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SBIRT - TIPS Screening, Brief Interven3on and

Referral to Treatment – Training Iowa Preceptors and Students

Carol Gorney MPAS, PA-C University of Iowa

Disclosures

•  University of Iowa Carver College of Medicine and College of Nursing

•  With funding from the Substance Abuse & Mental Health Services Administration (SAMHSA)

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Objectives Attheendofthispresenta/onpar/cipantswillbeableto:•  UnderstandthekeycomponentsofScreening,BriefInterven/onandReferraltoTreatment(SBIRT),

•  U/lizeascreeningtooltoiden/fyindividualwithbehaviorsthatputthematriskforusedisorders.

•  Iden/fystrategiestoincorporateSBIRTintoyourprac/ce?

•  BeabletohelplearnersandstaffapplySBIRT.

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

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SBIRT Goals The training project has two main goals à 1.  To promote adoption of SBIRT as “standard of care” by

health systems and practitioners in Iowa in cooperation with SBIRT-IOWA (a statewide initiative) and a national initiative.

2.  To educate physician assistant (PA) and doctor of nursing practice (DNP) students and providers to apply SBIRT in clinical practice

Why is SBIRT Important? •  Unhealthy and unsafe alcohol and drug use are

major preventable public health problems resulting in more than 100,000 deaths each year

•  The costs to society are more than $600 billion annually

•  Effects of unhealthy and unsafe alcohol and drug use have far-reaching implications for the individual, family, workplace, community, and the health care system

•  Current interventions are focused late after a use disorder is diagnosed

•  Focus is on prevention first

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Harms Related to Hazardous Alcohol and Substance Use Increased risk for: •  Injury/trauma •  Legal diffculties •  Social problems •  Mental health diagnosis (e.g., anxiety, depression) •  Increased workplace accidents •  More missed days of work

Rethinking Substance Use Problems From a Public Health Perspective

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The Current Model à A Continuum of Substance Use

Abstinence

Addiction

Responsible Use

The SBIRT Model à A Continuum of Substance Use

Abstinence

Experimental Use

Social Use

Binge Use

Abuse

Substance Use

Disorder

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Goal of SBIRT

•  To identify and implement effective earlier intervention for those who are at moderate or high risk for psychosocial or health care problems related to their substance use

•  To prevent use disorders.

SBIRT Outcomes/Effectiveness

A growing body of evidence supports SBIRT’s effectiveness: •  including cost-effectiveness •  positive outcomes •  effective way to reduce drinking and

substance use problems

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Brief Interventions •  Are low cost and effective •  Are most effective among persons with less

severe problems •  “Brief interventions are feasible and highly

effective components of an overall public health approach to reducing alcohol misuse.”

•  Reimbursable

(Whitlock et al., 2004, for U.S. Preventive Services Task Force)

Screening Two Levels of Screening �  Universal:

�  Provided to all patients. �  Serves to rule-out patients who are at low or no-risk. �  Can (should) be done at intake or triage. �  Positive universal screen = proceed with full screen for both alcohol or substance

use.

�  Targeted: �  Provided to specific patients (alcohol on breath, positive BAL, suspected alcohol/

drug related health problems) �  Provided to patients who score positive on the universal screen. Remember screening does not provide a diagnosis

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Prescreen Drinking

Determine the average drinks per day and average drinks per week—

ask:

On average, how many days a week do you have an alcoholic drink?

On a typical drinking day, how many drinks do you have? (Daily average)

Weekly average = days X drinks

RecommendedLimits

Men=2perday/14perweek

Women/anyone65+=1perdayor7drinksper

week

>thanlimits=at-riskdrinker

Screen Target Population

# Items Assessment

Setting (Most Common) URL

ASSIST (WHO)

-Adults -Validated in many cultures and languages

8 Hazardous, harmful, or dependent drug use (including injection drug use) [interview]

Primary Care http://www.who.int/substance_abuse/activities/assist_test/en/index.html

AUDIT (WHO)

-Adults and adolescents -Validated in many cultures and languages

10 Identifies alcohol problem use. Can be used as a pre-screen to identify patients in need of full screen/brief intervention [Self-admin, Interview, or computerized]

• Different Settings • AUDIT C- Primary Care (3 questions)

http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf

DAST-10

Adults 10 To identify drug-use problems in past year [Self-admin or Interview]

