1. 1 SBIRT: Reducing Alcohol Related Morbidity and Mortality in Primary Care J. Paul Seale, MD, Principal Investigator Sylvia Shellenberger, PhD, Director of Training Denice Crowe Clark, MFT, Project Coordinator Department of Family Medicine Mercer University School of Medicine The Southeastern Consortium for Substance Abuse Training (SECSAT) Funded by Grant 1U79T1020278-01 Substance Abuse and Mental Health Services Administration (SAMHSA)

2. SECSAT Key Personnel: Mercer Project Staff J. Paul Seale, MD, PI Denice Crowe Clark, MFT Project Coordinator Sylvia Shellenberger, PhD Director of Training J. Aaron Johnson, PhD Director of Evaluation Bonnie Cole, JD, MFT Standardized Patient Trainer 2

3. SECSAT Key Personnel: Site Coordinators David Miller, MD Wake Forest UBMC IM Residency Winston-Salem, NC David Parish, MD Mercer University School of Medicine IM Residency Macon, GA J. Paul Seale, MD Mercer University School of Medicine FM Residency Macon, GA Hunter Woodall, MD AnMed Health FM Residency Anderson, SC 3

4. 4 Module 1A Objectives Describe the importance of alcohol misuse as a health issue Describe the importance of alcohol misuse as a health issue Examine the evidence base for alcohol screening brief intervention & referral to treatment (SBIRT) Examine the evidence base for alcohol screening brief intervention & referral to treatment (SBIRT) Outline the rationale for implementing SBIRT in primary health care Outline the rationale for implementing SBIRT in primary health care Provide an overview of the steps in “SECSAT” Project Provide an overview of the steps in “SECSAT” Project

5. 5 What is SBIRT? S creening B rief I ntervention R eferral to T reatment

6. 6 What is SBIRT? SBIRT is a comprehensive, integrated, evidence-based approach to the delivery of early intervention and treatment services for individuals with substance use problems or risk. SBIRT is a comprehensive, integrated, evidence-based approach to the delivery of early intervention and treatment services for individuals with substance use problems or risk. Burge et al, 2009

7. 7 What is SBIRT? Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. 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. 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. Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.

8. 8 Relationship Between Alcohol Problems and Alcohol Use None Moderate Heavy None Moderate Severe ProblemsAlcohol Use FewLight

9. 9 NIAAA (2009) Definition of At-Risk Drinking Healthy Men ≤65 Healthy Men ≤65 More than 4 standard drinks in a day and/or More than 4 standard drinks in a day and/or More than 14 standard drinks in a week More than 14 standard drinks in a week Healthy Women and Healthy Men >65 Healthy Women and Healthy Men >65 More than 3 standard drinks in a day and/or More than 3 standard drinks in a day and/or More than 7 standard drinks in a week More than 7 standard drinks in a week A standard drink is 14 grams of pure alcohol http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdfhttp://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf, NIAAA 2009

10. 10 What is a Standard Drink? NIAAA, 2009 http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf Beer: 12 oz = 1 16 oz = 1 1/3 22 oz = 2 40 oz = 3 1/3 Malt Liquor: 12 oz = 1 1/2 16 oz = 2 22 oz = 2 1/2 40 oz = 4 1/2 Wine: 5 oz = 1 750 ml bottle = 5 Liquor: 1.5 oz shot = 1 Mixed drink = 1 or more Pint = 8 1/2 Fifth = 17

11. 11 Why is Management of Alcohol Misuse Important to Primary Care Physicians? Prevalence Prevalence Morbidity and mortality Morbidity and mortality Barrier to treatment of chronic conditions Barrier to treatment of chronic conditions Cost & time saving Cost & time saving Potential for effective intervention Potential for effective intervention

12. 12 Drinking Patterns in the U.S. http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htmhttp://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009 No Risk At Risk Dependent 4% 37% 24% Low Risk 35%

13. 13 Who Needs Attention? At Risk (19%) Abuse (5%) Functionally Dependent (3%) Severely Dependent (1%) Nearly 3 in 10 exceed limits but most (24%) do not have alcohol dependence Willenbring, 2010; NIAAA, 2009

14. 14 At Risk (19%) Abuse (5%) Functionally Dependent (3%) Severely Dependent (1%) These 24% account for more illness, death & social disruption than those with dependence Willenbring, 2010; NIAAA 2009 Who Needs Attention?

15. 15 Alcohol Misuse is Commonly Encountered by Primary Care Physicians 7-20% of primary care patients exhibit patterns of alcohol misuse 7-20% of primary care patients exhibit patterns of alcohol misuse 24-31% of patients in ERs 24-31% of patients in ERs 22% of minor trauma patients 22% of minor trauma patients 50% of severely-injured trauma patients 50% of severely-injured trauma patients Fiellin et al, 2000; D’Onofrio & Degutis, 2002

