1. SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT R. Lyle Cooper, Ph.D., LCSW Director of Research Department of Family and Community Medicine Meharry Medical College

2. Workshop Objectives 1.Provide a tool kit to tailor an SBIRT/MI learning experience for your students 2.Identify course(s) in which SBIRT/MI training will be progressively implemented across the curricula 3.Identify an SBIRT/MI Champion from the college

3. ACKNOWLEDGMENTS The material included in this course is based largely on the works of previously funded SAMHSA grantees. Other information sources will be noted within the course narration. A full bibliography is available for download in the Resources folder on our website.

4. T RAINING AGENDA What is SBIRT and why is it useful Screening for substance abuse and other common disorders Motivational interviewing Brief intervention Referral to treatment

5. WHAT IS SBIRT AND WHY USE IT?

6. W HAT IS SBIRT AND W HY U SE IT Training Objectives for this Module By the end of this module participants should be able to: Define SBIRT List the physical, psychiatric and societal harms of substance misuse Describe the public health paradigm for health care Identify germane national policies related to SBIRT Recount the evidence and cost effectiveness of SBIRT

7. W HAT 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.

8. H ISTORIC R ESPONSE AND P UBLIC H EALTH R ESPONSE TO S UBSTANCE A BUSE Previously, substance use intervention and treatment focused primarily on substance abuse, universal prevention strategies and on specialized treatment services for those who met the abuse and dependence criteria. There was a significant gap in service systems for at-risk populations.

9. GOAL The primary goal of SBIRT is to identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance abuse.

10. SCREENING FOR SUBSTANCE USE DISORDERS

11. Training Objectives for this Module By the end of this module participants should be able to: Describe the importance of universal screening. Demonstrate an ability implement the 3 question SBIRT prescreen. Identify common evidence based screening tools for alcohol and drug misuse. Identify substance use risk limits. Demonstrate the appropriate use of validated screening tools for further assessment. Describe how screening is used in brief intervention.

12. U NIVERSAL S CREENING Recommended American Academy of Pediatrics American Congress of Obstetricians and Gynecologists American Medical Association American Society of Addiction Medicine National Institute on Alcohol Abuse and Alcoholism United States Preventive Services Task Force Veteran’s Administration World Health Organization Mandated American College of Surgeons – Committee on Trauma: mandates SBIRT program for Level I trauma certification JCAHO is now piloting incorporating SBIRT mandate as part of hospital accreditation

13. R ATIONALE FOR U NIVERSAL S CREENING Rationale for Universal Screening Drinking and drug use are common. Drinking and drug use can increase the risk for health problems, safety risks, and a host of other issues. Drinking and drug use often go undetected People are more open to change than you might expect. Why Screen Universally? Detect current health problems related to at-risk alcohol and substance use at an early stage—before they result in more serious disease or other health problems. Detect alcohol and substance use patterns that can increase future injury or illness risks. Intervene and educate about at-risk alcohol and other substance use. Research has shown that approximately 90 percent of substance use disorders go untreated. (NSDUH, 2007).

14. Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages ? NO YES AUDIT C: How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you have on a typical day? 3. How often do you have six or more drinks on one occasion? Male score of 4 or more, Female score 2 or more, complete full screen. Sensitivity/Specificity: Male: 86%/89% Female: 73%/91% Source: www.integration.samhsa.gov/images/res/tool_auditc.pdf‎ A LCOHOL P RESCREENING

15. Determine the average drinks per day and average drinks per week—ask: On average, how many days a week do you have an alcoholic drink? On a typical drinking day, how many drinks do you have? ( Daily average ) Weekly average = days X drinks Recommended Limits Men = 2 per day/14 per week Women/anyone 65+ = 1 per day or 7 drinks per week > Regular limits = at-risk drinker P RESCREENING D RINKING L IMITS

16. A P OSITIVE A LCOHOL S CREEN = A T -R ISK D RINKER 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.

17. SBIRT Screening Flowchart Client is given a screen with single question pre-screens Social Worker reviews pre-screen prior to taking the client to the office Positive Screen Social worker reviews screen results and delivers brief intervention Client asked to complete (is administered) AUDIT and/or DAST Client in need of TX Referral to TX made at that time Follow-up appointment scheduled Client session documented in record 75% Screen Negative This means more assessment