Different Settings http://www.integration.samhsa.gov/clinical-practice/screening-tools

CRAFFT Adolescents 6 To identify alcohol and drug abuse, risky behavior, & consequences of use [Self-admin or Interview]

Different Settings http://www.ceasar-boston.org/CRAFFT/

CAGE Adults and Youth >16

4 -Signs of tolerance, not risky use [Self-admin or Interview]

Primary Care http://www.integration.samhsa.gov/clinical-practice/sbirt/CAGE_questionaire.pdf

TWEAK Pregnant Women 5 -Risky drinking during pregnancy. Based on CAGE. -Asks about number of drinks one can tolerate, & related problems [Self-admin, Interview, or computerized]

Primary Care, Women’s Organizations, etc.

http://www.sbirttraining.com/sites/sbirttraining.com/files/TWEAK.pdf

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Binge Drinking

Screen Positive

•  Move on to full screen

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AUDIT •  Alcohol Use Disorder Identification Test •  Nationally validated questionnaire with

specific domains (WHO) •  Simple scoring and risk assessment •  10 multiple choice questions •  Multiple languages available •  Addresses last 12 months

Scoring

Score Risk Level Intervention

0-7 Zone 1: Low Risk Use Alcohol education to support low-risk use – provide brief advice

8-15 Zone 2: At Risk Use Brief Intervention (BI), provide advice focused on reducing hazardous drinking

16-19 Zone 3: High Risk Use BI/EBI – Brief Intervention and/or Extended Brief Intervention with possible referral to treatment

20-40 Zone 4: Very High Risk, Probable Substance Use Disorder

Refer to specialist for diagnostic evaluation and treatment

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Substance Use Screening

Prescreening for Substance Use

“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

(…for instance because of the feeling it caused or experiences you have…)

If response is, “None,” screening is complete.

If response contains suspicious clues, inquire further.

Sensitivity/Specificity: 100%/74%

Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Arch Intern Med ,170(13), 1155−1160.

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A Positive Screen

Ask which drugs the patient has been using, such as

cocaine, meth, heroin, ecstasy, marijuana, opioids, etc.

Determine frequency and quantity.

Ask about negative impacts.

ANY positive on the drug prescreen question puts the patient in an “at-risk” category. The followup questions are to assess impact and whether substance use is serious enough to warrant a substance use

disorder diagnosis.

Consider 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)

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DAST

•  Drug Abuse Screening Test •  Nationally validated •  Effective for diagnosing lifetime risk •  10 questions, 10 points

DAST 10- Scores and Zones

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Screening: Summary •  Screening is the first step of the

SBIRT process and determines the severity and risk level of the patient’s substance use

•  The result of a screen allows the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient

What do I do with my positive full screen results

•  Brief Intervention •  Referral

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Brief Intervention •  Semi structured •  5-15 minutes in length(brief) •  Evidence based •  Can be used in patients with alcohol or

substance use risks •  Designed to motivate and raise awareness

in the patient •  Based on motivational interviewing (patient

centered)

What is Motivational Interviewing? The tasks of MI are to—

–  Engage, through having sensitive conversations with patients

–  Focus on what’s important to the patient regarding behavior, health, and welfare

–  Evoke the person’ personal motivation for change

–  Negotiate change plans –  Motivate by resolving conflicting and

ambivalent feelings and thoughts

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The MI Shift From feeling responsible for changing

patients’ behavior To supporting them in thinking & talking about their own reasons and means for

behavior change

Motivational Interviewing

•  Is focused on competency and strength –  Affirms the client –  Emphasizes free choice –  Supports self efficacy –  Encourages optimism that changes can be

made •  Is individualized and client centered •  Does not label àAvoids using names •  Those who may not agree

–  who do not see behavior as problematic

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Motivational Interviewing •  Creates therapeutic partnerships

–  Encourages active partnerships where the client and provider work together to establish goals and strategies

•  Uses empathy not authority –  Emphasizes warm supportive listening by

providers –  No lecturing –  non authoritarian

•  Focuses on less intensive treatment but equally effective care

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Goals of Brief Intervention •  Educate the patient on safe levels of

substance use •  Increase the patient’s awareness of the

consequences of substance use •  Motivate the patient towards changing

substance use behavior •  Assist the patient in making choices that

reduce their risk of substance use problems now or in the future

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Steps in the Brief Intervention •  Build rapport •  Pros and cons of use •  Provide Information and feedback •  Assess readiness to change •  Negotiate a patient centered plan for change

Readiness Ruler On a scale of 1-10 how ready are you to make a change in your drinking, drug use, substance use? Why not a lower number? Why would it take to move it to a higher number?