16. 16 Why Important: Morbidity & Mortality Alcohol is the third leading cause of preventable death in the US (CDC), (76,000 deaths, or 5% of all deaths in 2001) Alcohol is the third leading cause of preventable death in the US (CDC), (76,000 deaths, or 5% of all deaths in 2001) Alcohol is attributable to 4-8% of Disability- Adjusted Life Years (DALYs) in the US (WHO). Alcohol is attributable to 4-8% of Disability- Adjusted Life Years (DALYs) in the US (WHO). Globally, alcohol causes morbidity and mortality at a higher rate than tobacco (WHO). Globally, alcohol causes morbidity and mortality at a higher rate than tobacco (WHO). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004; http://www.who.int/substance_abuse/facts/alcohol/en/index.htmlhttp://www.who.int/substance_abuse/facts/alcohol/en/index.html, WHO, 2010; http://www.who.int/substance_abuse/publications/en/APDSSummary.pdfhttp://www.who.int/substance_abuse/publications/en/APDSSummary.pdf; WHO, 2002

17. 17 Possibly Alcohol-Dependent Patients Highest risk/ Dependent Significant morbidity, mortality, and economic cost http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htmhttp://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009 4%

18. 18 At-Risk Drinkers: Why Do They Need Attention? 24% At Risk drinking At risk for short and long term health problems & may put others at risk http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htmhttp://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009

19. Major Causes of Alcohol-related Morbidity & Mortality Chronic liver disease & cirrhosis Cancer Heart disease Pancreatitis Stroke Depression Injuries Homicide, suicide Family Violence Non-accidental/non- intentional poisoning 19 Smith, 1999; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004

20. 20 Morbidity & Mortality Due to Chronic Alcohol Misuse Due to Chronic Alcohol Misuse 46% of total deaths 46% of total deaths 35% of years of life lost 35% of years of life lost Leading cause of liver disease Leading cause of liver disease Due to Acute Alcohol Misuse Due to Acute Alcohol Misuse 54% of total deaths 54% of total deaths 65% of years of life lost 65% of years of life lost Leading cause of MVAs in US Leading cause of MVAs in US http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004

21. 21 Why Important : Morbidity Alcohol interacts with many medications Alcohol interacts with many medications Exacerbates numerous chronic medical conditions (HTN, DM, PUD, etc.) Exacerbates numerous chronic medical conditions (HTN, DM, PUD, etc.) Rehm et al, 2002; Stranges et al, 2004; http://pubs.niaaa.nih.gov/publications/aa26.htmhttp://pubs.niaaa.nih.gov/publications/aa26.htm, NIAAA 2000; http://pubs.niaaa.nih.gov/publications/Medicine/medicine.htmhttp://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm, NIAAA 2007

22. 22 Alcohol Misuse Complicates Treatment of Chronic Medical Conditions

23. 23 Economic Cost: $185 Billion Annually Mokdad et al, 2000; Harwood, 2000

24. 24 Increasing Patient Recognition of Alcohol as a Health Issue Expectation that health care providers will give sound advice about alcohol Expectation that health care providers will give sound advice about alcohol Potential benefits for cardiovascular conditions Potential benefits for cardiovascular conditions Potential breast cancer risk among women Potential breast cancer risk among women http://www.niaaa.nih.gov/FAQs/General-English/default.htm#hearthttp://www.niaaa.nih.gov/FAQs/General-English/default.htm#heart; NIAAA 2007; http://pubs.niaaa.nih.gov/publications/brochurewomen/women.htm#drinkinghttp://pubs.niaaa.nih.gov/publications/brochurewomen/women.htm#drinking; NIAAA 2008

25. 25 Patients’ Sense of Screening’s Importance % http://www.cdc.gov/InjuryResponse/alcohol-screening/resources.htmlhttp://www.cdc.gov/InjuryResponse/alcohol-screening/resources.html, 2009

26. 26 Patients’ Comfort with Screening % http://www.cdc.gov/InjuryResponse/alcohol-screening/resources.htmlhttp://www.cdc.gov/InjuryResponse/alcohol-screening/resources.html, 2009

27. 27 Why SBIRT? At-risk drinking is common At-risk drinking is common At-risk drinking increases risk for trauma and other health problems At-risk drinking increases risk for trauma and other health problems At-risk drinking exacerbates chronic health problems At-risk drinking exacerbates chronic health problems At-risk drinking often goes undetected At-risk drinking often goes undetected Patients are more open to change than you might expect Patients are more open to change than you might expect You can make a difference! You can make a difference! Adapted from Burge et al, 2009

28. 28 What is the Evidence Base for SBIRT? Does SBIRT really change patients’ drinking behavior? Does SBIRT really change patients’ drinking behavior?

