Using Screening, Brief Intervention & Referral to Treatment (SBIRT) in Practice: A Skills Building Workshop

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1 Using Screening, Brief Intervention & Referral to Treatment (SBIRT) in Practice: A Skills Building Workshop Joanne DeSanto Iennaco PhD, PMHNP BC, PMHCNS BC, APRN Acknowledgements Yale SBIRT Medical Health Professional Training Programs. Principal Investigator:Gail D Onofrio, Yale School of Medicine. Joanne Iennaco: Co Investigator and Team Leader for Yale School of Nursing. (SAMHSA: 1U79TI Funding Period: 9/1/2014 to 8/31/2017). Speaker has no further Conflict of Interest Objectives Participants will be able to: Identify current trends in substance use and abuse across the lifespan. Identify critical components in screening across the lifespan for hazardous or harmful substance use Utilize a brief negotiated intervention based on motivational interviewing techniques to engage Scope of the Problem Total annual economic costs to the U.S. are estimated to exceed $414 billion Jackson B. J Add Dis 2010 Given the high rates of medical comorbidities, individuals with substance use disorders are more likely to present to health care systems than any other service system. Mertens JR, et al. Arch Int Med % of ED patients need substance abuse treatment: 1% had a recorded diagnosis of substance abuse Rockett IRH. Ann Emerg Med National Survey on Drug Use & Health 59.7 million (23%) binge drinking in last 30 days 23.9 million (9.2%) used illicit drug 9.2% increase from million (8.5%) met DSM IV criteria for an alcohol or illicit drug use disorder 23.1 million need treatment for substance abuse 2.5 million, (or 12%) receive it. Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 1

2 Drug Trends Summarized Adults: Increasing use over time 9.4% used an illicit drug in past month (> 12y or older) Marijuana: 2007: 5.8% 2013: 7.5% Other rates have stabilized RX drugs, Hallucinogens (ecstasy, LSD) Cocaine use decreasing; Methamphetamine increasing First use: Most as Teenagers 54% of the 7800 new users per day Most begin with marijuana Highest rates late teens & 20 s Youth: Past Year Substance Use [12 th Grade, 2014 Monitoring the Future (UMich)] Alcohol: 60% Marijuana: 35% (approx. 6% are daily users) Synthetic Marijuana (spice, K2): 5.8% Prescription or OTC drugs: 1.8% to 6.8% Drinking Binge Drinking more widespread Men 30.2% (2013, > 12y, past month) Women 16% Heavy use more widespread Men 9.5% Women 3.3% Underage drinking has decreased Current use: 28.8% in 2002 to 22.7% in 2013 Binge drinking: 19.3% in 2002 to 14.2% in 2013 Heavy drinking: 6.2% in 2002 to 3.7% in 2013 Source: Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 2

3 From: topics/trends statistics/infographics/monitoring future 2014 survey results From: topics/trends statistics/infographics/monitoring future 2014 survey results From: From: Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 3

4 Opioid Misuse Prescription opioid and heroin abuse have reached epidemic proportions 2011 prevalence of high school seniors reporting past-year non medical use of opioid (2nd to marijuana use only) -8.1% hydrocodone -4.9% for oxycodone National Survey on Drug Use and Health 6.1 million Americans reported using prescription medications for nonmedical purposes 335,000 used heroin ED visits related to opioids increased 145,000 to 420,000 from Overdose death rates in the U.S. increased 3.4 to 12.4 per 100,000 ( ) eclipsing motor vehicle death rates for the first time in 2009 From: results Alcohol Screening Screen Positive Structured questionnaires CAGE/TWEAK CRAFFT AUDIT ASSIST What is a Standard Drink? Drug Screening In the past 12 months, have you used drugs other than those required for medical reasons? Have you ever requested refills earlier than prescribed? How long have you been taking? Ever taken more than prescribed? How do you take it? Ever concerned about misuse? Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 4