18. H OW M UCH I S “O NE D RINK ”? 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

19. C OMMON S CREENING T OOLS Age GroupAlcohol MeasuresDrug Measures <21CRAFFT (available in 13 languages) www.ceasar-boston.org/CRAFFT Adult 21-50AUDITDAST Older adultS-MAST-GCOMM lib.adai.washington.edu/instruments/

20. K EY P OINTS FOR S CREENING Screen everyone. Screen both alcohol and drug use including prescription drug abuse and tobacco. Use a validated tool. Prescreening is usually part of another health and wellness survey. Explore each substance; many patients use more than one. Follow up positives or "red flags" by assessing details and consequences of use. Use your MI skills and show nonjudgmental, empathic verbal and nonverbal behaviors during screening.

21. MOTIVATIONAL INTERVIEWING IN SBIRT

22. Training Objectives By the end of the day participants should be able to: Describe the Spirit of MI Review Demonstrate Ability to use the OARS Identify Change Talk Elicit and Respond to Change Talk Respond to Resistance Establishing a Change Plan

23. S PIRIT OF MOTIVATIONAL INTERVIEWING What it IS Evocative Collaborative Conversation about change Hopeful of clients possibilities for change Comes from a place of genuine interest A communication style What it AIN’T A technique Authoritative Imposing Persuasive Expert to client interaction Education Concerned with diagnostics

24. Exercise 1: Spirit of Motivational Interviewing You will be divided into 2 groups, speakers and counselors Each group will be provided instructions separately You will form diads after receiving instructions You will have a 5 minute conversation adhering to the instructions you were previously provided

25. Debrief How did this conversation feel? Speaker? Counselor? Speaker, did you notice your feelings regarding the behavior change at all? Did they stay the same? Did you enjoy the conversation? Speaker? Counselor

26. C ORE MI S KILLS  Open-ended questions  Affirmations  Reflections  Summaries

27. O PEN -E NDED Q UESTIONS What are open-ended questions Require more than a yes or no answer. Require more than a short answer. Often start with words such as… “How…” “What…” “Tell me about…” Enables the client to convey more information. Encourages engagement. Avoid the question-answer trap Exercise 2: Closed to open questions “Do you feel anxious or depressed?” “How many drinks do you have per day?” “Do you like weed?” Why use open-ended questions

28. A FFIRMATIONS  Affirmations are closely tied to our values.  What feels affirming to one person can be irrelevant to another.  Think of a compliment you received recently that was deeply meaningful to you. Write it down.  What made this affirmation personally meaningful to you?

29. L EVELS OF R EFLECTION  Simple Reflection (Level 1)—stays close to client meaning Repeating 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.

30.  Complex Reflection (Level 2)—makes a guess Paraphrasing—major restatement, infers meaning, “continuing the paragraph”  Examples Patient: “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint! Clinician: “It’s hard to imagine how I could possibly understand.” *** Patient: “I just don’t want to take pills. I ought to be able to handle this on my own.” Clinician: “You don’t want to rely on a drug. It seems to you like a crutch.” L EVELS OF R EFLECTION

31. Complex (Level 2)- A double-sided reflection attempts to reflect back both sides of the ambivalence the patient experiences. Patient: But I can't quit smoking. I mean, all my friends smoke! Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you. Patient: Yes. I guess I have mixed feelings. L EVELS OF R EFLECTION

32.  Complex Reflection (Level 3) 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. L EVELS OF R EFLECTION

33.  In small groups: 1.Review each sentence stem 2.Develop a reflection for each level noted in the directions 3.We will share the responses in the group and discuss E XERCISE 3: R EFLECTIVE R ESPONSES TO S ENTENCE S TEMS

34.  Periodically summarize what has occurred in the counseling session.  Summary usages Begin a session End a session Transition Typically start with “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…” S UMMARIES

35. 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. S UMMARIES

36. Exercise 4: Summaries Part 1: Get together in groups of 2: One person tells and one listens. 1. The person who tells talks for 90 seconds about a habit, behaviour, dilemma or situation that he/she is thinking about changing. 2. The listener’s task is to be an interested listener without saying anything or asking questions, and then give a summary of what you’ve been told. Do not try to solve the teller’s problem or give advice. Your task is to try to listen and remember as well as you can, and give an as exact summary as possible. When summarizing try to avoid changing or adding things to what you’ve been told. 3. Change roles and repeat.