29. 29 Brief Intervention Works! SBIRT meta-analyses & reviews: SBIRT meta-analyses & reviews: More than 34 randomized controlled trials More than 34 randomized controlled trials Focused primarily on at risk and problem drinkers Focused primarily on at risk and problem drinkers Result in 10-30% reduction in alcohol consumption at 12 months Result in 10-30% reduction in alcohol consumption at 12 months Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005; Kaner et al, 2007

30. 30 Net Percentage Reduction in Mean Drinks Per Week (USPSTF review) 9 high quality studies reviewed 9 high quality studies reviewed 3 single intervention studies resulted in reductions in weekly alcohol consumption ranging from 6-19% 3 single intervention studies resulted in reductions in weekly alcohol consumption ranging from 6-19% 6 multi-contact intervention studies resulted in reductions in weekly alcohol consumption ranging from 7-34% 6 multi-contact intervention studies resulted in reductions in weekly alcohol consumption ranging from 7-34% http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomissum.htmhttp://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomissum.htm, Whitlock et al, 2004

31. 31 US Preventive Services Task Force: SBIRT Recommended for All Adult PC Patients Class B recommendation (flu shots, cholesterol screening, SBIRT) Class B recommendation (flu shots, cholesterol screening, SBIRT) “…good evidence that screening in primary care can accurately identify patients whose levels of alcohol consumption…place them at risk for increased morbidity and mortality” “…good evidence that screening in primary care can accurately identify patients whose levels of alcohol consumption…place them at risk for increased morbidity and mortality” “…good evidence that brief behavioral counseling interventions…produce small to moderate reductions in alcohol consumption” “…good evidence that brief behavioral counseling interventions…produce small to moderate reductions in alcohol consumption” http://www.ahrq.gov/clinic/uspstf/uspsdrin.htmhttp://www.ahrq.gov/clinic/uspstf/uspsdrin.htm; USPSTF, 2004

32. 32 SBIRT & Joint Commission Accreditation Currently being considered by the Joint Commission as a requirement for hospital accreditation Currently being considered by the Joint Commission as a requirement for hospital accreditation Performance measures in development in 2009 for tobacco and alcohol use Performance measures in development in 2009 for tobacco and alcohol use Pilot testing in hospitals began in 2010 Pilot testing in hospitals began in 2010 The Joint Commission, November 2009 http://www.jointcommission.org/PerformanceMeasurement http://www.jointcommission.org/PerformanceMeasurement

33. 33 Nursing Involvement Significantly Increases Clinician Intervention Rates Vital Signs Study: clinicians were 12x more likely to intervene if nurses screened for at-risk drinking as part of vital signs Vital Signs Study: clinicians were 12x more likely to intervene if nurses screened for at-risk drinking as part of vital signs Healthy Habits Study: clinicians were 3x more likely to intervene with at-risk drinkers if given alcohol assessment results by the nurse Healthy Habits Study: clinicians were 3x more likely to intervene with at-risk drinkers if given alcohol assessment results by the nurse Seale et al, 2005; Seale et al, 2010

34. Number Needed to Treat 0 5 10 15 20 25 Cessation advice for smoking Nicotine replacement therapy Alcohol-related harm Hazardous alcohol use Tricyclics for depression 20 10 8 8 6 http://www.phepa.net/units/phepa/html/en/dir361/doc9736.htmlhttp://www.phepa.net/units/phepa/html/en/dir361/doc9736.html, Gaul et al, 2005

35. What Does This Mean for Your Patients? Calculate based on the numbers of adult patients you see per week… For example, if You see on average 40 patients per week If 20% of these patients are at risk (8 patients) With brief intervention, 1 patient weekly is likely to lower his/her risk http://www.phepa.net/units/phepa/html/en/dir361/doc9736.htmlhttp://www.phepa.net/units/phepa/html/en/dir361/doc9736.html, Gaul et al, 2005

36. 36 Other Benefits of SBIRT Fewer hospitalizations Fewer hospitalizations Fewer ER visits Fewer ER visits Benefit vs. Cost (48 months f/u) Benefit vs. Cost (48 months f/u) Medical Benefit-Cost Ratio4.3:1 Medical Benefit-Cost Ratio4.3:1 Societal Benefit-Cost Ratio 39:1 Societal Benefit-Cost Ratio 39:1 Fleming et al, 2002; Mundt, 2006; Kraemer, 2007

37. 37 SBIRT is Underutilized in Primary Care Less than half of self-reported problem drinkers are asked by their PC physicians about their alcohol consumption or advised to quit drinking or cut back. Less than half of self-reported problem drinkers are asked by their PC physicians about their alcohol consumption or advised to quit drinking or cut back. Most PC physicians prefer not to counsel nondependent problem drinkers themselves. Most PC physicians prefer not to counsel nondependent problem drinkers themselves. D’Amico et al, 2005; Spandorfer et al, 1999

38. 38 SBIRT Can Be Effectively Implemented in Primary Care Effective models exist for implementing screening and brief intervention in residency training. Effective models exist for implementing screening and brief intervention in residency training. Trained clinicians typically intervene with more than 70% of patients. Trained clinicians typically intervene with more than 70% of patients. Seale et al, 2005; Adams et al, 1998

39. 39 Key to Implementation: Systems Approach Targeting Both The Clinicians & Office System Train clinicians & clinic staff in SBIRT Train clinicians & clinic staff in SBIRT Create office system that will support SBIRT Create office system that will support SBIRT Screening & prompting system Screening & prompting system Assessment instruments Assessment instruments Intervention materials Intervention materials Reminder system for re-assessment & reinforcement Reminder system for re-assessment & reinforcement