5 AUDIT and DAST (10 Questions) What is a Brief Intervention & How do I perform it? What makes people change their substance use? The same things that make anyone change any problem behavior Autonomy (freedom-of-choice) Non-confrontational, but persistent questioning, reflective listening & feedback Making a plan for change Hearing themselves argue in favor of change for their own good reasons, because People only really listen to 1 person THEMSELVES! What if the patient does not want to talk about their use/abuse? That s absolutely your choice and I, of course, can t make you discuss that with me. But part of my job is to ask everyone a few questions about this topic. So, I ll do that but you don t have to answer. If you change your mind you can jump back into the conversation at any point. Brief Negotiation Interview Raise The Subject Establish rapport Raise the subject of drug use Assess comfort Provide Feedback Review patient s alcohol and/or drug use and patterns Make connection between AOD use and negative consequences; (e.g. impaired judgment leading to injury/unprotected sex/sharing needles) Make a connection between AOD use and ED visit D Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O Connor PG. Development and implementation of an emergency practitioner performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med 2005;12: Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 5

6 BNI (continued) Enhance Motivation Assess readiness to change: One a scale 1 to 10 how ready are you to stop using, cut back or enroll in program??? (Why didn t you pick a lower number?) Negotiate And Advise Negotiate goal Give advice Summarize and complete referral/prescription form Thank patient for their time D Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O Connor PG. Development and implementation of an emergency practitioner performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med 2005;12: The 4 Steps of Brief Intervention (your cheat-sheet ) Step 1: Establish Rapport & Screen Hello, I m Do you mind? Screen (card) & assess if risky or dependent Step 2: Provide Feedback Express concern & advise Ask for pt s concerns & reflect them Step 3: Enhance Motivation 1-10?; Why not a lower #?; Reflect Step 4: Negotiate a Plan What s your next step?; reinforce or add; f/u Still Not Ready for Change Don t Use shame or blame Preach Label Stereotype Confront Still Not Ready for change Do Reiterate autonomy Offer information, support and further contact Present feedback and concerns, if permitted Agree to disagree What would it take for you to consider a change? Leave the door open Express Empathy OTHER CONSIDERATIONS Attitude : Acceptance by provider Technique: Skillful reflective listening Basis of change: Resolving (vs. confronting) patient ambivalence Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 6

7 Avoid Argumentation Counter productive Defending breeds defensiveness Perceptions can be shifted Labeling is unnecessary Resistance is a signal to change strategies Rolling with resistance Develop Discrepancy; Explore Pros and Cons Discrepancy between present behavior and important goals as change motivator Let the patient name the problem and the pros and cons Dangerous Assumptions Dangerous Assumptions This person ought to change. This person is ready to change. This person s health is the prime motivating factor for him/her. If they decide not to change the SBIRT has failed. Patients are either motivated or not Now is the right time to change A tough approach is best I am the expert and they should follow my advice Summary Alcohol & drug problems are common, identifiable and treatable disorders. Knowledge and skills for screening and intervention can be learned. Remember, ask yourself, Why might I just start the conversation? You may save a life! Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 7

8 Yale University School of Medicine Ultimate Goal ADOPTION OF SBIRT INTO PRACTICE Dissemination and Sustainability Adoption Engage residency directors and other faculty Incorporated SBIRT into orientation programs Even better: value added help with the core competencies Incorporated into procedure logs Adoption: Screening Procedures Some things to consider: Who will perform the screening or be responsible for its completion? (e.g. receptionist, nurse, health educator, physician ) How will the screening be performed (e.g. self administered, paper, ipad etc. or by staff) Where will the screening be performed? (e.g. waiting room, triage area, patient room) What screening tools will you use? (e.g. NIAAA single questions screen or AUDIT etc) Adoption: Providing the BNI Some things to consider: Who will conduct the BNI? When will the BNI be delivered? What immediate resources are available on site for urgent/severe problems that are identified? (e.g. social work, health educators) What community specialty services are available for referral? Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 8

9 Elements of Success Implementation Buy in Community partners Faculty/ED champions Training Scripted Laminated Cards Standardized Patient Encounter Feedback Fulfills ACGME core competency requirements Integration into Clinical Practice New Technologies Automated Bilingual Computerized Alcohol Screening & Intervention in Latinos (F. Vaca) BNI log and alcohol/drug screens incorporated into EMR Medicine, Pediatrics, and Emergency Medicine CRAFFT screen Log of BNI performed SBIRT Benefits Clearly SBIRT Broadens the Base.Offers Opportunities Evidence for SBIRT is Emerging Reducing alcohol and drug use Linking substance use disorders to specialized treatment Reducing negative consequences Reducing healthcare costs Efforts MUST be feasible &sustainable Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 9

10 Links Background & Trends ta.html#2014data drugs ts/nationwide trends Joanne DeSanto Iennaco, PhD, PMHNP BC, PMHCNS BC, APRN 10