SCREENING AND BRIEF INTERVENTION AND REFERRAL FOR TREATMENT (SBIRT) AN EVIDENCE-BASED APPROACH TO ALCOHOL PROBLEM PREVENTION Shahrzad Bazargan-Hejazi, PhD Professor, College of Medicine, Charles R. Drew University of Medicine and Science David Geffen School of Medicine at UCLA 10 th Drug Abuse Research Symposium August 7/2015 1

OBJECTIVE  Provide definition and rationale for utilizing SBIRT.  Highlight the application and elements of motivational interviewing (MI) in conducting BI.  Describe the delivery method of SBIRT. 2

SBIRT DEFINITION & COMPONENTS SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services * Increase access to care for persons with substance use disorders and those at risk of substance use disorders * Foster a continuum of care by integrating prevention, intervention, and treatment services * Improve linkages between health care services and alcohol/drug treatment services  Screening  Brief Intervention  Referral to Treatment 3

MLK Hospital ED-Based Alcohol Study 11%= Dependent Drinkers 25%: Hazardous Drinkers 28%: Problem Drinkers 36%= At-Risk Drinkers SBIRT WHY SBIRT Referral to treatment Screen & Brief intervention Shahrzad Bazargan-Hejazi, Korcha, R; Cherpitel, C; Ye, Y; Bond, J; Andreuccetti, G; Borges, G; Bazargan-Hejazi, S. Alcohol Use and Injury Severity Among Emergency Department Patients in Six Countries. Journal of addictions nursing, Volume 24(3), July/September 2013, p 158–165

WHY SBIRT: AUD IS A NATIONAL PROBLEM 16.6 million adults (+18 years) had AUD in 2013  Alcohol-Related Death  The 3 rd leading preventable cause of death in the U.S.  ~ 88,000 people die from alcohol related causes, annually.  Economic Burden:  AUD cost the U. S. $223.5 billion, in  ~ ¾ of the cost is related to binge drinking.  Burden of Care  In inpatient and out-patient clinics: o ~ 55% and 42% of visits per year are due to harmful drinking, respectively.  In ER: o 10% to 40% of patients screen positive for alcohol misuse. 5

Survey on Patient Attitude s 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% WHY SBIRT: PATIENTS ARE OPEN TO DISCUSS THEIR ALCOHOL USE Source: Miller, P. M., et al. (2006). Alcohol & Alcoholism. Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum ( 6

WHY: SBIRT IS EFFECTIVE Source: Substance Abuse and Mental Health Services Administration (SAMHSA). White Paper on Screening, Brief Intervention and Referral to Treatment (SBIRT) in Behavioral Healthcare. Key:  Evidence for effectiveness/utility of component * Component Demonstrated to show Promising Results — Not Demonstrated and/or Not Utilized 7

WHY: SBIRT IS FAVORED BY ED. PROVIDERS ED studies have reported the feasibility, benefit of SBIRT Bazargan-Hejazi S. The Academic ED SBIRT Research Collaborative. An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance abuse : official publication of the Association for Medical Education and Research in Substance Abuse. 2007; 28(4): Substance abuse : official publication of the Association for Medical Education and Research in Substance Abuse Bazargan-Hejazi S. The Academic ED SBIRT Research Collaborative. The Impact of Screening, Brief Intervention, and Referral for Treatment (SBIRT) on Emergency Department Patients’ Alcohol Use. Ann Emerg Med, 2007; 50(6),

WHY: SBIRT IS PROMOTED 9  2006, The American College of Surgeons Committee (ACS) on Trauma mandated all ED settings implement SBIRT.  2007 the US Center for Medicare and Medicaid Services (CMS) allowed hospital EDs to get reimbursed for alcohol and drug related SBIRT.  Endorsed by the U.S Preventive Services Task Force (PSTF) as one of the top 5 cost-effective prevention activity.

SBIRT Settings Aging/Senior ServicesInpatient Behavioral Health ClinicPrimary Care Clinic Community Health CenterPsychiatric Clinic Community Mental Health CenterSchool-Based/Student Health Drug Abuse/Addiction ServicesTrauma Centers/Trauma Units Emergency RoomUrgent Care Federally Qualified Health CenterVeterans Hospital Homeless FacilityOther Agency Sites Hospital WHY: A HIGHLY FLEXIBLE INTERVENTION

