Overview of the SBIRT Process David P. Miller, MD, MS, FACP Associate Professor Internal Medicine and Public Health Sciences

5 Basic Components of an SBIRT System Prescreening (1-2 question screen) Screening (AUDIT / DAST; CRAFFT) Clinician Intervention for all screen-positive clients Referral as appropriate for clients with higher levels of risk or possibly dependent Follow-up assessment/reinforcement at future visits

STEP 1: Prescreen is routinely performed every 6-12 months Tools: Single alcohol screening question (SASQ - NIAAA) single drug screening question (NIDA)

Prescreening Questions “Single Alcohol Screening Question” (NIAAA) Do you sometimes drink beer, wine, or liquor? How many times in the past year have you had more than (3 or 4) drinks in a day? “Single-Item Drug Use” (NIDA) How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?

STEP 2: Administer screening IF prescreen is positive Tools: AUDIT (for alcohol) DAST-10 (for drugs)

AUDIT (for + alcohol prescreen) Adapted from World Health Organization 3 quantity & frequency questions (1-3) 3 questions probing signs of dependency (4-6) 4 questions about alcohol-related problems (7-10) Score Range: 0 - 40

DRUG USE QUESTIONNAIRE (DAST -10) These questions refer to the past 12 months only: Circle Response 1. Have you used drugs other than those required for medical reasons? Yes No 2. Do you abuse more than one drug at a time? 3. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 4. Have you had “blackouts” or “flashbacks” as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parent) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Are you always able to stop using drugs when you want to? DAST-10 score (add circled responses in left column) See printed form (color?) www.sbirtonline.org Southeastern Consortium for Substance Abuse Training © 2013

DAST-10 Advantages Short, self-administered Disadvantages Is not drug-specific Validation data is limited Does not distinguish between active and inactive illicit drug use Focuses on dependence www.sbirtonline.org Southeastern Consortium for Substance Abuse Training © 2012

Sensitivity & specificity in the discrimination of drug use disorders Risk Zones AUDIT Score: DAST Score: High Risk At Risk Low/No Risk 1-13 ≥ 14 1-2 3-10 (No drug use) Sensitivity & specificity in the discrimination of drug use disorders with psych populations are optimized with a score of ≥3 (Maisto et al., 2000). Sensitivity & specificity in the discrimination of drug use disorders with psych populations are optimized with a score of ≥3 (Maisto et al., 2000) www.sbirtonline.org Southeastern Consortium for Substance Abuse Training © 2012

Prescreening/Screening for Adolescents: CRAFFT During the past 12 months, did you: Drink any alcohol (more than a few sips)? Smoke any marijuana or hashish? Use anything else to get high?

Prescreening/Screening for Adolescents: CRAFFT Ask everyone

Risk Zones High Risk At Risk Low/No Risk CRAFFT >2 0 or 1 (use alcohol or drugs) Sensitivity & specificity in the discrimination of drug use disorders with psych populations are optimized with a score of ≥3 (Maisto et al., 2000). www.sbirtonline.org Southeastern Consortium for Substance Abuse Training © 2012

STEP 3: Administer Brief Intevention

Components of a Brief Intervention Ask permission Provide feedback Enhance motivation Provide advice Discuss next steps Close on good terms

Intervention Guide Zone I: At Risk AUDIT 1-13 (≥ 1 binge); DAST 1-2 Zone II: High Risk, Possibly Dependent AUDIT ≥ 14; DAST 3-10 www.sbirtonline.org Rev. Mar 2012 Funded by: Ask Permission “I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?” Provide Feedback Refer to pyramid & provide patient’s AUDIT/DAST score & risk level(s). [As your physician] “Drinking/using at this level can be harmful to your health and possibly responsible for the health problem for which you came in today. What do you make of that?” Enhance Motivation & Elicit Change Talk “What are the good things/not so good things about your alcohol/drug use?” (Decisional balance) “On a scale of 0-10, how important is it that you cut back or quit your alcohol/drug use?” If >0, “Why that number and not a lower one?” [Use rulers to also ask about confidence, readiness] “Have you ever considered cutting back or quitting?” If so, “Why?” If not, “What would have to happen for you to consider cutting back/quitting?” Provide Advice Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines (or offer advice to quit or cut back drug use). Zone II Additional Steps: Ask: “If you go a day or 2 without drinking/using do you ever get sick, shaky, have tremors/seizures/cramps, or see/hear things that are not there?” Offer menu of options for more help: ► Medication (naltrexone, acamprosate, disulfiram, methadone, Suboxone) ► Referral •Counseling/Brief treatment •Support group (e.g., AA, NA, Celebrate Recovery) •Treatment or substance abuse program Discuss Next Steps “If you were to make a change, what would be your first step?” Close on Good Terms Summarize, emphasize patient strengths, highlight change talk and decisions made. Arrange for follow-up as appropriate. Intervention card adapted from Oregon Health & Sciences University SBIRT Primary Care Residency Initiative

STEP 4: Refer to Treatment (if indicated)

Local Treatment Resources Detox Inpatient Outpatient Faith-based Long-term residential Every site needs to develop their own resource list.

STEP 5: Follow-up Reassess Reinforce