstainers (0)

23. Screening: Screening for Alcohol Use During Pregnancy https://www.youtube.com/watch?v=qlwqTQh_Hlo

24. Key Points for Screening • Screen everyone. • Screen both alcohol and drug use including prescription drug abuse and tobacco. • Use a validated tool. • Prescreening is usually part of another health and wellness survey. • Explore each substance; many patients use more than one. • Follow up positives or "red flags" by assessing details and consequences of use. • Use your MI skills and show nonjudgmental, empathic verbal and nonverbal behaviors during screening.

25. Brief Intervention: MotivationalInterviewing

26. Definition of Motivational Interviewing “Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

27. Applications of MotivationalInterviewing • MI enhances change for a range of behaviors: • Diet • Exercise • Reduction of alcohol and illicit drugs • Safer sex practices • Medication adherence • (Burke et al., 2003; Hettema et al., 2005; Rubak et al., 2005).

28. Four Stepsof theMIProcess 1.Engage (Express Empathy, Ask Open-Ended Questions) 2.Focus (Reflecting, Summarizing) 3.Evoke (Motivations, Concerns) 4.Plan (Raise Subject, Support Self-Efficacy)

29. Spirit of Motivational Interviewing • Collaborative (not confrontation) • - Developing a partnership in which the patient’s expertise, perspectives, and input are central to the consultation • - Fostering and encouraging power sharing in the interaction • Evocative • - Motivation for change resides within the patient • - Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals

30. Spirit of Motivational Interviewing • Respectful of autonomy (not authority) • - Respecting the patient’s right to make informed choices facilitates change • - The patient is in charge of his/her choices and responsible for the outcomes • - Emphasize patient control and choice • Compassionate • - Empathy for the experience of others • - Desire to alleviate the suffering of others • - Belief and commitment to act in the best interests of the patient

31. Stages of Change Prochaska & DiClemente (1984)

33. MotivationalInterviewing Coreskills

34. Core MI Skills • Open-Ended Questions • Affirmations • Reflections • Summaries

35. Open-EndedQuestions • Using open-endedquestions— • Enablesthe patienttoconveymore information • Encouragesengagement • Opensthe doorfor exploration

36. Open-EndedQuestions • Whatareopen-endedquestions? • Gatherbroaddescriptiveinformation • Requiremoreofa responsethana simple yes/noor fill intheblank • Oftenstartwithwordssuchas— • “How…” • “What…” • “Tell meabout…” • Usually gofromgeneral tospecific

37. Closed-EndedQuestions PresentConversationalDead Ends • Closed-endedquestions • typically— • Are for gatheringvery specific information • Tendtosolicityes-or-noanswers • Convey impression that the agenda is not focusedonthe patient

38. Closed-EndedQuestions • Avoid “Why?” Questions • Putspatientin a passive, or defensive,role • No opportunityfor patient toexploreambivalence

39. Learning Exercise Turningclosed-endedquestionintoan open-endedone. Doyoufeeldepressed oranxious?

40. Affirmations • What is anaffirmation? • Complimentsorstatementsof appreciationandunderstanding • Praisepositivebehaviors • Supportthe personastheydescribe difficult situations

41. Affirmations • Why affirm? • Supportandpromoteself-efficacy,prevent • discouragement • Buildrapport • Reinforce openexploration • (patienttalk) • Caveat • Mustbedonesincerely

42. AffirmationsMayInclude: • Commentingpositivelyonanattribute: • "Youare determinedtogetyourhealth back.” • A statement ofappreciation: • "I appreciate your openness and honesty today." • A compliment: • "Thankyouforall yourhardwork today."

43. Learning Exercise Provide an affirmation for each given patient scenario.

44. Reflective Listening Reflectivelisteningis oneofthe hardestskillstolearn. “Reflectivelisteningis away of checkingratherthanassumingthat you know whatismeant.” (MillerandRollnick, 2002)

45. Reflective Listening • Why listenreflectively? • Demonstratesthatyou have accurately heard andunderstoodthe patient • Strengthensthe • empathicrelationship

46. Reflective Listening • Why listenreflectively? • Encouragesfurtherexplorationofproblemsand feelings • Avoidthepremature-focus trap • Canbeusedstrategicallytofacilitate change

47. Levels ofReflection • SimpleReflection—staysclose • Repeating • Rephrasing(substitutessynonyms) • Example • Patient: Ihear whatyouare sayingabout my drinking,butIdon’tthinkit’ssucha bigdeal. • Clinician:So,atthismomentyouare nottooconcernedaboutyourdrinking.

48. Levels ofReflection • Complex Reflection—makes a guess • – Paraphrasing—majorrestatement,infersmeaning, “continuingtheparagraph” • Examples • Patient:“Whoareyouto begivingmeadvice?Whatdoyouknowabout drugs?You’veprobablyneverevensmokedajoint! • Clinician:“It’shard to imaginehowIcouldpossiblyunderstand.” • *** • Patient:“Ijustdon’twanttotakepills. Ioughtto beableto handlethison my • own.” • Clinician:“Youdon’twantto rely onadrug.Itseemsto youlike acrutch.”

49. Levels ofReflection • ComplexReflection • – Reflection offeeling—deepest • Example • Patient:My wifedecidednottocometoday.Shesaysthisis my problem,andI needto solveit orfindanewwife.After alltheseyearsof my usingaround her,nowshewantsimmediatechangeanddoesn’twantto helpme! • Clinician:Herchoosingnottoattendtoday’smeetingwasabig • disappointmentforyou.

50. Learning Exercise Turningpatient statements into reflections. Ex: Work has been hectic and some wine helps me relax.