Resident Training in Screening, Brief Intervention and Referral to Treatment for Patient Substance Abuse Problems Nikole J. Cronk, PhD University of Missouri

Objectives Participants will be able to: 1.Identify resident barriers to addressing substance use problems in clinical practice 2.Identify at least 2 benefits of the current training program to prepare residents to address substance use in clinical practice 3.Describe the basic skills included in screening and brief intervention for substance use problems

Alcohol and Drug Education for Prevention and Treatment SBIRT – Screening, Brief Intervention and Referral for Treatment

Dan Vinson, MD – Primary Investigator Bruce Horwitz, PhD – Primary Investigator Kristen Deane, MD – Associate Residency Director Nikole Cronk, PhD – Behavioral Science Coordinator Debra Sprague – MU ADEPT Project Coordinator Personnel

Substance Abuse is Common 16.5% of US adults have had >1 episode of heavy drinking in past 30 days – 8.4% have a current AUD 8.3% of 12+ year-olds report illicit drug use in past month 4.8% report non-medical use of prescription opioids in past year – 2% have current drug use disorder

Substance Abuse is Costly 79,000 deaths annually are attributed to excessive alcohol use $184.6 billion (1998) – $18.8 billion in healthcare Drug abuse cost $180.8 billion (2002) – $15.8 billion in healthcare

Substance Abuse is Hidden Despite frequency and costliness, healthcare system is woefully inadequate in identification and treatment Similar to Type 2 Diabetes and hypertension – Heritable, environmentally influenced, affected by lifestyle – stigma

Grant SAMHSA grant application – Training residents across disciplines in SBIRT services – Multiple specialties: FCM, Internal Medicine, Child Health, Psychiatry, Surgery, OB/GYN, Emergency Medicine Medical students Nursing, social work

MU ADEPT 5 phases (evolving curriculum) – Online modules – Role plays/didactics – Simulated patient encounters – Clinical practice – Advanced, specialty-specific practice

Substance Use in Medical Settings 5% 20% 35% 40% Dependent (referred for tx) At-Risk Drinkers (Primary focus of SBIRT) Low Risk Drinkers Abstainers

SBIRT Annual Brief Screen Evaluation of Severity High Risk Brief Intervention + Possible referral For specialized tx Low to Moderate Risk Brief Intervention + ++

Risky Drinking Men <65 o >4/day o >14/week Women <65 o >3/day o >7/week Men and Women >65 o >3/day o >7/week NIAAA low risk drinking limits

Risky Substance Use Rx and Illicit drugs o Any Rx drug misuse o Any illicit drug use Tobacco – Any tobacco use

Risky Drinking For every 1 person w/ alc dep – 6+ are at risk or have experienced px related to alcohol use >107,000 alcohol related deaths annually 1/3 of ER admissions are alcohol related 60% of trauma ctr patients are under the influence

Risky Drinking Major risk factor for all injuries – Px drinkers have 2x as many injury events/year – Px drinkers have 4x as many hospitalizations for injury 34% of yr-olds engage in binge drinking Risk for health px: – Heart disease, liver disease, gastritis, seizure, stroke, psychiatric disorders

Why SBIRT in Primary Care? Preventable cause of injury and illness Specialized services – Segregated from general medical settings fostering stigma & ignorance – Difficult to access: 13% of those who need tx, get it – Serve dependent drinkers who are less common than risky drinkers

Why SBIRT in Primary Care? 25% will screen positive for some type of substance abuse/misuse Of those, 80% will be “at-risk” drinkers Most will be open to addressing px

Barriers to Addressing Alcohol Use in Primary Care 58% belief that patients lie 35% time constraints 29% fear it questions patient’s integrity 25% fear of frightening/angering patient 16% uncertainty about treatments 13% personally uncomfortable w/ subject 11% may encourage pt to see other PCP 11% insurance doesn’t reimburse PCP time

Patient Perspective Agree/Strongly Agree “If my doctor asked me how much I drink, I would give an honest answer.” 92% “If my drinking is affecting my health, my doctor should advise me to cut down on alcohol.” 96% “As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.” 93% Disagree/Strongly Disagree “I would be annoyed if my doctor asked me how much alcohol I drink.” 86% “I would be embarrassed if my doctor asked me how much alcohol I drink.” 78%

MU ADEPT Phase 1 MU Adept Website 4 Online modules w/ quizzes Module 1 – What is SBIRT – What is risky substance use Prevalence, morbidity, mortality, costs – Checking assumptions – Effectiveness of SBIRT

Online Module1 Checking Assumptions – Substance abuse is a moral failing not a medical issue – Treating substance misuse is not my job – My job is to diagnose and advise treatment – take it or leave it – My patient should be ready to change – A patient’s health should be their prime motivation – If my patient doesn’t change, the brief intervention 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

Online Module1 Effectiveness of SBIRT (meta-analyses) – >34 randomized controlled trials At-risk drinkers 10-30% reduction in alcohol consumption at 12 mo. – Less data for drug use, but compelling evidence of effectiveness Cocaine, Heroin, Cannabis, Benzodiazepines, general illicit drug use

Online Module 2 Screening and Assessment 1.Screening 2.Brief Assessment 3.Assessment for use disorder

Online Module 2 Pre-screen – (yes – indicates further assessment) Tobacco UseYesNo Do you smoke? Alcohol Use For men: In the past year, have you had 5 or more standard drinks in one day? For women: In the past year, have you had 4 or more standard drinks in one day? Drug Use In the past year, have you used prescription drugs more than the doctor prescribed? In the past year, have you used street drugs?

