SBIRT SCREENING BRIEF INTERVENTION REFERRAL TO TREATMENT Terrie

SBIRT SCREENING, BRIEF INTERVENTION, & REFERRAL TO TREATMENT Terrie Fritz, LCSW ANNE AND HENRY ZARROW SCHOOL OF SOCIAL WORK CENTER FOR SOCIAL WORK IN HEALTHCARE

Screening Brief Intervention and Referral to Treatment IS : ■ An evidence based, comprehensive, integrated approach to identify and provide brief and effective early intervention for: 1. Alcohol misuse 2. Substance use 3. Tobacco use 4. Depression/anxiety ■ Carried out at in primary care, specialty care, hospital E/D, and other health care and community settings. ■ Based on Motivational Interviewing strategies

Goal of sbirt ■ to identify and effectively/efficiently intervene with those who are at risk for health problems related to one or more of those conditions. ■ Seeks to identify those in the ‘risky or harmful’ use categories ■ Not only those with dependency and in need of specialty referral/treatment.

A Public Health Perspective

Why SBIRT is being Adopted ■ Drinking, drug use, and depression are VERY common ■ They are Contributing factors to many chronic and acute care concerns ■ Drinking, drug use and depression often go undetected ■ People are more open to discussion and change than you might expect ■ SBIRT is efficient and effective

SCREENING Universal Screening is the first step of SBIRT. The result of a screen allows the provider to determine if a brief intervention or referral to treatment is necessary.

Universal First Level Screening ■ ■ Results in earlier detection Reduces Risk of future injury or illness Helps determine provider response Normalizes the Screening and subsequent discussion ■ Cues the patient on importance ■ Often initiates reflection by the patient ■ Increases efficiency

Patient Stress Questionnaire Over the last 2 weeks, how often have you been bothered by the following: 1. Feeling nervous, anxious, or on edge 2. Not being able to stop or control worrying 3. Little interest or pleasure in doing things 4. Feeling down, depressed, or hopeless 5. Thoughts that you would be better off dead or of hurting yourself in some way Alcohol/Drug use in the past year: 6. How often do you have a drink containing alcohol. 7. How many drinks of alcohol do you have on a typical day when you are drinking? 8. How often do you have five or more drinks on one occasion? 9. How many times in the last year have you In the past year: 10. Have you been hit, kicked, punched, or otherwise hurt someone? (If so, by whom? ) In the past month, how much have you been bothered by: 11: Repeated, disturbing memories, thoughts, or images of stressful experience from the past? 12. Feeling very upset when something reminded you of a stressful experience from the past?

This tool incorporates: ■ For Anxiety – Gad-2 ■ For Depression – PHQ-2 ■ For suicidality – accepted single question ■ For Alcohol – Audit-C ■ For illicit and prescription drug abuse – Single question (prescreen) ■ A personal violence question ■ PTSD screen

More Points on Screening ■ The questions have been normed and have been found to be valid and reliable indicators when used in healthcare settings. ■ The tool is generally self administered using paper or electronic tool such as tablet. ■ When a response is positive to any question, further screening and/or discussion is indicated. ■ Best practice is to conduct a brief review of the screen with patient – even if there are no areas of concern.

Based on Findings of Initial or Pre-Screening ■ A positive response on any section will initiate a full screen ■ The clinician has valid, patient self-reported information that can be used as the basis for the brief intervention. ■ Often the process of screening sets in motion patient reflection on their substance use behavior.

AUDIT Questionnaire 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have four or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking one you had started? 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 0 1 2 3 4 Never Monthly or Less 2 -4 times a month 2 -3 times a week 4 or more times a week 0 -2 3 to 4 5 to 6 7 to 9 10 or more Weekly Daily or almost daily Never Less than Monthly monthly

AUDIT Questionnaire (cntd. ) 6. How often in the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session 7. How often during the last year have you had a feeling of guild or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured by your drinking? 10. Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down? 0 1 2 Never Less than Monthly monthly 3 4 Weekly Daily or almost daily No Yes, but not in the last year Yes, in the last year No Yes, but not in the last year Yes, during the last year

Screening for Alcohol Use When Screening, It’s Useful To Clarify What One Drink Is!

What is a standard drink?

