SBIRT Angela McClellan, OCPS I Director Coalition for a Drug-Free Mahoning County September 5, 2013

A Wise Judge Once Told Me… http://pointsadhsblog.wordpress.com/2013/05/20/9832/

Continuum of care Source: http://www.jmir.org/2010/5/e60/, http://captus.samhsa.gov/prevention-practice/prevention-and-behavioral-health/behavioral- health-lens-prevention/3

Prevention Continuum of Care Taxonomy: Problem ID & Referral Problem Identification and Referral is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence. Source: Ohio Department of Mental Health and Addiction Services Prevention Continuum of Care Taxonomy

Problem ID & Referral: Direct Services Interventions that directly serve the customer and allow for two-way interaction at that instance. Intervention, Brief Screening and Referral Services Drug-Free Workplace Programs/EAP Programs Student Assistance Program Services Support Groups Consumer Advocacy and Linkage Risk Reduction Activities Source: Ohio Department of Mental Health and Addiction Services Prevention Continuum of Care Taxonomy

The Current Model: A Continuum of Substance Use Abstinence Responsible Use Dependence As we begin discussing SBIRT: Important to note that SU has often been viewed in black-and-white, either/or terms With a focus on whether a person is addicted—or not. Services targeting these populations- Reality: SU appears along a continuum, from abstinence to dependence (often referred to as addiction). Within this spectrum, there is diversity of how individuals might appear along it. Some progress through the continuum gradually as their SU increases. Some quickly experience SU related problems. Some sustain low-risk SU and never encounter harmful effects. Using this same continuum: Traditional SU intervention has often focused on either Universal Prevention strategies or Specialized Treatment According to NIDA: With regard to universal prevention strategies: “Many of these research‐based programs include approaches to identifying early risk factors and addressing them long before a child encounters SA.” Specialized treatment services: Have often been segregated from general health care, which has reinforced stigma Have frequently been difficult to access Only address SA and/or dependence – not the much more common at risk SU behaviors. We believe that, as opposed to thinking only those men and women whose drinking has progressed to the point where they need help, that many people in the mid-range may also be suffering as a result of drinking. That suffering may take the form of declining job performance and declining health so that the individual does not yet recognize it as being related to drinking. Joseph Nowinski, a clinical psychologist,  and Robert Doyle, a clinical psychiatry instructor at Harvard Medical School, recently wrote a book called Almost An Alcoholic: Is My (or My Loved One’s) Drinking a Problem? Source: Jim Aiello, MA, Med, Institute for Research, Education and Training in Addictions (IRETA), (www.ireta.org)

The outdated model defines a substance use problem as… Dependence Source: Jim Aiello, MA, Med, Institute for Research, Education and Training in Addictions (IRETA), (www.ireta.org)

The SBIRT model defines a substance use problem as… Excessive Use Source: Jim Aiello, MA, Med, Institute for Research, Education and Training in Addictions (IRETA), (www.ireta.org)

The SBIRT Model A Continuum of Substance Use Social Use Abstinence Abuse Experimental Use Binge Use Dependence Source: Jim Aiello, MA, Med, Institute for Research, Education and Training in Addictions (IRETA), (www.ireta.org)

71% 25% Drinking Behavior Intervention Need Brief Intervention and Referral for additional Services 4% Dependent 25% Hazardous Harmful Symptomatic Brief Intervention or Brief Treatment No Intervention; screening and feedback only Low Risk or Abstinence 71% Drinking Behavior Intervention Need Source: Jim Aiello, MA, Med, Institute for Research, Education and Training in Addictions (IRETA), (www.ireta.org)

Source: http://www.samhsa.gov/prevention/sbirt/ What Is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur. Source: http://www.samhsa.gov/prevention/sbirt/

What is it REALLY? SBIRT is a tool to detect risky or hazardous substance use before the onset of abuse or dependence, early intervention, and treatment for people who have problematic or hazardous [alcohol] problems. http://www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf

Why SBIRT? Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care. Source: http://www.samhsa.gov/prevention/sbirt/

Six Characteristics of SBIRT It is brief (e.g., typically about 5-10 minutes for brief interventions; about 5 to 12 sessions for brief treatments). The screening is universal. One or more specific behaviors are targeted. The services occur in a public health or other non-substance abuse treatment setting. It is comprehensive (comprised of screening, brief intervention/treatment, and referral to treatment). Strong research or experiential evidence supports the model’s effectiveness. http://www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf

1. Use of Brief, Validated, Universal Pre-Screening / Screening Tools AUDIT Alcohol Use Disorders identification Test AUDIT-C Alcohol Use Disorders Identification Test - Consumption DAST Drug Abuse Screening Test ASSIST Alcohol, Smoking, Substance, Involvement, Screening Test CAGE Cut Down, Annoyed, Guilty, Eye Opener * Also Single Question Method has been found to be effective.

2. Relatively Easy to Use By Diverse Providers The SBIRT approach is easy to learn relative to other behavioral treatment techniques It can be implemented by diverse health professionals, e.g. Physicians, Nurses, Social Workers, Health Educators, Prevention Specialists, Paraprofessionals, etc.

3. Incorporation of strong referral linkages to specialty treatment The goal is to provide a quick hand off to specialty treatment if the Primary Care site cannot provide more intensive service. Close tracking to confirm patient compliance with treatment is critical to good health care provision.

SBIRT Flow Chart Screening Low Risk No Further Intervention Moderate Risk Brief Intervention Moderate to High Risk Severe Risk to Dependency Referral to Specialty Treatment

It Starts With One Person Doug Wentz, M.A., O.C.P.S. II Community Services Director

One Health Ohio Federally Qualified Healthcare Center Began SBIRT with patients at one site in Youngstown, OH. (Five other sites in region serve as control group). Social Worker/Prevention Specialist (former CDCA) to screen Preliminary results: 99% of clients voluntarily participate in the screening 70% of 1-Question screens are positive for AOD or depression Diagnostic rates more than doubled (vs. increase of 1.6% at control location)

“So what does this have to do with my coalition?” We have the Know How! Coalitions have connections in all twelve sectors “New” definition of problem has been our definition all along

“So what does this have to do with my coalition?” Information Dissemination Training Networking Bringing new faces to the table Grants and other Funding Training Revenue

The Truth Fairy

FAQs How do we pay for this? No, seriously, how do we pay for this? So what, this isn’t our target substance? Have you ever tried to get doctors to attend anything? <<sarcasm font>> How can we/our collaborative partners get paid for this? How do we get trained to be trainers? Where can I find resources?

SBIRT Resources Angela McClellan, OCPS I www.ireta.org www.attcnetwork.org/sbirt www.sbirtonline.org www.niaa.nih.gov www.HealthTeamWorks.org www.drugabuse.gov www.samhsa.gov/prevention/sb irt Angela McClellan, OCPS I Director Coalition for a Drug-Free Mahoning County Angela@DrugFreeMahoningCounty.org (ofc) 330.953.3212 (cell) 330.771.7732 Doug Wentz, MA, OCPS II Community Services Director Neil Kennedy Recovery Clinic Douglas.Wentz@GatewayRehab.org (ofc) 330.792.4724 x 7128 (cell) 330.509.3650