40. 40 5 Basic Components of This Project’s SBIRT System Prescreening of all patients using single question screen Prescreening of all patients using single question screen Screening of all prescreen-positive patients using the Alcohol Use Disorders Identification Test (AUDIT) Screening of all prescreen-positive patients using the Alcohol Use Disorders Identification Test (AUDIT) Clinician Interventions for all screen-positive patients Clinician Interventions for all screen-positive patients Referral for patients desiring more help Referral for patients desiring more help Follow-up (re-assessment & reinforcement) at future visits Follow-up (re-assessment & reinforcement) at future visits

41. 41 Summary of Module 1A Alcohol misuse is a major cause of morbidity & mortality in the US Alcohol misuse is a major cause of morbidity & mortality in the US SBIRT is effective in decreasing at risk drinking & its related consequences SBIRT is effective in decreasing at risk drinking & its related consequences Clinician training & systems intervention are effective in implementing primary care SBIRT protocols Clinician training & systems intervention are effective in implementing primary care SBIRT protocols Training Modules 1B & 1C will equip this clinic to effectively perform SBIRT—stay tuned! Training Modules 1B & 1C will equip this clinic to effectively perform SBIRT—stay tuned!

42. 42 Module 1B The Procedures of Screening, Brief Intervention & Referral to Treatment

43. 43 Objectives for Module 1B Describe the procedures of SBIRT Describe the procedures of SBIRT Practice using and scoring the Healthy Habits Prescreen and the Healthy Lifestyles Screen (AUDIT) Practice using and scoring the Healthy Habits Prescreen and the Healthy Lifestyles Screen (AUDIT) Review the steps of the intervention for Review the steps of the intervention for at- risk drinkers at- risk drinkers Review added steps for those possibly dependent Review added steps for those possibly dependent Practice conducting interventions Practice conducting interventions

44. 44 5 Basic Components of This Project’s SBIRT System Prescreening (single question screen) Prescreening (single question screen) Screening (Alcohol Use Disorders Identification Test or AUDIT) Screening (Alcohol Use Disorders Identification Test or AUDIT) Clinician Interventions for all screen-positive patients Clinician Interventions for all screen-positive patients Referral as appropriate for patients with higher levels of risk or possibly dependent Referral as appropriate for patients with higher levels of risk or possibly dependent Follow-up assessment/reinforcement at future visits Follow-up assessment/reinforcement at future visits

45. 45 STEP 1: Prescreen is routinely performed every 6-12 months Tool: Single alcohol screening question (SASQ - NIAAA)

46. 46 Single Question: “How many times in the past 12 months have you had X or more drinks in a day?” “How many times in the past 12 months have you had X or more drinks in a day?” X = 5 for men X = 5 for men X = 4 for women X = 4 for women Positive screen = one or more times in the past year Positive screen = one or more times in the past year

47. 47 NIAAA, 2009 http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf Standard Drink Sizes Beer: 12 oz = 1 16 oz = 1 1/3 22 oz = 2 40 oz = 3 1/3 Malt Liquor: 12 oz = 1 1/2 16 oz = 2 22 oz = 2 1/2 40 oz = 4 1/2 Wine: 5 oz = 1 750 ml bottle = 5 Liquor: 1.5 oz shot = 1 Mixed drink = 1 or more Pint = 8 1/2 Fifth = 17

48. 48 Process When Prescreen is Positive Patient is given the Healthy Lifestyles Screen (AUDIT) Patient is given the Healthy Lifestyles Screen (AUDIT) Patient completes the AUDIT and gives it to his/her clinician Patient completes the AUDIT and gives it to his/her clinician Physician performs intervention Physician performs intervention

49. 49 Expected Results of Prescreen 80-85% negative Prescreen 15-20% will receive full screen

50. 50 Step 2: Screening

51. 51

52. 52 Instrument: Healthy Lifestyles Screen (AUDIT) Adapted from World Health Organization Adapted from World Health Organization Validated in numerous studies worldwide Validated in numerous studies worldwide Fits US guidelines for at risk drinking Fits US guidelines for at risk drinking Content Content 3 quantity & frequency questions (1-3) 3 quantity & frequency questions (1-3) 3 questions probing signs of dependency (4-6) 3 questions probing signs of dependency (4-6) 4 questions about alcohol-related problems (7-10) 4 questions about alcohol-related problems (7-10)

53. 53 Screening Procedures 1. Patient completes form 2. Patient gives form to clinician 3. Clinician notes items marked 4. Clinician calculates the score 5. Clinician obtains & documents recent alcohol & drug use

54. 54 AUDIT Screen – Scoring Note numbers in top shaded row Note numbers in top shaded row Enter checked number for each question Enter checked number for each question Enter total score of 10 questions Enter total score of 10 questions Ask the 3 questions under Provider Use Only (frequency, quantity, drugs) Ask the 3 questions under Provider Use Only (frequency, quantity, drugs)

55. 55 View Video One Nursing staff Asking Healthy Habits Prescreen & Giving Healthy Lifestyles Screen (AUDIT)

56. 56 Clinicians: Practice Scoring Healthy Lifestyles Screen (AUDIT) Nursing staff: Practice Giving Healthy Habits Prescreen & Administering AUDIT

