Screening, Brief Intervention, and Referral to Treatment Core Skills Training Prepared by JBS International, Inc., for the Department of Health lhand Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment Contract No. HHSS28320070000311HHSS28300002T
Forget Everything You Know About what constitutes a substance use problem. About how substance use problems are identified. About how to treat substance use problems. 3
A New Initiative Substance use screening, brief intervention, and referral to treatment (SBIRT) is a systems change initiative. As such, we are required to shift our view toward a new paradigm, and; Re conceptualize how we understand substance use problems. Re define how we identify substance use problems. Re design how we treat substance use problems. 4
Historically 5 Society has viewed substance use as: A moral problem An individual problem A family problem A social problem A criminal justice problem A combination of one or more The solution to any problem must be driven by its presumedcause cause. If substance use is caused by a moral problem.what is its solution? If substance use is caused by a criminal justice problem what is its solution?
Substance Use Is A Public Health hproblem 6
Learning from Public Health The public health system of care routinely screens for potential medical problems (cancer, diabetes, hypertension, tuberculosis, vitamin deficiencies, renal function), provides preventative services prior to the onset of acute symptoms, and delays or precludes the development of chronic conditions. 7
Historically Substance Use Services have been bifurcated, focusing on twoareas only: Primary Prevention Precluding or delaying the onset of substance use. Tertiary Treatment Providing time, cost, and labor intensive care to patients who are acutely or chronically ill with a substance use disorder. 8
Substance Dependent Traditional ltreatment t Abstinence Primary Prevention No Problem No Intervention Drink Responsibly 9
The Current Model A Continuum of Substance Use Abstinence Responsible Use Dependence 10
An Outdated Model This model (paradigm) of substance use: 11 Fails to recognize a full continuum of substance use behavior. Fails to recognize a full continuum of substance use problems. Fails to provide a full continuum of substance use interventions. ti WHY?
The outdated model defines a substance use problem as Dependence 12
By failing to recognize a full continuum of substance use behavior, a full continuum of substance use problems, and not providing a full continuum of substance use interventions the outdated model has failed to provide resources in the area of greatest need. 13
The SBIRT model defines a substance use problem as Excessive Use 14
Excessive Use Results In Trauma and trauma recidivism. Causation or exacerbation of health conditions. Exacerbation of mental health conditions. Alcohol poisoning. DUI. Domestic and other forms of violence. Transmission of sexually transmitted diseases. Unintended pregnancies. Substance Dependence. 15
By recognizing a full continuum of substance use behavior, a full continuum of substance use problems, and by providing a full continuum of substance use interventions the SBIRT model can provide resources in the area of greatest need. 16
Substance Dependent Traditional Treatment Abstinence Excessive Use Brief Intervention Brief Therapy No Problem Primary Prevention Screening and Feedback Drink Responsibly 17
The SBIRT Model A Continuum of Substance Use Abstinence Social Use Abuse Experimental Use Binge Use Dependence 18
19 U.S. Population
20 Dependent
21 Excessive
Dependent 4% Brief Intervention and Referral for additional Services 25% Low Risk or Abstinence 71% No Intervention or screening and Feedback Drinking Behavior 22 Intervention Need
6 1 23
The Costs of Substance Use The bulk of the societal, personal, and health care related costs are not a result of substance dependence but of excessive substance use. Until such time as we acknowledge this fact, and address it appropriately, we are unlikely to make significant progress towards a solution. Consider This 24
If We could provide a 100% cure to every substance dependent person in the United States we wouldn t be close to solving most of the substance related problems in our country. 25
The SBIRT Model A Continuum of Interventions Primary Prevention Precluding or delaying the onset of substance use. Secondary Prevention and Intervention Providing time, cost, and labor sensitive care to patients who are at risk for psycho social or healthcare problems related to their substance use choices. Tertiary Treatment Providing time, cost, and labor intensive care to patients who are acutely or chronically ill with a substance use disorder. 26
Primary Goal The primary goal of SBIRT is not to identify those who are dependent and need higher levels of care. The primary goal of SBIRT is to identify those who areat at moderate or high risk for psycho socialsocial or health care problems related to their substance use choices. 27
NIAAA Definitions Low Risk: Healthy Men < 65 4 drinks per day AND 14 drinks per week Healthy Women & Men 65 3 drinks per day AND 7 drinks per week Hazardous: Pattern that increases risk for adverse consequences. Harmful: Negative consequences have already occurred. 28
The SBIRT Concept SBIRT uses a public health approach to universal screening for substance use problems. SBIRT provides: Immediate rule out of non problem users; Identification of levels of risk; Identification of patients t who would benefitfrom brief advise; Identification of patients who would benefit from higher levels of care, and; Progressive levels of clinical interventions based on need and motivation for change. 29
The Moving Parts Pre screening (universal). Full screening (for those with a positive pre screen). Brief Intervention (for those scoring over the cut off point). Extended Brief Interventions or Brief Treatment or (for those who have moderate risk, ikhigh h risk, ikabuse, or dependence, would benefit from ongoing, targeted interventions, and are willing to engage). Traditional Treatment (for those who are dependent and are willing to engage). 30
Let s Review SBIRT is a systems change initiative requiring us to reconceptualize, re define, and re design our entire approach to substance use problems and services. SBIRT uses a public health approach. The current model defines the problem as dependence. The SBIRT model defines the problem as excessive use. SBIRT recognizes a continuum of substance use behavior, a continuum of substance use problems, and a continuum of substance use interventions. 31
Prescreening Strategy Use brief yet valid screening questions: The NIAAA Single Question Screener The Single Question Drug Screener Negative Positive Based on previous experiences with SBIRT, screening will yield 75 80 percent negative responses. If you get a positive screen, you may ask further assessment questions.