37. Part 2: Change partners: Once again one person tells, and the other listens. 1. The person who tells repeats his/her story talks for 90 seconds without being interrupted. 2. The listener’s task is to be an interested listener without saying anything or asking questions and then give a summary of what you’ve been told. Do not try to solve the teller’s problem or give advice. However, your summary may now include what you think is the underlying meaning, feeling or dilemma in the story you’ve heard. 3. Change roles and repeat. Exercise 4: Summaries

38. What are the differences between the two types of summaries? How was it for the person who received the summary? How was it for the person who gave the summary? Which summary was most difficult? Why? What is the effect of telling a story several times? Exercise 4: Summaries- Debrief

39.  Desire: wish, want, like  Ability: can, could, able  Reasons: ct gives reasons for change  Need: need, should, got to, must Commitment Language  Commitment: will, promise, intend  Taking steps: ct expresses things they have done to change Change Talk

40.  I am going to read a series of statements  You all listen, and if you hear change talk drum on your table or legs or something  If you year commitment language, I want you to rub the pearl as it is precious in terms of change Exercise 5: Drumming for Change Talk

41. 1.Ask evocative questions 2.Explore pros and cons 3.Ask for elaboration 4.Imagine extremes 5.Importance Ruler 6.Looking forward 7.Looking back Eliciting Change Talk

42.  Identify a change that would be important for one of your clients  Ask your clients: 1.Why would you want to make this change? (reflect) 2.If you decide to make this change, how might you go about it to succeed? (reflect) 3.What are the three best reasons for you to do this? (reflect) 4.How important is it for you to make this change, on a scale from 0 to 10, where 0 is not at all important and 10 is the most important thing you could do? (follow up: why a ___ and not a zero (or a lower number)?) 5.So what do you think you will do? (reflect) Eliciting Change Talk

43.  Get into dyads: One person will be the client, the other the clinician Client: Select a life change you have some ambivalence over, that you feel comfortable sharing in the group, e.g. exercising more, eating less, going back to school, etc. Clinician: Use the script we just went over to have a talk about the situation Exercise 6: Eliciting Change Talk

44. T RANSITIONING 1.Decreased Resistance 2.Decreased Problem Discussion 3.Resolution 4.Change Talk 5.Questions About Change 6.Envisioning 7.Experimenting

45. P HASE 2 H AZARDS Underestimate Ambivalence Over Prescription Insufficient Direction

46. P HASE 2  Recapitulation: Take all of the clients self- motivational statements, ambivalence, objective evidence, and your own perception of the client situation and say it to them  Key Question: after recapitulation, form an open question about what the client will do next  Giving Information or Advice : to remain genuine we want to tell clients when we have ideas or knowledge about their change process

47. I am going to read a long excerpt from a client/behavioral health therapist interview. Each of you, on a piece of paper, write out a 5-7 sentence recapitulation (write EXACTLY how you would say it to the client) that ends with a key question We will share these recapitulations and key questions with the group Exercise 7: Dr. Clarks Referral

48. R EFERRAL G UIDELINES FOR G REATEST S UCCESS  Determine if patient is drug or alcohol dependent and needs medical detoxification (usually inpatient).  A nondependent substance abuser is usually treated as an outpatient unless there are other risk factors.  Most patients can be successfully served in outpatient treatment.

49. A S TRONG R EFERRAL TO A PPROPRIATE T REATMENT P ROVIDER I S K EY When your patient is ready—  Make a plan with the patient.  You or your staff should actively participate in the referral process. The warmer the referral handoff, the better the outcome.  Decide how you will interact/communicate with the provider.  Confirm your follow-up plan with the patient.  Decide on the ongoing follow-up support strategies you will use.

50. W HAT I S A W ARM -H ANDOFF R EFERRAL ? The “warm-handoff referral” is the action by which the clinician directly introduces the patient to the treatment provider at the time of the patient’s medical visit. The reasons behind the warm-handoff referral are to establish an initial direct contact between the patient and the treatment counselor and to confer the trust and rapport. Evidence strongly indicates that warm handoffs are dramatically more successful than passive referrals.