Our goal for this training is to instruct providers in specific SBIRT procedures and to develop participants’ skills to deliver SBIRT in their practices. Resources Participants Educational materials from ATTCs and other centers Trainers Activities Didactic learning Role plays Group discussions Brief assessment Links to additional training Outcomes Develop skills to deliver SBIRT Discuss implementation challenges and possible solutions Integrate SBIRT in practice (long-term outcome)

Please complete the pre-test. Thank you!!

This course will teach you how to: Administer screening Deliver a brief intervention Employ a motivational approach Make referrals to specialized treatment

Take some time to think about the most difficult change that you had to make in your life. How much time did it take you to move from considering that change to actually taking action?

Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that raises awareness of risks and motivates client toward acknowledgement of problem. Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help. Referral: Procedures to help patients access specialized care.

Substance abuse SBI may reduce alcohol and drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency department visits, depression, drug-related infections and infectious diseases Health care costs Studies have indicated that SBI for alcohol saves $2 - $4 for each $1.00 expended Other outcomes SBI may reduce work-impairment, reduce DUIs, and improve neonatal outcomes

Increases clinicians’ awareness of substance use issues. Offers clinicians more systematic approach to addressing substance use (less of a “judgment call”).

“I had a vague idea on how to assess substance use, but now I think I have a lot more knowledge in these other areas. I know what to look for and it is a way to give me a gauge to see if the person is at risk and how to approach them [about that risk].” Mental health clinician, UCLA Counseling and Psychological Services

Brief interventions are successful when clinicians relate patients’ risky substance use to improvement in patients’ overall health and wellbeing.

“I just kind of relate it by saying…there’s just a big connection with mood and substance use, so I talk about that more as they could be someone who is anxious and they’re drinking or smoking pot. The drug use could be intensifying as a problem even if they are not identifying their use as a problem. So just pointing that out to them in a motivational interviewing way by saying, why don’t you track this and see what’s happening with your depression. And it just opens another way of talking about it. Sometimes you can see them glaze over and think, ‘‘Oh here we go with the alcohol and drug part.’’ But when you start linking it with mood and anxiety then they are like ‘Oh OK’.” Mental health clinician, UCLA Counseling and Psychological Services

College students Primary care patients Mental health patients Patients in infectious disease clinics People with alcohol- or drug-related legal offenses (e.g., DUI)

Can SBIRT work in your setting?

Screening to Identify Patients At Risk for Substance Use Problems

Screening Assessment What’s going on in these pictures?

Self-report Interview Self-administered questionnaires Biological markers Breathalyzer testing Blood alcohol levels Saliva or urine testing Serum drug testing See reference list

Brief (10 or fewer questions) Flexible Easy to administer, easy for patient Addresses alcohol and other drugs Indicates need for further assessment or intervention Has good “sensitivity” and “specificity”

Provide historical picture Inexpensive Non-invasive Highly sensitive for detecting potential problems or dependence

Screen Target Population # ItemsAssessment Setting (Most Common)URL ASSIST (WHO) -Adults -Validated in many cultures and languages 8Hazardous, harmful, or dependent drug use (including injection drug use) [interview] Primary Care ance_abuse/activities/assi st_test/en/index.html AUDIT (WHO) -Adults and adolescents -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 [Self- admin, Interview, or computerized] Different Settings AUDIT C- Primary Care (3 questions) hq/2001/who_msd_msb_ 01.6a.pdf DAST- 10 Adults10To identify drug-use problems in past year [Self-admin or Interview] Different Settings mhsa.gov/clinical- practice/screening-tools CRAFFTAdolescents6To identify alcohol and drug abuse, risky behavior, & consequences of use [Self-admin or Interview] Different Settings boston.org/CRAFFT/ CAGEAdults and Youth >16 4-Signs of dependence, not risky use [Self-admin or Interview] Primary Care mhsa.gov/clinical- practice/sbirt/CAGE_ques tionaire.pdf TWEAKPregnant Women 5-Risky drinking during pregnancy. Based on CAGE. -Asks about number of drinks one can tolerate, alcohol dependence, & related problems [Self-admin, Interview, or computerized] Primary Care, Women’s Organizations, etc. om/sites/sbirttraining.co m/files/TWEAK.pdf