Prescreening for Alcohol Prescreen: Do you sometimes di drink kbeer, wine, or other alcoholic beverages? NO YES NIAAA Single Screener: How many times in the past year have you had five drinks (for men) or four drinks (for women or clients over age 65) or more in a day? Sensitivity/Specificity: 82%/79% If you get one or more affirmative answers, move on to full screen. Source: Smith, P. C., Schmidt, S. M., Allensworth Davies, D., & Saitz, R. (2009). Primary care validation of a single question alcohol screening test. J Gen Intern Med, 24(7), 783 788.
When Screening, It Is Useful To Clarify What Constitutes One Drink!
How Much Is One Drink? 5 oz glass of wine (5 glasses in one bottle) 1.5 oz 1.5 oz spirits 80 proof 1 jigger 12 oz glass of beer (one can)) g ( Equivalent to 14 grams pure alcohol
THE ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENT SCREENING TEST (ASSIST)
The ASSIST Developed under the auspices of the World Health Organization (WHO) A group of addiction researchers and clinicians developed the ASSIST to address the overwhelming public health burden associated with psychoactive substance use worldwide.
The ASSIST continued The ASSIST (version 3.1) is an 8 item questionnaire designed to be administered by a health worker to a client using paper and pencil Takes about 5 10 minutes to administer ASSIST was designed dto be culturally ll neutral
The ASSIST screens for use of the following substances: tobacco products alcohol cannabis cocaine amphetamine type stimulants (ATS) sedatives and sleeping pills (benzodiazepines) hallucinogens inhalants opioids other drugs
ASSIST Q 1 4 Question 1 (Q1) asks about which h substances have ever been used in the client s lifetime. Question 2 (Q2) asks about the frequency of substance use in the past three months, which gives an indication of the substances which are most relevant to current health status. Question 3 (Q3) asks about the frequency of experiencing a strong desire or urge to use each substance in the last three months. Question 4 (Q4) asks about the frequency of health, social, legal or financial problems related to substance use in the last three months. See ASSIST screen handout
ASSIST Q 5 8 Question 5 (Q5) asks about the frequency with ihwhich h use of each substance has interfered with role responsibilities in the past three months. Question 6 (Q6) asks if anyone else has ever expressed concern about the client s use of each substance and how recently that occurred. Question 7 (Q7) asks whether the client has ever tried to cut down or stop use of a substance, and failed in that attempt, and how recently that occurred. Question 8 (Q8) asks whether the client has ever injected any substance and how recently that occurred. See ASSIST screen handout
Scoring of the ASSIST The ASSIST screening questions provide an indication of the level of risk associated with the client s substance use, and whether use is hazardous and likely to be causing harm (now or in the future) if use continues.