WHY: SPECIALTY FRIENDLY

12  Screening  Brief Intervention  Referral to Treatment RECAP: COMPONENTS OF SBIRT

ScreenTarget Population # Items AssessmentSetting (most common) Type ASSIST (WHO) -Adults -Validated in many cultures and languages 8Hazardous, harmful, or dependent drug use (including injection drug use) Primary Care Interview CRAFFTAdolescent s 6To identify alcohol and drug abuse, risky behavior, & consequences of use Different settings Self-admin AUDIT (WHO) -Adults and adolescent s -Validated in many cultures and languages 10Identifies alcohol problem use and dependence. Can be used as a pre-screen to identify patients in need of full screen/brief intervention -Different settings -AUDIT C- Primary Care (3 questions) Self-admin, Interview, or computeriz ed CAGEAdults and youth >16 4-Signs of dependence, not risky use Primary Care Self-admin or Interview TWEAKPregnant women 5-Risky drinking during pregnancy. Based on CAGE. -Asks about number of drinks one can tolerate, alcohol dependence, & related problems Primary Care, Women’s organization s, etc. Self-admin, Interview, or computeriz ed SBIRTS STARTS WITH SCREENING TWEAKPregnant women 5-Risky drinking during pregnancy. Based on CAGE. -Asks about number of drinks one can tolerate, alcohol dependence, & related problems Primary Care, Women’s organization s, etc. Self-admin, Interview, or computeriz ed ASSIST (WHO) -Adults -Validated in many cultures and languages 8Hazardous, harmful, or dependent drug use (including injection drug use) Primary Care Interview AUDIT (WHO) -Adults and adolescent s -Validated in many cultures and languages 10Identifies alcohol problem use and dependence. Can be used as a pre-screen to identify patients in need of full screen/brief intervention -Different settings -AUDIT C- Primary Care (3 questions) Self-admin, Interview, or computeriz ed

Score range AUDIT SCREENER  Scoring Range: 0-40

BRIEF INTERVENTION 15 S creening B rief I ntervention

16 MI Style MI Processes MI Skills MI Core Concepts Stages of Change MI Definition TO ACHIEVE OUR GOAL IN THE BI, IT IS NECESSARY TO USE MI STYLE

17 MI DEFINITION “It is an effective way of talking with people about change” (Bill Matulich)

 Wanting and not wanting to change at the same time.  MI can help to resolve it so that the person can move toward change, by eliciting person’s own motivation to change  People are better persuaded by the reasons they themselves discovered than those that come into the minds of others (Blaise Pascal) AMBIVALENCE IS NORMAL 18

STAGES OF CHANGE: 1.Pre-contemplation Not yet thinking about change or is unwilling to change. 2. Contemplation Is ambivalent about change 3. Determination Committed to changing. Still considering strategies. 4. Action Taking steps toward change but hasn’t stabilized in the process. 5. Maintenance Has achieved the goals and is working to maintain change. 6. Relaps Experienced a recurrence of the symptoms. 19

READINESS TO CHANGE Assess Readiness On a scale of 1–10…  How ready are you to change your drinking?  How important it is ….  How confident you are to….  Why didn’t you give it a lower number?  What would it take to raise that number? 20 Bernstein E.; Bernstein, J.; and Levenson, S. Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annals of Emergency Medicine. 1997;30(2):181–

MI CORE CONCEPTS: THE SPIRIT OF MI 21 Autonomy - Accept and respect patient autonomy - Focusing on patient choice - Asking “permission” to provide assistance, info. Collaboration - Nonjudgmental listening - Viewing the patient as the “expert”. Evocation - Best ideas about change come from the patient - Elicited behavior change from the patient. - Direct persuasion is not effective. Empathy - Show understanding and compassion with respect to where the patient is coming - We keep patient’s best interest in mind.

22 MI CORE SKILLS: OARS The most important skill in MI. Listening and understanding what the client is saying, thinking and feeling, then saying it back to the client. Reflection Pointing out positive things we notice about the patient. Prior achievements, accomplishments, success. Affirmations Long reflection of several statements used by the patient. Strategically selecting patients own reasons to change Summaries Ask more open questions than Yes & No Qs. How, Why, What? Open Questions

23 MI PROCESSES Engaging “To establish a trusting and mutually respectful relationship”; Avoid dis- engaging traps: Question-Answer Confrontation- Denial Expert Labeling Blaming. Focusing -Involve direction for change -Setting an agenda or agreeing on an agenda/topic while considering patients goals and priorities. -To create a clear direction for change plan -OARS skills can help with this. Evoking Eliciting patient’s own motivation for change. Elicit “Change Talk”: are clients speech that favors movement toward change: I want to I wish I could The reason Planning -Developing a specific patient- centered SMART change plan: Specific Measureable Achievable Relevant Timed

REFERRAL TO TREATMENT FOR PATIENT WITH ALCOHOL DEPENDENCY  Approximately 5-10% of patients screened will require referral to AUD treatment.  Provide “warm hand-off” approach to referrals.  Describe treatment options to patients based on available services.  Develop relationships between health centers, who do screening, and local treatment centers.  Facilitate hand-off by:  Calling to make appointment for patient.  Providing directions and clinic hours to patient.  Coordinating transportation when needed. 24

PUTTING IT ALL TOGETHER Engaging & Screening & Feedback & Respect Patient Autonomy Listening, Reflecting & Find a Focus NOT READYUNSURE READY EXPRESS CONCERN, OFFER INFO. FOLLOW-UP SMART PLAN EXPLORE & RESOLVE ABMIVALENCE SMART PLAN HELP PLAN, TREAT, MAKE REFERRAL SMART PLAN Summarize & Assess Readiness

26 ACKNOWLEGEMENT C. Cherpitel, DrPH T. Moyer, Ph.D E. Bernstein, MD W. Miller, Ph.D B. Matulich, Ph.D Sinan Jabori, BA.

Thank You For additional information on SBIRT Visit

HOW DO WE DEFINE RISK? At-Risk Alcohol Use MenWomen Older Adults (65 +) Per occasion >4 >3 >1 Per week >14 >7 28