At-Risk Alcohol Use MenWomen Older Adults (65 +) Per occasion >4 >3 Per week >14 >7 See reference list

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief intervention. Self-report, 1-4 questions Biological, blood alcohol level test

NIAAA 1-item for alcohol use “How many times in the past year have you had X or more drinks in a day?” 5 for men 4 for women Identifies unhealthy alcohol use Positive screen = 1 or more (provide BI) See reference list

NIDA 1-item for illicit drug use "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Identifies overall drug use Positive screen = 1 or more See reference list

Alcohol: Women = 0 – 2 Men = 0 – 4 Alcohol: Women = 4+ Men = 5+ Other Drugs: Any Yes Other Drugs: All Nos Administer the AUDIT Administer the DAST Alcohol Screen Complete Other Drug Screen Complete Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT Complete Pre-Screen

10-question alcohol use screening instrument Target groups include: Medical patients Accident victims DWI offenders Mental health clients Designed for primary health care workers

Hazardous Alcohol Use Question 1: Frequency of Drinking Question 2: Typical quantity Question 3: Frequency of heavy drinking

Dependence Symptoms Question 4: Impaired control over drinking Question 5: Failure to meet expectations because of drinking Question 6: Morning drinking

Harmful Consequences of Alcohol Use Question 7: Guilt after drinking Question 8: Blackouts Question 9: Alcohol-related injuries Question 10: Others’ concerns about drinking

I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients. Your responses will be confidential. These questions help me to provide the best possible care. You do not have to answer them if you are uncomfortable. See reference list

Feedback? Reactions?

ScoreLevelAction 0-7LowEncouragement 8-19Low/ModerateBI 16-19ModerateBI/RT 20+HighBT/RT

1Have you used drugs other than those required for medical reasons?YesNo 2Do you abuse more than one drug at a time?YesNo 3Are you unable to stop using drugs when you want to?YesNo 4Have you ever had blackouts or flashbacks as a result of drug use?YesNo 5Do you ever feel bad or guilty about your drug use?YesNo 6Does your spouse (or parents) ever complain about your involvement with drugs? YesNo 7Have you ever neglected your family because of your use of drugs?YesNo 8Have you engaged in illegal activities in order to obtain drugs?YesNo 9Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? YesNo 10Have you had medical problems as a result of your drug use (eg, memory loss, hepatitis, convulsions, bleeding)? See reference list YesNo

Guidelines for Interpretation of DAST-10 Interpretation (Each “Yes” response=1) ScoreDegree of Problems Related to Drug Abuse Suggested Action 0No problems reportedEncouragement; Education 1-2Low levelRisky behavior – feedback and advice 3-5Moderate levelHarmful behavior – feedback and counseling; possible referral for specialized treatment 6-8Substantial levelIntensive assessment and treatment 9-10Severe LevelIntensive assessment and treatment

Self-reports are more accurate when people are: Alcohol- or drug-free when interviewed Told that their information is confidential Asked clearly worded, objective questions Provided memory aides (calendars, response cards) See reference list

Administer the AUDIT Administer the DAST-10 Alcohol Screen Complete Other Drug Screen Complete Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT

Brief Interventions for Patients at Risk for Substance Use Problems

“Brief opportunistic interventions are short, face-to-face conversations regarding drinking, motivation to change, and options for change which are provided during a window of opportunity or potentially teachable moment occasioned by a medical event.” See reference list

Presenting problem Screening results Awareness of Problem Motivation Behavior Change

Brief interventions trigger change. A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min. Research is less extensive for illicit drugs, but promising. A randomized study with cocaine and heroin users found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls. See reference list

FLO (Feedback, Listen and understand, Options explored) 4 Steps of the BNI (Raise the Subject; Provide Feedback; Enhance Motivation; Negotiate and Advise) Brief Negotiated Interview (BNI) Algorithm (Build Rapport; Pros and Cons; Information and Feedback; Readiness Ruler; Action Plan) FRAMES (Feedback; Responsibility; Advice; Menu of options; Empathy; Self efficacy)

What you do depends on where the patient is in the process of changing. The first step is to be able to identify where the patient is coming from.