ASSIST Scoring A) ASSIST risk score for tobacco (range 0 31) B) ASSIST risk score for alcohol (range 0 39) C) ASSIST risk score for cannabis (range 0 39) D) ASSIST risk score for cocaine (range 0 39) E) ASSIST risk score for amphetamine type stimulants (range 0 39) F) ASSIST risk score for inhalants (range 0 39) G) ASSIST risk score for sedatives or sleeping pills (range 0 39) H) ASSIST risk score for hallucinogens (range 0 39 ) I) ASSIST risk score for opioids (range 0 39) J) ASSIST risk score for other drug (range 0 39 )
ASSIST Levels of Risk
Questions/Discussion About Screening
BREAK
SBIRT Brief Intervention Based on MI There are several examples for brief intervention, including the Brief Negotiation Interview (BNI), originally developed by GailD Onofrio DOnofrio, MD, Ed Bernstein, MD; and Steven Rollnick, MD. The BNI is a semistructured interview process based on MI that is a proven evidence based practice and can be completed in 5 15 minutes.
Goals of Brief Intervention For the at risk user: The goal is to negotiate a reduction in use to lower risk levels. For the person who appears to have a substance use disorder: The goal is to negotiate a treatment referral for full assessment and a level of intervention to be determined.
Starting Off. How Not To Intervene video example http://www.bu.edu/bniart/sbirt in health care/sbirthttp://www.bu.edu/bniart/sbirt in health care/sbirt educational materials/sbirt videos/
Steps in the Brief Negotiation Interview (BNI) 1. Build rapport raise the subject. Discuss the pros and cons of use. 2. Provide feedback. 3. Build readiness to change. 4. Negotiate a plan for change.
1. Build Rapport Raise the Subject 1. Begin with a general conversation. 2. Ask permission to talk about alcohol or drugs: Would you mind taking a few minutes to talk with me about your use of alcohol (or X)? What s a normal day look like for you, and where and how does alcohol fit?
Discussing the Pros and Cons of Use 1. Help me understand through your eyes. What are the good things about using alcohol? 2. What are some of the not so good things about using alcohol? 3. Summarize using a decisional balance So on the one hand PROS PROS, and on the other hand CONS.
2. Provide Feedback 1. Ask permission to give information: I have some information about guidelines for low risk drinking; would you mind if I shared them with you? We know that 4 or more drinks (for a female), 5 or more drinks (for a male) in one sitting, or more than 7 (for a female), 14 (for a male) in a week, and/or use of illicit drugs can put a person at risk for illness or injury and other problems. 2. Discuss screening findings. 3. Link use behaviors to any known consequences. 4. Elicit a reaction, facilitate a reflective discussion.
3. Build Readiness To Change So could we talk for a few minutes about your interest in making a change? On a scale from 1 to 10, with 1 being not ready at all and 10 being completely ready, how ready are you to make any changes in your alcohol use? You marked (or said). That s great. That means you are % ready to make change. Why did you choose that number and not a lower one like a 1 or a 2? Sounds like you have some important reasons for change.
4. Plan for Change A plan for reducing use to low risk levels OR An agreement to follow up with specialty treatment services
How To Intervene BNI Video Demonstration ti http://www.bu.edu/bniart/sbirt in health care/sbirt educationalmaterials/sbirt videos/
BNI Practice Session Roles Patient Interviewer Observer
Process: Role Play
Closing Discussion Why might you choose to implement SBIRT?
Questions?
Additional Information on SBIRT Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, brief intervention, and referral to treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse 28, 7 30. Center for Substance Abuse Treatment. (2007). Alcohol Screening and Brief Intervention (SBI) for trauma patients: Committee on Trauma Quick Guide. Substance Abuse and Mental Health Services Administration, HHS. Publication No. (SMA) 07 4266. Washington, DC: U.S. Government Printing Office. Available at http://sbirt.samhsa.gov/documents/sbirt_guide_sep07.pdf D Onofrio, G., Bernstein, E., & Rollnick, S. (1996). Motivating patients for change: A brief strategy for negotiation. In E. Bernstein and J. Bernstein (Eds), Case studies in emergency medicine and the health of the public (pp. 295 303). Boston: Jones and Bartlett,. D Onofrio, G., Pantalon, M. V., Degutis, L. C., Fiellin, D. A., & O Connor, P. G. (2005). Development and implementation of an emergency practitioner performed brief intervention for hazardous and harmful drinkers in the emergency department. Academy of Emergency Medicine 12, 249 256. National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: A clinician s guide. http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/clinicians_guide.htm World Health Organization. Brief intervention for substance use: A manual for use in primary care. (n.d.). http://www.who.int/substance_abuse/activities/en/draft_brief_intervention_for_substance_use.pdfwho abuse/activities/en/draft for pdf
Acknowledgement We wish to thank Gail D Onofrio, MD, Ed Bernstein, MD; and Steven Rollnick, MD for granting permission to use materials developed at the Boston University Medical Center and the Yale University School of Medicine.