Scoring and interpreting the audit Score Zone Action 0 -3: Women 0 -4 Men I - Low Risk Brief Education 4 -12: Women 5 -14: Men II - Risky Brief Intervention 13 -19: Women 15 -19: Men III - Harmful Brief Intervention or Referral to Specialized Treatment 20+: Women 20+: Men IV - Severe Referral to Specialized Treatment

CATEGORIES OF DRINKING IV DEPENDENT: 5% III HARMFUL: 8% LOW-RISK DRINKING LIMITS Men 14 Drinks Per Week 4 Drinks Per Day II RISKY: 9% Women I HEALTHY: 78% 7 Drinks Per Week 3 Drinks Per Day All Age > 65 7 Drinks Per Week 3 Drinks Per Day

Categories of Response CATEGORIES OF DRINKING IV DEPENDENT: 5% III HARMFUL: 8% II RISKY: 9% I HEALTHY: 78% ACTION § Refer to Assessment or Treatment § Brief Intervention or Refer to Assessment § Brief Intervention § Support and Education

Instructions ■ ■ Get with your two neighbors in your triad/set Review handouts for Low Risk Jill Take turns being patient, provider, and observer. Practice giving brief feedback to someone who is below the healthy drinking limits. – – Give personal feedback Use card Ask their thoughts, any questions Give brief information/education about how alcohol can play a role in many health conditions/illnesses – No more than one to two minutes – Twos start as provider, threes as patient and ones as observer, then rotate

Goal of Brief Interventions Awareness of problem Motivation Presenting Screening problem results Behavior change

During the Brief Intervention you help the patient to: ■ Find personal and compelling reasons to change (NOT YOURS!) ■ Build readiness to change ■ Make commitment to change

Five steps of Brief intervention Initiate reflective discussion Negotiate commitment Provide feedback based on screening/ assessment data Enhance motivation Evoke personal meaning

Initiating Reflective Discussion ■ Start the reflective discussion by asking permission of our patients to have the conversation. ■ Example: “Would it be all right with you to spend a few minutes discussing the results of the wellness survey you just completed? ”

Providing Feedback ■ Review score ■ Discuss Level of risk ■ Provide information about the risk ■ Share why you would hope to see a reduction Dependent Harmful Risky Healthy Low 0 Moderate High Very High 40

Evoking Personal Meaning Reflective questions: From your perspective…. . ■ Have you had any thoughts before today about the relationship between alcohol and your health? (or your blood pressure, diabetes, etc. ) ■ What relationship might there be between drinking and ____? ■ What are your concerns About this? ■ What are the important reasons for you to decrease use of alcohol? ■ What are possible benefits you can see from cutting down?

Enhancing motivation ■ Uses skills to move patient along in the change process ■ Increases the likelihood of taking next steps ■ Relies on tools such as: – Highlighting Change talk – Developing discrepancy – Readiness assessment

Negotiating Commitment ■ ■ ■ Simple Realistic Specific Attainable Follow-up time line Negotiating a PLAN

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

Benefits of Using MI E vidence based P atient centered P rovides structure R eadily adaptable

“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others. ” —Blaise Pascal

MOTIVATIONAL INTERVIEWING: THE BASICS

Avoid Argumentation ■ Resistance to change is strongly affected by your response ■ Normalize to patient that having difficulties while changing is not uncommon

Rolling with Resistance ■ Example 1 : – Patient: I don’t plan to quit drinking anytime soon – Clinician: You don’t think that abstinence would work for you right now ■ Example 2: – Patient: My husband often brings up my drinking —He says I drink too much. It really bothers me – Clinician: It sounds like he is concerned, but expresses it in a way that makes you angry

Remember “Readiness to change” State Trait

Core MI ■ ■ Open-ended questions Affirmations Reflections Summaries

Open-Ended Questions (continued) ■ Why open-ended questions? ■ They avoid the question/answer trap ■ Puts patient in an active role ■ Provides opportunity to explore ambivalence

Affirmations ■ What is an affirmation? ■ Compliments or statements of appreciation and understanding – Praise – Support – Caveat – Must be done sincerely

Reflective Listening ( ■ Involves listening and understanding the meaning of what the patient says ■ Accurate empathy is a predictor of behavior change ■ Demonstrates that you have accurately heard and understood the patient ■ Strengthens trust and the relationship

Summaries ■ Periodically summarize what has occurred in the Brief Intervention ■ Summary usages – Begin a session – End a session – Transition

Using Rulers: I-C-R Importanc e ■ Importance ■ Confidence ■ Readiness Confidenc e Readiness rulers can address—

Enhancing Motivation Readiness Ruler

Short Video ■ Shows many of the points I have made thus far ■ Is really pretty good, overall ■ Watch for – the five steps https: //youtu. be/WFj. FIu. UY 8 o 4 – the OARS – things you want to copy – things you might do differently

Five steps of Brief intervention Initiate reflective discussion Negotiate commitment ■ #1 s will take 5 -7 minutes to do steps 1, 2 and 3. ■ #2 s will perform Provide feedback based on screening/ assessment data Enhance motivation 3, 4 and 5 Evoke personal meaning

Practice ■ Brief intervention Part One (Jill Risky/Harmful) – Ones will be provider – Two will be patient – Threes will observe ■ 5 to 7 minutes – Your objective is to do the first three steps of a brief intervention

Practice ■ Brief Intervention Part Two (Jill Risky/Harmful) – Twos will be provider – Threes will be patient – Ones will be observer – 5 -7 minutes – Objective is to review and augment step three and complete steps four and five.