57. 57 Not at allExtremely 010567892341 cm Lower Risk Drink Limits No drinking if: driving, pregnant or possibly dependent Per Day Per Week Healthy Men Healthy Women All ages >65 414 37 73 Standard Drink Sizes The percent of “pure” alcohol expressed here as alcohol/volume varies by beverage. ~5% ~7 % ~12% ~40% 12 oz Beer 1.5 oz/ 1 shot Liquor 5 oz Wine 8-9 oz Malt Liquor === Your AUDIT score: Major consequences/ Possibly dependent At-risk drinking Zero (no risk) 16+ 15 0 1 STEP 3: Intervention Clinician identifies level of intervention based on Healthy Lifestyles Screen (AUDIT) score Clinician identifies level of intervention based on Healthy Lifestyles Screen (AUDIT) score Clinician conducts the intervention using the intervention card as a guide Clinician conducts the intervention using the intervention card as a guide

58. Intervention Guide Zone I: At Risk AUDIT 1-15 (≥ 1 binge) Zone II: Possibly Dependent AUDIT ≥ 16 Discuss Next Steps Close on Good Terms Enhance Motivation & Elicit Change Talk Provide Advice Ask Permission Provide Feedback Offer menu of options for more help: ► Medication (naltrexone, acamprosate, disulfiram) ► Referral Counseling/Brief treatment Support group (e.g., AA, NA, Celebrate Recovery) Treatment or substance abuse program “If you were to make a change, what would be your first step?” Summarize, emphasize patient strengths, highlight change talk and decisions made. Arrange for follow-up as appropriate. “What are the good things/not so good things about your alcohol use?” (Decisional balance) “On a scale of 0-10, how important is it that you cut back or quit your alcohol 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?” Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines. If ZONE II: “If you go a day or 2 without drinking, do you ever get sick, shaky, have tremors/seizures/ or see/hear things that are not there?” “I appreciate you answering our health questionnaire. Could we take a minute to discuss your results?” Refer to bar graph & provide patient’s AUDIT score. [As your physician] “Drinking 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?” 58

59. 59 Stratified Intervention Protocols: Zone I: At Risk Drinker At risk drinker with limited or no consequences (AUDIT score 1-15 & positive prescreen) At risk drinker with limited or no consequences (AUDIT score 1-15 & positive prescreen) Brief intervention Brief intervention Ask permission Ask permission Provide feedback Provide feedback Enhance motivation Enhance motivation Provide advice Provide advice Discuss next steps Discuss next steps Close on good terms Close on good terms

60. 60 Stratified Intervention Protocols: Zone II: Possibly Dependent Patient with major consequences/possibly dependent (AUDIT score ≥ 16 or polysubstance abuse) Patient with major consequences/possibly dependent (AUDIT score ≥ 16 or polysubstance abuse) Brief intervention Brief intervention Ask permission Ask permission Provide feedback Provide feedback Enhance motivation Enhance motivation Provide advice encouraging abstinence Provide advice encouraging abstinence Evaluate & address possible withdrawal risk Evaluate & address possible withdrawal risk Discuss next steps including information about getting help Discuss next steps including information about getting help Close on good terms Close on good terms

61. 61 How to Use the Intervention Guide

62. 62 Step 1: Ask for Permission “I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?” “I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”

63. 63 Step 2: Provide Feedback from Prescreen and AUDIT Screen Refer to bar graph & provide patient’s AUDIT score Refer to bar graph & provide patient’s AUDIT score [As your physician] “Drinking at this level can be harmful to your health and possibly responsible for the health problem for which you came in today.” [As your physician] “Drinking 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?” “What do you make of that?” 16+ 15 0 Your AUDIT Score: Major consequences/ Possibly dependent At-risk drinking Zero (no risk) 1

64. 64 Step 3: Enhance Motivation: Decisional Balance Ask, “What are some of the good/not-so-good things about your alcohol use?” Ask, “What are some of the good/not-so-good things about your alcohol use?” Summarize both sides of their thinking Summarize both sides of their thinking On the one hand… and on the other hand… On the one hand… and on the other hand…

65. 65 Step 3: Enhance Motivation: Rulers “On a scale of 0 to 10, how important is it for you to cut back or quit your alcohol use?” [Clarify whether discussing quitting or cutting back.] “On a scale of 0 to 10, how important is it for you to cut back or quit your alcohol use?” [Clarify whether discussing quitting or cutting back.] If > 0, ask “Why that number and not a lower one?” [Also ask about confidence, readiness] If > 0, ask “Why that number and not a lower one?” [Also ask about confidence, readiness] Explore asking “Have you ever considered cutting back (or quitting)? If so, “Why?” If not, “What would have to happen for you to consider cutting back (or quitting)?” Explore asking “Have you ever considered cutting back (or quitting)? If so, “Why?” If not, “What would have to happen for you to consider cutting back (or quitting)?” 0 10

66. 66 Step 3: Enhance Motivation: Summarize, Highlight Change Talk 0 10 Summarize information from decisional balance and rulers highlighting change talk in particular Summarize information from decisional balance and rulers highlighting change talk in particular