Online Module 2 Standard Drinks

Online Module 2 Brief Assessment for positive screen Quantity and Pattern 1. How many days do you drink in a typical week? 2. How many drinks do you have in a typical day? Functional Impairment 3. In the past 12 months, how often have you had a lot more to drink than you intended to have? 4. In the past 12 months, how often have you been under the influence of drugs or alcohol in situations where you could have caused an accident or gotten hurt?

Online Module 3 Brief Intervention Basics – Stages of Change – MI basics Links to MI video examples MI Spirit 4 key elements – Express empathy – Develop discrepancy – Roll with resistance – Support self-efficacy – Difference between abstinence and harm reduction

Online Module 3 MI Tools – Self-evaluation rulers – Readiness rulers – Decisional balance – Self-help on-line resources OARS – Open-ended questions – Affirmations – Reflections – Summarizations

Online Module 4 Brief Intervention 1.Raise the subject 2.Provide feedback 3.Offer advice 4.Enhance motivation 5.Negotiate a plan Providing Feedback Example Case examples

MU ADEPT Phase 2 Role plays w/ didactics – Residents LOVE to role play! – Cases from actual practice – Facilitator-scripted cases

MU ADEPT Phase 3 Clinical Simulation Center – Residents REALLY LOVE to be taped! – Groups of 6; 3 pairs (One R1 with one R3) – 90 min: Discussion - 15 min. Partner 1 (R3) - 20 min. Partner 2 (R1) - 20 min. Review - 35 min.

MU ADEPT Phase 3 Video Example

MU ADEPT Phase 3 (part 2) Advanced Practice Simulation – More beloved role plays (no, really!) – Simulated patient Group format Time-outs – Discussion of difficult patient encounters

MU ADEPT Phase 3 (part 2) Patient Description Harold Johnson is a 58 year-old married father of 2 adult children. He is a prominent attorney in town and is friendly with several senior attendings. Harold has a history of hypertension that has been treated with beta blockers with moderate success. However, today his BP is 152/97. He has a medical history significant for 2 MIs that occurred when he was 48 and 54 years old. He presents today in clinic for follow-up on a recent increase in his medication dosage. He is also complaining of insomnia and is hoping you may be able to prescribe an effective sleep medication. He has tried Ambien in the past with no success.

MU ADEPT Phase 4 SBIRT in clinical practice – Shadowed by psychologist – Questionnaires from 10 consecutive visits Patient fills one out – “My doctor asked about my drinking” – “I wanted my doctor to ask about my drinking” Physician fills one out (faculty too)

Tobacco Use Alcohol Use Drug Use Quantity and Pattern Functional Impairment Do you smoke or use tobacco? In the past year, have you had ___ (Men= 5, Women= 4) or more standard drinks in one day? In the past year, have you used prescription drugs more or other than as prescribed? In the past year, have you used street (or recreational) drugs? How many standard drinks do you have in a day? SCREENSCREEN ASSESS How many days do you drink in a typical week? In the past 12 months, how often did you drink or use more drugs than you intended? In the past 12 months, have you been intoxicated on alcohol or drugs when you could have hurt yourself or others such as driving under the influence? Yes Over Low Risk Limits Low Risk Limits Drinks/ Week Drinks/Day Men144 Women73 All >Age 6573 Any Tobacco/Rx/Street Drug UseBrief Intervention > Daily or Week Limit Moderate Risk Brief Intervention > Daily + Week LimitHigh RiskBrief Intervention Functional Impairment Possible Use Disorder Brief Intervention Possible Referral Reminder Cards

1. Raise the Subject 2. Provide Feedback 3. Offer Advice 4. Enhance Motivation 5. Negotiate a Plan Is it OK if we talk about your substance use? Your [alcohol/drug] use is above safe limits and I am concerned about how that affects your health. I would like you to consider cutting back on your _____ use. Use OARS techniques to enhance internal motivation What are some of the pros and cons of your _____ use? On a scale of 1-10, how ready are you to cut down? What steps can you take to cut down? Can we schedule a follow up visit to talk about this? Key Motivational Interviewing Techniques OARSOpen ended questions Affirmations Reflections Summaries REDSRoll with Resistance Express Empathy Develop Discrepancy Support Self Efficacy Readiness Ruler INTERVENEINTERVENE Not Now 0cm Now v0 ADEPT Alcohol and Drug Education for Prevention and Treatment Health Care Reminder Cards

Next Steps Collect more data! – Physician and patient exit questionnaires – Document clinical SBIRT practice Develop a plan for monitoring & providing expert feedback to residents in clinical setting Train attendings