Stages of Change: Primary Tasks 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate change strategies 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills for maintaining recovery 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences and determine what to do next

Stages of Change: Intervention Matching Guide Offer factual information Explore the meaning of events that brought the person to treatment Explore results of previous efforts Explore pros and cons of targeted behaviors Explore the person’s sense of self- efficacy Explore expectations regarding what the change will entail Summarize self-motivational statements Continue exploration of pros and cons Offer a menu of options for change Help identify pros and cons of various change options Identify and lower barriers to change Help person enlist social support Encourage person to publicly announce plans to change Support a realistic view of change through small steps Help identify high-risk situations and develop coping strategies Assist in finding new reinforcers of positive change Help access family and social support Help identify and try alternative behaviors (drug-free sources of pleasure) Maintain supportive contact Help develop escape plan Work to set new short and long term goals Frame recurrence as a learning opportunity Explore possible behavioral, psychological, and social antecedents Help to develop alternative coping strategies Explain Stages of Change & encourage person to stay in the process Maintain supportive contact 1. Pre- contemplation 2. Contemplation 3. Determination 4. Action 5. Maintenance 6. Recurrence

All change contains an element of ambivalence. We “want to change and don’t want to change” Patients’ ambivalence about change is the “meat” of the brief intervention.

Use reflective listening and empathy Avoid confrontation Explore ambivalence Elicit “change talk”

Young man is treated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video? See reference list

Same scenario, but different doctor. What does this doctor do that is different? Does it work? See reference list

Listen to both what the patient says and to what the person means Show empathy and don’t judge what patient says You do not have to agree Be aware of intonation Reflect what patient says with statement not a question, e.g., “You couldn’t get up for work in the morning.”

Repeating – Repeating what was just said. Rephrasing – Substituting a few words that may slightly change the emphasis. Paraphrasing – Major restatement of what the person said. Listener infers meaning of what was said. Can be thought of as continuing the thought. Reflecting Feeling – Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

What change are you wanting to make? What makes you want to change? What are the good things about making this change? Not-so-good things?

Challenging “What do you think you are doing?” Warning “You will damage your liver if you don’t stop drinking.” Finger-wagging “If you want to be a good student, you must stop drinking on school nights.”

Benefits of change Costs of using drugs Benefits of using drugs Costs of change

Avoid questions that inspire a yes/no answer. The good things about ______ The not- so-good things about ____ The good things about changing The not-so- good things about changing

Change talk consists of self-motivational statements that suggest: Recognition of a problem Concern about staying the same Intention to change Optimism about change

See reference list

Avoid Warnings! F L O W Feedback Listen & Understand Warn Options Explored (that’s it)

Feedback Setting the stage Tell screening results Listen & understand Explore pros & cons Explain importance Assess readiness to change Options explored Discuss change options Follow up

F L O Feedback Listen & Understand Options Explored

The Feedback Sandwich Ask Permission Give Advice Ask for Response

What you need to cover. 1. Ask permission; explain how the screen is scored 2. Range of scores and context 3. Screening results 4. Interpretation of results (e.g., risk level) 5. Substance use norms in population 6. Patient feedback about results

What do you say? 1. Range of score and context - Scores on the AUDIT range from Most people who are social drinkers score less than Results - Your score was 18 on the alcohol screen. 3. Interpretation of results - 18 puts you in the moderate- to-high risk range. At this level, your use is putting you at risk for a variety of health issues. 4. Norms - A score of 18 means that your drinking is higher than 75% of the U.S. adult population. 5. Patient reaction/feedback - What do you make of this?

See reference list

Handling Resistance Look, I don’t have a drug problem. My dad was an alcoholic; I’m not like him. I can quit using anytime I want to. I just like the taste. Everybody drinks in college. What would you say?

Chronic Pain SUD Family Con- fusion Medical Issues Pain SUD

To avoid this… LET GO!!!

Easy Ways to Let Go I’m not going to push you to change anything you don’t want to change. I’d just like to give you some information. What you do is up to you.

Finding a Hook Ask the patient about their concerns Provide non-judgmental feedback/information Watch for signs of discomfort with status quo or interest or ability to change Always ask this question: “What role, if any, do you think alcohol played in your (getting injured)? Let the patient decide. Just asking the question is helpful.