67. 67 Step 4: Provide Advice Use Chart on Front of Card for Low-Risk Drinking (NIAAA Guidelines) Use Chart on Front of Card for Low-Risk Drinking (NIAAA Guidelines) Healthy men ≤ 65 years old Healthy men ≤ 65 years old No more than 4 per day or 14 per week No more than 4 per day or 14 per week Healthy women of all ages Healthy women of all ages No more than 3 per day or 7 per week No more than 3 per day or 7 per week All healthy individuals >65 years of age All healthy individuals >65 years of age No more than 3 per day or 7 per week No more than 3 per day or 7 per week Per Week Per Day Men 14 4 Wome n 7 3 All ages >65 7 3 Per Week Per Day Men 14 4 Wome n 7 3 All ages >65 7 3 Lower Risk Drink Limits No drinking if driving, pregnant or possibly dependent 73All ages >65 73Healthy Women 144Healthy Men Per Week Per Day

68. 68 Inform All Patients of the Risks of Drinking: When driving—this causes the largest proportion of alcohol-related death and disability When driving—this causes the largest proportion of alcohol-related death and disability When pregnant or considering pregnancy- alcohol is the most frequent cause of preventable birth defects When pregnant or considering pregnancy- alcohol is the most frequent cause of preventable birth defects When contraindicated by a medical condition or medication When contraindicated by a medical condition or medication If a history of failed attempts to cut back If a history of failed attempts to cut back

69. 69 Step 5: Discuss Next Steps “If you were to make a change, what would be your first step?” “If you were to make a change, what would be your first step?”

70. 70 Step 6: Close on Good Terms Summarize Summarize Emphasize patient strengths Emphasize patient strengths Highlight change talk Highlight change talk List decisions made regarding next steps List decisions made regarding next steps Arrange for followup as appropriate Arrange for followup as appropriate

71. 71 View Video Two Clinician Intervention for At-risk Drinker

72. 72 Practice Intervention with Patient with At-Risk Drinking

73. 73 Dealing with Time Pressure Dealing with Time Pressure Do your brief intervention over multiple visits Do your brief intervention over multiple visits At the first visit, use 1 minute to cover the first three steps At the first visit, use 1 minute to cover the first three steps Ask permission to discuss alcohol use Ask permission to discuss alcohol use Provide feedback on patient’s risk level Provide feedback on patient’s risk level Offer advice to reduce drinking at least to low risk levels Offer advice to reduce drinking at least to low risk levels Invite the patient to discuss alcohol use at a future visit Invite the patient to discuss alcohol use at a future visit Investing a few minutes now may avoid a greater problem later Investing a few minutes now may avoid a greater problem later

74. 74 Zone II: Added Steps for Those Patients with Possible Alcohol Dependence & Polysubstance Abuse AUDIT score of ≥ 16 indicates possible dependence on alcohol AUDIT score of ≥ 16 indicates possible dependence on alcohol Advice is to stop Advice is to stop Assess withdrawal risk Assess withdrawal risk Discuss other resources available if patient is interested Discuss other resources available if patient is interested

75. 75 Intervention Steps for Possibly Dependent Patients (AUDIT ≥ 16) Brief intervention Brief intervention Ask permission Provide feedback Enhance motivation Provide advice encouraging abstinence Assess & address possible withdrawal risk With permission, offer menu of other helps Discuss Next Steps Close on Good Terms

76. 76 Withdrawal Assessment: “Some people have the following after a day or two without drinking. Have you ever had these symptoms?” “Some people have the following after a day or two without drinking. Have you ever had these symptoms?” Felt sick or shaky Felt sick or shaky Tremors Tremors Nausea Nausea Heart racing Heart racing Seizures Seizures Seen or heard things that were not there Seen or heard things that were not there

77. 77 Two Options for Addressing Potential Withdrawal Arrange withdrawal treatment immediately Arrange withdrawal treatment immediately Transfer to detox unit or treatment center Transfer to detox unit or treatment center Outpatient detox where appropriate Outpatient detox where appropriate Tell patient what to do if these symptoms occur Tell patient what to do if these symptoms occur Present to ED/Detox Center Present to ED/Detox Center Call on-call physician Call on-call physician Document what you do in the patient’s chart Document what you do in the patient’s chart

78. 78 Red Zone Offers Information on Getting Help Menu of options Menu of options Medication: (naltrexone, acamprosate, or disulfiram) Medication: (naltrexone, acamprosate, or disulfiram) Referral Referral Self-help/support group (e.g., Alcoholics Anonymous, Celebrate Recovery, etc.) Self-help/support group (e.g., Alcoholics Anonymous, Celebrate Recovery, etc.) In-house counseling (brief treatment) In-house counseling (brief treatment) Treatment or substance abuse program Treatment or substance abuse program Offer menu of options for more help: ► Medication (naltrexone, acamprosate, disulfiram, suboxone, methadone) ► Referral Support group (e.g., AA, NA, Celebrate Recovery) In-house counseling (Brief treatment) Treatment or substance abuse program

79. 79 Referral to Treatment Local treatment referral sources Local treatment referral sources Detox Detox Inpatient Inpatient Outpatient Outpatient Faith-based Faith-based Long-term residential Long-term residential

