1. SBIRT

2. Learning Objectives At the end of the session, participants will be able to: 1.Understand SBIRT’s role in preventing the effect of substance abuse on individual and public health 2.Identify substance use risk limits 3.Identify how screening is conducted in a practice setting 4.Practice how to use two screening tools 5.Identify MI basic steps and core skills for the brief intervention 6.Demonstrate and practice MI using core skills

3. What Is SBIRT? An intervention based on “motivational interviewing” strategies  Screening: Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse  Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users  Referral to Treatment: Referrals to specialty care for patients with substance use disorders Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment.

4. Detecting Risk Factors Early Screening can be a significant step toward effective intervention:  The clinician is often the first point of contact  Early identification and intervention lead to better outcomes  Patients are often seen by a clinician because of a related physical problem  Patients are open to speaking with their providers about substance use Source: Treatnet. (2008). Screening, assessment and treatment planning. Retrieved from http://www.unodc.org/ddt-training/treatment/a.html

5. Substance use among HIV+ individuals  Individuals living with HIV/AIDS have higher rates of substance use than the general population (Galvan et al., 2002): – Rates of heavy drinking are roughly twice as high among HIV-positive individuals (15%) – National sample of individuals receiving HIV care, approximately half reported illicit drug use in the past year, with 12% marijuana only, 12% drug dependence and 25% non-marijuana, non-dependent illicit drug use (Bing et al., 2001). – In one study, 60% of youth living with HIV screened positive for problem substance use (Tanney et al., 2010).

6. Substance use among HIV+ individuals  Alcohol and drug use lower rates of adherence to HAART – Odds of medication non-adherence among risky drinkers with HIV were almost 9x higher on days during which they consumed alcohol, and each additional drink consumed increased the odds of skipped or delayed medication doses by 20% (Parsons et al., 2008).  In HIV-positive populations, substance use is associated with multiple adverse effects, including reduced adherence to medication, disease progression, health complications and increased risky sexual behavior, which can lead to further transmission of the disease (recent review at Hormes et al., 2011).

7. Dependent Use Harmful Use At-Risk Use Low Risk Based on Findings of Screening

8. A Positive Alcohol Screen = At-Risk Drinker Binge drink (  5 for men or  4 for women/anyone 65+) Or patient exceeds regular limits? (Men: 2/day or 14/week Women/anyone 65+: 1/day or 7/week) YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT. NO Patient is at low risk.

9. How Much Is “One Drink”? 12-oz glass of beer (one can) 5-oz glass of wine (5 glasses in one bottle) 1.5-oz spirits 80-proof 1 jigger Equivalent to 14 grams pure alcohol

10. AUDIT Alcohol Use Disorders Identification Test  What is it? – Ten questions, self-administered or through an interview; addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems – Developed by World Health Organization (WHO)

11. AUDIT Alcohol Use Disorders Identification Test  What are the strengths? – Public domain—test and manual are free – Validated in multiple settings, including primary care – Brief, flexible – Focuses on recent alcohol use – Consistent with ICD-10 and DSM IV definitions of alcohol dependence, abuse, and harmful alcohol use  Limitations? – Does not screen for drug use or abuse, only alcohol

12. Scoring the AUDIT Dependent Use (20+) Harmful Use (16 ‒ 19) At-Risk Use (8 ‒ 15) Low Risk (0 ‒ 7)

13. Learning Exercise

14. Motivational Interviewing Steps and Core skills

15. Video Demonstration of Motivational Interviewing: Ineffective Provider https://www.youtube.com/watch?v=80XyNE89eCs

16. “Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Definition of Motivational Interviewing

17. Applications of Motivational Interviewing MI enhances change for a range of behaviors: Diet Exercise Reduction of alcohol and illicit drugs Safer sex practices Medication adherence (Burke et al., 2003; Hettema et al., 2005; Rubak et al., 2005).

18. Four Steps of the MI Process 1.Engage (Express Empathy, Ask Open-Ended Questions) 2.Focus (Reflecting, Summarizing) 3.Evoke (Motivations, Concerns) 4.Plan (Raise Subject, Support Self-Efficacy)

19. Spirit of Motivational Interviewing Collaborative (not confrontation) - Developing a partnership in which the patient’s expertise, perspectives, and input are central to the consultation - Fostering and encouraging power sharing in the interaction Evocative - Motivation for change resides within the patient - Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals

20. Spirit of Motivational Interviewing Respectful of autonomy (not authority) - Respecting the patient’s right to make informed choices facilitates change - The patient is in charge of his/her choices and responsible for the outcomes - Emphasize patient control and choice Compassionate - Empathy for the experience of others - Desire to alleviate the suffering of others - Belief and commitment to act in the best interests of the patient

21. Motivational Interviewing Core skills

22. Core MI Skills Open-Ended Questions Affirmations Reflections Summaries

23. Open-Ended Questions Using open-ended questions—  Enables the patient to convey more information  Encourages engagement  Opens the door for exploration

24. Open-Ended Questions What are open-ended questions?  Gather broad descriptive information  Require more of a response than a simple yes/no or fill in the blank  Often start with words such as— – “How…” – “What…” – “Tell me about…”  Usually go from general to specific

25. Closed-Ended Questions Present Conversational Dead Ends Closed-ended questions typically—  Are for gathering very specific information  Tend to solicit yes-or-no answers  Convey impression that the agenda is not focused on the patient