Let’s practice F : Role Play Giving Feedback Using Completed Screening Tools Focus the conversation Get the ball rolling Gauge where the patient is Hear their side of the story

ScoreLevelAction 0-7LowEncouragement 8-19Low/ModerateBI 16-19ModerateBI/BT 20+HighBT/RT

F L O Feedback Listen & Understand Options Explored

Ambivalence is Normal

Tools for Change Talk Pros and Cons Importance/Readiness Ruler

Strategies for Weighing the Pros and Cons What do you like about drinking? What do you see as the downside of drinking? What else? Summarize Both Pros and Cons “On the one hand you said.., and on the other you said….”

Listen for the Change Talk Maybe drinking did play a role in what happened. If I wasn’t drinking this would never have happened. Using is not really much fun anymore. I can’t afford to be in this mess again. The last thing I want to do is hurt someone else. I know I can quit because I’ve stopped before. Summarize, so they hear it twice!

Importance/Confidence/Readiness On a scale of 1–10… How important is it for you to change your drinking? How confident are you that you can change your drinking? How ready are you to change your drinking? For each ask: Why didn’t you give it a lower number? What would it take to raise that number?

Let’s practice L : Role Play Listen & Understand Using Completed Screening Tool Pros and Cons Importance/Confidence/Readiness Scales Develop Discrepancy Dig for Change

O Options Explored F L Feedback Listen & Understand

What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next?

Offer a Menu of Options Manage drinking/use (cut down to low-risk limits) Eliminate your drinking/drug use (quit) Never drink and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment)

During MENUS you can also explore previous strengths, resources, and successes Have you stopped drinking/using drugs before? What personal strengths allowed you to do it? Who helped you and what did you do? Have you made other kinds of changes successfully in the past? How did you accomplish these things?

Giving Advice Without Telling Someone What to Do Provide Clear Information (Advise or Feedback ) What happens to some people is that… My recommendation would be that… Elicit their reaction What do you think? What are your thoughts?

The Advice Sandwich Ask Permission Give Advice Ask for Response

Closing the Conversation (“SEW”) S ummarize patients views (especially the pro) E ncourage them to share their views W hat agreement was reached (repeat it)

Let’s practice O : Role Play Options Explored Ask about next steps, offer menu of options Offer advice if relevant Summarize patient’s views Repeat what patient agrees to do

Feedback Range Listen and Understand Pros and Cons Importance/Confidence/Readiness Scales Summary Options Explored Menu of Options

1) Raise The Subject 2) Provide Feedback 3) Enhance Motivation 4) Negotiate And Advise See Reference List

Key Components Be respectful Ask permission to discuss use Avoid arguing or being confrontational Key Objectives Establish rapport Raise the subject

What you need to cover. 1. Ask permission; explain how the screen is scored 2. Range of scores and context 3. Screening results 4. Interpretation of results (e.g., risk level) 5. Substance use norms in population 6. Patient feedback about results

What do you say? Range of score and context - Scores on the AUDIT range from Most people who are social drinkers score less than 8. Results - Your score was 18 on the alcohol screen. Interpretation of results - 18 puts you in the high risk range. At this level, your use is putting you at risk for a variety of health issues and other negative consequences. Norms - A score of 18 means that your drinking is higher than 70% of the U.S. adult population. Patient reaction/feedback - What do you make of this?

Ask Permission Give Feedback Ask for Response

Handling Resistance Look, I don’t have a drug problem. My dad was an alcoholic; I’m not like him. I can quit using anytime I want to. I just like the taste. Everybody drinks. What would you say?

To avoid this… LET GO!!!

Easy Ways to Let Go 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.

Chronic Pain SUD Family Con- fusion Medical Issues Pain SUD

Finding a Hook Ask the patient about their concerns Provide non-judgmental feedback/information Watch for signs of discomfort with status quo or interest or ability to change Always ask this question: “What role, if any, do you think alcohol played in your (getting injured)? Let the patient decide. Just asking the question is helpful.

Lets practice Feedback: Give Feedback Using Completed Screening Tools Establish rapport Raise the subject Give feedback results Express concern Substance use norms in population Elicit patient feedback about the feedback

ScoreLevelAction 0-7LowEncouragement 8-19Low/ModerateBI 16-19ModerateBI/RT 20+HighBT/RT

Critical components: Develop discrepancy Reflective listening Open-ended questions Assess readiness to change

Ambivalence is Normal

Importance/Confidence/Readiness On a scale of 1–10: How important is it for you to change your drinking? How confident are you that you can change your drinking? How ready are you to change your drinking? For each ask: Why didn’t you give it a lower number? What would it take to raise that number?