80. 80 Get Help: Procedures Ask permission to tell the patient about resources that have helped other patients Ask permission to tell the patient about resources that have helped other patients If the patient is interested, attempt to make contact with referral sources while patient is still in your office, if possible If the patient is interested, attempt to make contact with referral sources while patient is still in your office, if possible Ambivalence is common—encourage treatment providers or AA contacts to call the patient, if patient agrees Ambivalence is common—encourage treatment providers or AA contacts to call the patient, if patient agrees Get patient’s “best phone number(s)” Get patient’s “best phone number(s)”

81. 81 Tips to Enhance Intervention Resist the urge to fix the patient at this visit—behavior change starts with “seed planting” Resist the urge to fix the patient at this visit—behavior change starts with “seed planting” Focus on building rapport Focus on building rapport Avoid labeling (don’t say Avoid labeling (don’t say“alcoholic”) Encourage self efficacy based on Encourage self efficacy based on past successes past successes “Look at successes you have had “Look at successes you have had in the past”

82. 82 View Video Three Clinician Intervention for Patients with Major Consequences & Possible Dependence

83. 83 Cultural Competence & SBIRT Consider cultural context of drinking Consider cultural context of drinking Work collaboratively Work collaboratively Show empathy Show empathy Build trust Build trust Elicit patient concerns about drinking Elicit patient concerns about drinking Label Label Judge Judge Assume alcohol is viewed the same in the patient’s culture as in yours Assume alcohol is viewed the same in the patient’s culture as in yours Stereotype Stereotype Use stigmatized language Use stigmatized language DO’sDON’Ts

84. 84 Practice Intervention with Patient Who is Possibly Dependent

85. 85 Follow-up Procedures (Clinician tasks)* Assess 7-day alcohol use & last binge Assess 7-day alcohol use & last binge Determine patient’s view of his/her use Determine patient’s view of his/her use Repeat decisional balance Repeat decisional balance Repeat rulers (importance, confidence) Repeat rulers (importance, confidence) Explore and reflect Explore and reflect Discuss readiness to make a change Discuss readiness to make a change Discuss next steps, change plan where appropriate Discuss next steps, change plan where appropriate Consider menu of options for help Consider menu of options for help *Follow-up procedures will be covered in-depth in a future training

86. 86 Module 1C Establishing Office Systems

87. 87 Objective for This Module Introduce Implementation Committee & their areas of responsibility Introduce Implementation Committee & their areas of responsibility Clarify any questions regarding procedures Clarify any questions regarding procedures Give information on locating SBIRT materials Give information on locating SBIRT materials Summarize documentation & coding Summarize documentation & coding Suggest channels & procedures for feedback Suggest channels & procedures for feedback

88. SBIRT Committee Members Faculty—Drs. Seale, Boltri & McLaurin Faculty—Drs. Seale, Boltri & McLaurin Residents—Drs. Ansari & Chhabria Residents—Drs. Ansari & Chhabria Screening & Nursing--Denise Gary, RN Screening & Nursing--Denise Gary, RN Brief Int. & Brief Tx--Denice Clark, MFT Brief Int. & Brief Tx--Denice Clark, MFT Referrals—Tim Prather Referrals—Tim Prather Medical Records--Keisha Hill Medical Records--Keisha Hill Administration—Leslie Scarbary, RN Administration—Leslie Scarbary, RN Suboxone—Seale, McLaurin, Davis-Smith Suboxone—Seale, McLaurin, Davis-Smith Evaluation—Dr. Johnson Evaluation—Dr. Johnson 88

89. 89 Where to Find SBIRT Materials: All materials can be found in black notebooks in the MD stands outside clinic rooms Healthy Habits Prescreen Information (salmon sheet)* Healthy Habits Prescreen Information (salmon sheet)* Healthy Lifestyles Screens (AUDITs)* Healthy Lifestyles Screens (AUDITs)* Intervention Cards Intervention Cards Brochures Brochures Referral resource sheets Referral resource sheets *These items are also kept behind the nurses’ desk with check-in materials

90. Nursing Procedures & Documentation When patients are put in the rooms, nurses will check for completed salmon sheets When patients are put in the rooms, nurses will check for completed salmon sheets If sheet is blank, they will ask the tobacco & alcohol questions, fill in answers and give out blue & pink sheets for positive answers to tobacco or alcohol questions If sheet is blank, they will ask the tobacco & alcohol questions, fill in answers and give out blue & pink sheets for positive answers to tobacco or alcohol questions If AUDIT is given, mark checkbox on physician’s office note for the day If AUDIT is given, mark checkbox on physician’s office note for the day 90

91. 91 Physician Documentation Guidelines—DOCUMENT! Physician Documentation Guidelines—DOCUMENT! Problem: Clinicians frequently fail to document alcohol-related diagnoses and interventions Problem: Clinicians frequently fail to document alcohol-related diagnoses and interventions Results: Results: Failure to reinforce interventions at future visits Failure to reinforce interventions at future visits Other providers lack important clinical information when caring for these patients Other providers lack important clinical information when caring for these patients Potential medicolegal risk Potential medicolegal risk

92. 92 Documentation System: Goals Designed to Designed to Remind provider to follow up on alcohol consumption Remind provider to follow up on alcohol consumption Alert other providers to at risk or problem drinking Alert other providers to at risk or problem drinking Protect patients from stigma or discrimination Protect patients from stigma or discrimination Respect current privacy legislation Respect current privacy legislation