26. Closed-Ended Questions  Avoid “Why?” Questions Puts patient in a passive, or defensive, role No opportunity for patient to explore ambivalence

27. Exercise Turning closed-ended question into an open-ended one. Do you feel depressed or anxious?

28. Affirmations What is an affirmation?  Compliments or statements of appreciation and understanding – Praise positive behaviors – Support the person as they describe difficult situations

29. Affirmations Why affirm?  Support and promote self-efficacy, prevent discouragement  Build rapport  Reinforce open exploration (patient talk) Caveat  Must be done sincerely

30. Affirmations May Include:  Commenting positively on an attribute: "You are determined to get your health back.”  A statement of appreciation: "I appreciate your efforts despite the discomfort you’re in."  A compliment: "Thank you for all your hard work today."

31. Reflective Listening Reflective listening is one of the hardest skills to learn. “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002)

32. Reflective Listening  Why listen reflectively? – Demonstrates that you have accurately heard and understood the patient – Strengthens the empathic relationship

33. Levels of Reflection  Simple Reflection—stays close  Rephrasing (substitutes synonyms)  Example  Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal.  Clinician: So, at this moment you are not too concerned about your drinking.

34. Levels of Reflection  Complex Reflection – Reflection of feeling—deepest  Example Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me! Clinician: Her choosing not to attend today’s meeting was a big disappointment for you.

35. Exercise Turning statements into reflections Work has been hectic and a few glasses of wine help me relax.

36. Summaries  Periodically summarize what has occurred in the visit.  Summary usages – Begin a session – End a session – Transition

37. Summaries  Strategic summary—select what information should be included and what can be minimized or left out.  Additional information can also be incorporated into summaries—for example, past conversations, assessment results, collateral reports, etc.

38. Summaries  Examples – “So, let me see if I’ve got this right…” – “So, you’re saying… is that correct” – “Make sure I’m understanding exactly what you’ve been trying to tell me…”  Double sided reflections are often highly effective as summaries to illustrate ambivalence.

39. Sustain Talk and Change Talk Sustain Talk  Patient explanations for why they want to continue current activities  I don’t see how I could give up drinking  I don’t think I need to stop using heroin Change Talk  Any statements the Patient makes about wanting to change current behaviors  Desire for Change  Reasons for Change  Need for Change

40. Video Demonstration of Motivational Interviewing: Effective Provider https://www.youtube.com/watch?v=URiKA7CKtfc

41. Referral to Treatment Referral

42. What Is Treatment? Treatment may include—  Counseling and other psychosocial rehabilitation services (Inpatient and outpatient services)  Medications  Involvement with self-help (AA, NA, Al-Anon)  Complementary wellness (diet, exercise, meditation)  Combinations of the above

43. Referral Guidelines for Greatest Success  Determine if patient is drug or alcohol dependent and needs medical detoxification (usually inpatient)  A nondependent substance abuser is usually treated outpatient unless there are other risk factors  Most patients can be successfully served in outpatient treatment

44. What Is a Warm-Handoff Referral?  The clinician directly introduces the patient to the treatment provider to confer trust and build rapport  Evidence strongly indicates that warm handoffs are dramatically more successful than passive referrals

45. Common Mistakes To Avoid  Rushing into “action” and making a treatment referral when the patient isn’t interested or ready  Not knowing your referral base  Not considering pharmacotherapy in support of treatment and recovery  Seeing the patient as “resistant” or “self-sabotaging” instead of having a chronic disease

46. Video Demonstration of Screening, Brief Intervention and Referral to Treatment  https://www.youtube.com/watch?v=uL8QyJF2 wVw https://www.youtube.com/watch?v=uL8QyJF2 wVw

47. Prescription Drug Misuse Although many people take medications that are not prescribed to them, we are primarily concerned with—  Opioids (oxycodone, hydrocodone, fentanyl, methadone)  Benzodiazepines (clonazepam, alprazolam, diazepam)  Stimulants (amphetamine, dextroamphetamine, methylphenidate  Sleep aids (zolpidem, zaleplon, eszopicione)  Other assorted (clonidine, carisoprodol)

48. Common Illicit Drugs  Marijuana (Cannabinoids)  Crack/Cocaine (Stimulants)  Heroin (Opiods)  Crystal Methamphetamine (Stimulants)  Ecstasy (Club Drugs)  LSD, Shrooms (Hallucinogens)

49. Prescreening for Drugs “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” (…for instance because of the feeling it caused or experiences you have…) If response is, “None,” screening is complete. If response contains suspicious clues, inquire further. Sensitivity/Specificity: 100%/74% Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Arch Intern Med,170(13), 1155−1160.

50. A Positive Drug Screen Ask which drugs the patient has been using, such as cocaine, meth, heroin, ecstasy, marijuana, opioids, etc. Determine frequency and quantity. Ask about negative impacts. ANY positive on the drug prescreen question puts the patient in an “at-risk” category. The followup questions are to assess impact and whether substance use is serious enough to warrant a substance use disorder diagnosis.

51. Scoring the DAST(10) High Risk (6+) Harmful Use (3 ‒ 5) Hazardous Use (1 ‒ 2) Abstainers (0)

52. Exercise OARS in practice

53. Learning Exercise