Strategies for Weighing the Pros and Cons What do you like about drinking? What do you see as the downside of drinking? What else? Summarize Both Pros and Cons “On the one hand you said.., and on the other you said….”

I’d like to hear you opinions about… What might you enjoy about… If you decided to ____ how would you do it? What are some things that bother you about using? What role do you think ____ played in your ______? How would you like your drinking/using to be 5 years from now? What do you need to do in order to_____?

Ask: Why do you want to make this change? What abilities do you have that make it possible to make this change if you decided to do so? Why do you think you should make this change? What are the 3 best reasons for you to do it? Give short summary/reflection of speaker’s motivation for change Then ask: “So what do you think you’ll do?”

Activity 7: Role Play Let’s practice Enhance Motivation: Using Completed Screening Tool Importance/Confidence/Readiness Scales Pros and Cons Develop Discrepancy Dig for Change Talk Summarize

Step 4: Negotiate and Advise Critical components: Negotiate a plan on how to cut back and/or reduce harm Direct advice Provide patient health information Follow-up

What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next?

You can also explore previous strengths, resources, and successes Have you stopped drinking/using drugs before? What personal strengths allowed you to do it? Who helped you and what did you do? Have you made other kinds of changes successfully in the past? How did you accomplish these things

Offer a Menu of Options Manage drinking/use (cut down to low-risk limits) Eliminate your drinking/drug use (quit) Never drink and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment)

Giving Advice Without Telling Someone What to Do Provide Clear Information (Advice or Feedback ) What happens to some people is that… My recommendation would be that… Elicit their reaction What do you think? What are your thoughts?

The Advice Sandwich Ask Permission Give Advice Ask for Response

Closing the Conversation (“SEW”) Summarize patients views (especially the pro) Encourage them to share their views What agreement was reached (repeat it)

Let’s practice Negotiate and Advise Ask about next steps, offer menu of options Offer advice Summarize patient’s views Repeat what patient agrees to do

1. Raise The Subject Establish rapport Raise the subject 2. Provide Feedback Provide screening results Relate to norms Get their reaction 3. Enhance Motivation Assess readiness Develop discrepancy Dig for Change 4. Negotiate and Advise Menu of Options Offer advise

1. Build Rapport 2. Pros and Cons 3. Information and Feedback 4. Readiness Ruler 5. Action Plan See reference list

Set up a safe environment by exhibiting a non- judgmental, empathetic attitude. Introduce yourself and take time to remember the patient’s name and how he/she prefers to be addressed (first name or Mr./Ms.) Show an interest in understanding the patient’s point of view. Use reflective listening Your attitude and demeanor will increase the likelihood that the patient will be honest

Let’s practice building rapport Introduce yourself and determine how to address the patient Ask permission to talk about drinking: Would you mind taking a few minutes to talk about your drinking? What is a typical day like for you? Where does your drinking fit in to your day? Be sure to use reflective listening.

Strategies for Weighing the Pros and Cons Ask the patient to put his/her hands out as if you were going to drop something in each hand. Then ask the patient to mentally drop into the right hand the “good” things about drinking; and into the left the things that aren’t so good about drinking. Summarize for the patient and ask which hand feels heavier? Use the discussion to underscore the patient’s ambivalence.

Let’s practice asking about pros and cons Ask: Help me understand through your eyes the good things about your drinking? What are some of the downsides about drinking for you? Use the “hands” exercise if you’d like (or just ask the questions). Summarize: On the one hand you said (Pros); and on the other hand (Cons)

The Feedback Sandwich Ask Permission Give Feedback and Information Ask for Response

What you need to cover. 1. Ask permission; explain how the screen is scored 2. Range of scores and context 3. Screening results 4. Interpretation of results (e.g., risk level) 5. Substance use norms in population 6. Patient feedback about results

Let’s practice giving Information and feedback: Role Play Giving Feedback Using Completed Screening Tools and information about at-risk drinking levels Focus the conversation Get the ball rolling using the AUDIT score Provide at-risk drinking information Elicit the patient’s reaction

ScoreLevelAction 0-7LowEncouragement 8-19Low/ModerateBI 16-19ModerateBI/BT 20+HighBT/RT

Use the “readiness ruler” to help the patient visualize how ready he/she is to consider reducing the amount they drink (or stopping altogether) in reaction to the feedback and information. Reinforce positives: “ You marked x. That’s great. That means you’re x% ready to change. Why did you choose that number and not a lower one like a 1 or 2? Allow the patient time to consider and share what is motivating them to consider change See reference list

I’d like to hear you opinions about… What might you enjoy about… If you decided to ____ how would you do it? What are some things that bother you about using? What role do you think ____ played in your ______? How would you like your drinking/using to be 5 years from now? What do you need to do in order to_____?