1 2 3 4 5 6 7 8 9 10

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Providers Role �  Provide feedback about the screening results. �  Offer information on low-risk substance use, the link between

substance use and other lifestyle or healthcare related problems.

�  Understand the client’s viewpoint regarding their substance use.

�  Explore a menu of options for change. �  Assist the patient in making new decisions regarding their

substance use. �  Support the patient in making changes in their substance use

behavior. �  Give advice if requested.

Zingers •  Push back, Resistance, Denial, Excuses:

–  Look, I don’t have a drinking problem. –  My dad was an alcoholic; I’m not like him. –  I can quit anytime I want to. –  I just like the taste. –  That’s all there is to do in this town!!!!

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Handling Zingers •  “I’m not going to push you to change

anything you don’t want to change”

•  “I’m not here to convince you that you have a problem/are an alcoholic.”

•  “I’d just like to give you some information.”

•  “I’d really like to hear your thoughts about…”

•  “What you decide to do is up to you.”

Example of Brief Intervention

•  https://www.youtube.com/watch?v=sRUHv6_cRpE

•  6 minute total encounter

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Screening in a Practice Setting •  Use 2 question prescreen on all patients •  Perform prescreen annually •  Have a plan if prescreen is positive to use

standardized tools for further risk assessment •  Utilize the whole team-including students •  Remember the goals:

–  identifying at risk individuals to provide BI to reduce incident of use disorders

–  refer individual with use disorders when ready

Referral to Treatment

•  Always: –  Follow appropriate confidentiality (42, CFR-Part 2)

and HIPAA regulations when sharing information. –  Establish a relationship with your community

provider(s) and ensure you have a referral agreement.

–  Maintain a list of providers, support services, and other information that may be helpful to patients.

–  Reduce barriers and build bridges.

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When to Refer to Treatment?

Referral

Referral Resources •  SAMHSA’s National Treatment

Facility Locator http://findtreatment.samhsa.gov

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Screening in a Practice Setting

AUDIT Questionnaire

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DAST(10) Questionnaire

Source: Yudko et al., 2007

Billing Codes in Iowa

Payer Code Description Commercial Insurance, Medicaid

99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

Commercial Insurance, Medicaid

99409 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

Medicare G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

Medicare G0442 Prevention: Screening for alcohol misuse in adults, including pregnant women, once per year; no coinsurance; no deductible for patient

Medicare G0443 Prevention: Up to four, 15-minute, brief face-to-face behavioral counseling interventions per year for individuals, including pregnant women, who screen positive for alcohol misuse; no coinsurance; no deductible for patient

Medicaid H0049 Alcohol and/or drug screening (code not widely used)

Medicaid H0050 Alcohol and/or drug service, brief intervention, per 15 minutes (code not widely used)

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Resources JBS International Ideas Exchange http://www.ideas-exchange.net/user/registerie_lms_support@jbsinternational.com

http://www.idph.iowa.gov/sbirt/ www.attcnetwork.org http://www.niaaa.nih.gov http://www.drugabuse.gov http://www.integration.samhsa.gov/clinical-practice/SBIRT

http://attcnetwork.org/marijuana/index.aspx www.iowaaces360.org

www.cdc.gov/ace

developingchild.harvard.edu http://facilitylocator.drugfreeinfo.org/Agency/Default.aspx

References •  National Institute on Alcohol Abuse and Alcoholism. (2013). What is a standard drink? Retrieved from

http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/standard-drink •  Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question

screening test for drug use in primary care. Arch Intern Med ,170(13), 1155−1160. •  (Whitlock et al., 2004, for U.S. Preventive Services Task Force) •  http://findtreatment.samhsa.gov •  http://www.integration.samhsa.gov/clinical-practice/sbirt/referral-to-treatment •  http://store.samhsa.gov/product/TAP-33-Systems-Level-Implementation-of-Screening-Brief-

Intervention-and-Referral-to-Treatment-SBIRT-/SMA13-4741