REFERRAL TO TREATMENT Referral

Overview ■ Substance abuse treatment works! ■ Following are strategies to realize the greatest likelihood of a successful assessment or treatment referral.

If a patient is a Category IV You will either need to refer them to an assessment/evaluatio n service Or directly to an inpatient or outpatient program

What Is Treatment? ■ ■ ■ ■ Treatment may include— Counseling and Therapy on an outpatient basis Various levels of inpatient/residential care other psychosocial rehabilitation services Smart Recovery Medications Involvement with self-help (AA, NA, Al-Anon) ■ Complementary wellness (diet, exercise, meditation) ■ Combinations of the above

What Is Treatment? (continued) ■ Treatment is provided within levels of care often available in multiple treatment settings. ■ Level of care is determined by severity: Is the patient a dependent or nondependent substance abuser, are they of danger to self or others, and are there medical or psychiatric comorbidities? ■ Inpatient treatment is reserved for those with more serious illness (dependence, Severe psychosis, Active suicidal/homicidal ideation).

Referral Guidelines for Greatest Success ■ Determine if patient is drug or alcohol dependent and needs medical detoxification (usually inpatient care). ■ Determine if patient is a serious threat to self or others. ■ A nondependent substance abuser or a depressed patient is usually treated as an outpatient unless there are other risk factors.

WHEN THE PATIENT FALLS INTO THE POSSIBLY DEPENDENT (OR SOMETIMES HARMFUL) RANGE ON THE AUDIT, YOUR GOAL FOR THE BRIEF INTERVENTION IS TO GET THE PATIENT TO OBTAIN AN ASSESSMENT OR TREATMENT.

A Strong Referral to Appropriate Treatment Is Key ■ When your patient is ready— ■ Make a plan with the patient. ■ You or your staff should actively participate in the referral process. The warmer the referral handoff, the better the outcome. ■ Decide how you will interact/communicate with the provider. ■ Review your follow-up plan with the patient. ■ Decide on the ongoing followup support strategies you will use.

Practice ■ Brief intervention-all parts! (Jill Possibly Dependent) – Threes will be provider – Ones will be patient – Twos will observe – 10 to 12 minutes – Your objective is to do a brief intervention with the goal of enhancing motivation to accept a referral for further assessment.

Common Mistakes To Avoid ■ Rushing into “action” and making a referral when the patient isn’t interested or ready ■ Referring to a program that is full or does not take the patient’s insurance ■ Seeing the patient as “resistant” or “selfsabotaging” instead of having a chronic disease

Referral Resources ■ ■ 211: http: //www. 211 oklahoma. org/ SAMHSA SBIRT: http: //www. samhsa. gov/sbirt/about SAMHSA Website: http: //www. samhsa. gov/ Behavioral Health Treatment locator: https: //findtreatment. samhsa. gov/ ■ Suicide prevention lifeline: http: //www. suicidepreventionlifeline. org/ ■ National helpline: http: //www. samhsa. gov/find-help/nationalhelpline ■ Disaster distress helpline: http: //www. samhsa. gov/findhelp/disaster-distress-helpline

Readings (before Didactic) § § SBIRT White Paper Medical Consequences of Alcohol Abuse Alcohol SBI in Primary Care Recommendation Brief Negotiated Interview and Active Referral to Treatment Provider Training Algorithm Videos (after Didactic, before §Simulation Introduction to SBIRT https: //youtu. be/gc. G_3 Rq 1 sfs § Brief Intervention with Jill https: //www. youtube. com/watch? v=Max. Huf 17 A 44 § Brief Intervention with Steve https: //www. youtube. com/watch? v=b-ilxv. HZJDc § At Risk Alcohol Brief Intervention https: //www. youtube. com/watch? v=Ac. GCRJcfl 4 w § Possibly Dependent Alcohol Brief Intervention https: //www. youtube. com/watch? v=BVs. Bq 3 l. ZUZk § Follow Up Brief Intervention for Possibly Dependent Alcohol Use https: //www. youtube. com/watch? v=b 5 PUe 8 RRfe 8

WRAP UP DISCUSSIO N Questions? ? ?

Contact information ■ Terrie Fritz – Email: terrie. fritz@ou. edu ■ Katrina Meyers – Email: katrina. meyers@ou. edu