Create an action plan identifying steps the patient is willing and able to take in order to reduce the risks they have identified as connected to their drinking. Help the patient identify strengths and supports they can tap into based on their successes of the past and current available resources. Write down the action plan and give it to the patient Make referrals as appropriate Close the session by thanking the patient

Lets practice readiness to change and prescription for change: Ask the patient where they see themselves on a scale of 1 to 10 in terms of their readiness to change. Ask them why they didn't select a lower number and elicit “change talk” statements. Discuss options/steps that will work for the patient. Help them to identify strengths/supports/resources to support change. Summarize and write down the plan for the patient to take with them. Make a referral as appropriate. Thank the patient.

Build Rapport Ask about Pros and Cons Give Feedback and Information Assess Readiness to Change Develop a Prescription for Change

Feedback Responsibility Advice Menu of options Empathy Self efficacy See Reference List

The Feedback Sandwich Ask Permission Give Feedback Ask for Response

What do you say? 1. Range of score and context (Using an AUDIT score as an example)- Scores on the AUDIT range from Most people who are social drinkers score less than Results - Your score was 18 on the alcohol screen. 3. Interpretation of results - 18 puts you in the moderate- to-high risk range. At this level, your use is putting you at risk for a variety of health issues. 4. Norms - A score of 18 means that your drinking is higher than 75% of the U.S. adult population. 5. Patient reaction/feedback - What do you make of this?

Once you have given the feedback, let the patient decide where to go with it. Remember that it’s the patients responsibility to make choices about their substance use Your responsibility is to create an opportunity for the patient to discuss their substance use in a non-threatening, non-judgmental environment

The Advice Sandwich Ask Permission Give Advice Ask for Response

Ask the patient if they are open to hearing your recommendations Offer advice from your professional perspective Elicit the patient’s response

You can consider these ideas: Manage your drinking (cut down to low risk limits) Eliminate your drinking (Quit) Never drink and drive (Reduce Harm) Nothing (no change) Seek help (referral for treatment) See reference list

A consistent component of effective brief interventions is a warm, reflective, empathic and understanding approach by the person delivering the intervention. Use of a warm, empathic style is a significant factor in the patient’s response to the intervention and leads to reduced substance use at follow up

Self-efficacy has been described as the belief that one is capable of performing in a certain manner to attain certain goals Solution focused interventions Focuses on solutions not problems Techniques designed to motivate and support change

Let’s practice the FRAMES model: Begin with Feedback Using Completed Screening Tools Emphasize that the patient can make a change but what she will do is up to her (Responsibility). Share at-risk drinking levels and give Advice about alcohol consumption techniques. Discuss a Menu of Options with the patient and help the patient decide what changes she can realistically make in relation to reducing consumption. Express an understanding of the patient’s situation and acknowledge that change can be difficult (Empathy); endorse the idea that even small changes in the direction of risk reduction can be very beneficial. Express optimism that any change the patient can make will be a step on the path to achieving a lager, health-related goal. The key is to leave the patient with and increase in self-confidence (Self-Efficacy)

At follow-up visit: Inquire about use Review goals and progress Reinforce and motivate Review tips for progress See reference list

Enhancing Motivation for Change Inservice Training Based Treatment Improvement Protocol (TIP) 35 Published by the Center for Substance Abuse Treatment See reference list

Referral to Treatment for Patients at Risk for Substance Dependence

Approximately 5% of patients screened will require referral to substance use evaluation and treatment. A patient may be appropriate for referral when: Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use. These high risk patients will receive a brief intervention followed by referral. See reference list

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/student Providing directions and clinic hours to patient/student Coordinating transportation when needed

What I learned… What I’d like to work on next…

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