93. 93 Clinician Documentation Procedures in This Clinic Salmon sheet—initial and date if complete Salmon sheet—initial and date if complete If not filled out, recycle it (don’t sign it!) If not filled out, recycle it (don’t sign it!) Healthy Lifestyles Screen (AUDIT)—score AUDIT and complete “Provider Use Only” area Healthy Lifestyles Screen (AUDIT)—score AUDIT and complete “Provider Use Only” area Choose the appropriate Zone Choose the appropriate Zone Use check boxes within Zone to document what you did Use check boxes within Zone to document what you did On your progress note On your progress note Record AUDIT score in “lab results” area Record AUDIT score in “lab results” area Use check box to document intervention—”advised to stop drinking or cut back” Use check box to document intervention—”advised to stop drinking or cut back”

94. 94 Diagnosis Wording & Coding Options (Clinicians) Options: Options: V65.42 Counseling on substance use & abuse V65.42 Counseling on substance use & abuse Alcohol use (no ICD code) Alcohol use (no ICD code) 305.0 Alcohol abuse*, excessive drinking (episodic) 305.0 Alcohol abuse*, excessive drinking (episodic) 303.9 Alcohol dependence*, alcoholism 303.9 Alcohol dependence*, alcoholism V69.9 Lifestyle problem V69.9 Lifestyle problem V79.1 Special screening for mental disorders (alcoholism) V79.1 Special screening for mental disorders (alcoholism) At risk drinking (no ICD code)—probably should not be used until ICD code is approved, as this could be miscoded or misinterpreted as alcohol abuse At risk drinking (no ICD code)—probably should not be used until ICD code is approved, as this could be miscoded or misinterpreted as alcohol abuse *See DSM-IV diagnostic criteria in Support Materials

95. 95 Billing Options for Patients Receiving 15-30 minutes of SBIRT 2010 Medicare [& Medicaid*] Billing Codes 2010 Medicare [& Medicaid*] Billing Codes G0396 Alcohol/Drug Screening 15-30 minutes ($30) G0396 Alcohol/Drug Screening 15-30 minutes ($30) G0397 Alcohol/Drug Service >30 minutes ($60) G0397 Alcohol/Drug Service >30 minutes ($60) For Patients with Commercial Insurance: CPT Codes For Patients with Commercial Insurance: CPT Codes 99408 15-30 minutes ($30) 99408 15-30 minutes ($30) 99409 > 30 minutes($60) 99409 > 30 minutes($60) Note: Faculty may use your usual E&M code and add -25 modifier *Medicaid codes valid in NC, not yet “turned on” in Georgia

96. 96 Other Billing Options Since most interventions involve greater time spent or greater complexity, document and code for your work Since most interventions involve greater time spent or greater complexity, document and code for your work If time and complexity criteria are met, non- residents may code 99214 or 99215 If time and complexity criteria are met, non- residents may code 99214 or 99215 In your private practice, have/train a non- MD to do SBIRT In your private practice, have/train a non- MD to do SBIRT Advantage: less rushed, often will use 15 minutes or more Advantage: less rushed, often will use 15 minutes or more Can then use CPT or G codes and generate $30-$60 per BI Can then use CPT or G codes and generate $30-$60 per BI

97. 97 Options for Protecting Privacy & Confidentiality Nationally, there is no consensus or clear guideline about whether Regulation 42CFR Part 2, which requires special confidentiality measures for mental health and substance abuse treatment, applies to SBIRT activities Nationally, there is no consensus or clear guideline about whether Regulation 42CFR Part 2, which requires special confidentiality measures for mental health and substance abuse treatment, applies to SBIRT activities Each individual practice should make its own decision regarding how to manage SBIRT patient records Each individual practice should make its own decision regarding how to manage SBIRT patient records

98. 98 Options for Protecting Privacy & Confidentiality Most primary care clinicians do not use special confidentiality measures for mental health diagnoses made in the context of routine primary care office practice Most primary care clinicians do not use special confidentiality measures for mental health diagnoses made in the context of routine primary care office practice Some clinicians use more general terms describing behavior (“alcohol use”), not diagnoses Some clinicians use more general terms describing behavior (“alcohol use”), not diagnoses Some place AUDITs in chart areas separate from office notes, others file them with progress notes Some place AUDITs in chart areas separate from office notes, others file them with progress notes A few practices place AUDITs in protected areas requiring special release of information A few practices place AUDITs in protected areas requiring special release of information

99. Privacy Protections at This Clinic AUDITs are filed with progress note for the day AUDITs are filed with progress note for the day No Special Precautions for SBIRT Documentation No Special Precautions for SBIRT Documentation HIPAA precautions are considered adequate privacy protection HIPAA precautions are considered adequate privacy protection 99

100. Questions re SBIRT Procedures? Good luck! Good luck! Call us with any questions Call us with any questions Where to call for help: Where to call for help: Dr Seale’s pager #1248 Dr Seale’s pager #1248 Denice Clark’s extension 3-5731 Denice Clark’s extension 3-5731 100