1. SBIRT PROTOCOL AND TRAINING: HERE AND EVERYWHERE Lyle Cooper, PhD, LCSW

2. O BJECTIVES  Understand the importance of utilizing SBIRT for alcohol use/misuse  Identify the types of issues an alcohol user may have  Utilize the SBI questionnaire to know how to handle various drinking levels of patients

3. W HAT IS SBI?  Screening, Brief Intervention, and Referral to Treatment  Alcohol use  Drug use  Can be a method for gauging alcohol use in patients  Hazardous  Dependence  Harmful http://www.who.int/substance_abuse/activities/sbi/en/

4. W HAT IS DRINKING TOO MUCH …  5 or more drinks on one occasion for men  4 or more drinks on one occasion for women  Exceeding weekly limits  15 for men  8 for women  Any use by pregnant women  Any use by individuals under the age of 21

5. http://www.aplacealongtheway.org/drugs.html

7. A LCOHOL USE : IS IT A PROBLEM  Associated with numerous health and social problems  Further issues in women of childbearing age or pregnant  88,000 deaths/year  Shortened life spans  4 th leading preventable cause of death  38 million American adults binge drink  on average  4 times a month  drink 8 drinks per occasion

10. D RUG U SE : I S IT A P ROBLEM ?  22.6 million Americans (8.9%) used illicit drugs in past month  In TN high production of METH continues to be substantial threat to adults and children in state, being one f the most addictive and neurotoxic drugs of abuse  Number of METH-related incidents increased by 41% between 2009 and 2010  Substance abuse associated with multiple physical, emotional, behavioral and interpersonal problems in addition to work and legal problems  Only about 10% of individuals who required intervention for a substance-related problem actually received care  About 23 million do not receive the care they need

11. W HY YOU ?  You should want to promote healthy lifestyle recommendations  It’s a preventive service  Should at least occur during the wellness visit  Interventions in the primary care setting can positively affect unhealthy drinking behaviors in adults engaging in risky or hazardous drinking  Decrease employer costs due to lost productivity with adequate screening, brief intervention, and potential referral to treatment

12. R ECOMMENDED S CREENS  AUDIT  AUDIT-C  NIAAA one question screen How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65) or more drinks in a day?  DAST (drugs)  CRAFFT (adolescents)

13. Abuse 16-19 Risky 7-15 Healthy or Abstinence 0-6

14. SCREENING FOR DRUGS  Differs from Alcohol Screenings in that no level of use is considered Healthy  DAST consist of 10 questions pertaining to illicit drug use over past 12 months Dependence ≥6 Abuse 3-5 Risky 1-2 Healthy/ Abstinence 0

15. SCREENING ADOLESCENTS  Should talk with adolescents alone and establish confidentiality without parents  Physician must decide what constitutes sufficient risk of harm and if/when to inform parents/guardians  Differences in screening adolescents:  For alcohol, 3 question screen: “In past 12 months did you drink any alcohol greater than a few sips?”  CRAFFT: assesses risk of harm involving drug/alcohol behavior (C=CAR; R=RELAX; A=ALONE; F=FORGET; F=FAMILY/FRIENDS; T=TROUBLE)

16. I T SHOULD BE INCLUDED IN WHAT YOU DO TO SERVE OUR PATIENTS EVERYDAY !!!

17. P ROTOCOL  Semi-annually  Patients 18 and older will be given the short AUDIT form (AUDIT C)  MA or nursing staff will grade the AUDIT C  Risky drinking scores of ≥8 for men and ≥7 for women  IF the patient is found to score positively for risky drinking the rest of the AUDIT screen will be given by the MA  Completed by the patient while they are waiting to be seen by the provider  The PROVIDER will review the answers of the remaining AUDIT form  Brief intervention or referral based on zone scores  DOCUMENT

19. M EASURING PATIENT ’ S READINESS FOR CHANGE  Decisional Balance  Tool to analyze patient’s motivation to change  Motivates patient to recognize the cons of their substance abuse to help make decision to change  Readiness Ruler  Help to identify what state of change they are in: “On a scale of 1-10, how ready are you to stop or cut back on ______?” [----I----I----I----I----I----I----I----I----I----] Not at all Very Ready 0-3 = not ready to change = precontemplation 4-7 = unsure about change = contemplation 8-10 = ready to change = preparation/action

20. P ATIENT ’ S S TAGE OF C HANGE For those in precontemplation: Not considering behavior change Not physician’s task to make them agree to change; instead, task is to elicit patient’s perceived negative consequences and express concern. May also offer information, but ask first. Eliciting negative consequences: “What have you done while drinking that you later regretted?” Express concern: “I am concerned about how [ ] contributes to [health problem].” Offer information: “Would you like more information about how [ ] affects your health?” For those in contemplation: Explore motivation to change: “Why did you indicate a 5 and not a 2 on the readiness ruler?” Assist in strategies to cut back: “What strategies could you use to cut back?” For those in Action: Elicit patient’s motivation to change: “What might get in the way of accomplishing this goal?” Help patient develop action plan: “Let’s identify the steps you can take to help stop [ ]” or “What would be your first step?”

21. P ROCESSES OF CHANGE FORPATIENTS & P HYSICIAN G OALS StageCommitmentCharacteristicsPatient Verbal CuesPhysician Goals Pre-contemplation No firm commitment to change No intention to change behavior Unaware or under-aware of problem “I don’t have a problem. Why would I quit if I don’t have a problem?” Help patient consider they have a problem Contemplation No firm commitment to change Aware of problem & seriously considering change, but no commitment to take action “I know I need to cut back my drinking, but it’s not a good time.” Raise awareness of problem by observation of behavior Preparation Firm commitment to change Patient intends to change and makes small behavioral changes “I hate feeling paranoid and I know cutting out pot will help I just need another way to relax.” Encourage & support change process and commit to make change a top priority Action Firm commitment to change Patient takes a decisive action to change “I bought the patch after our last meeting, and it’s helping a lot.” Make action plan suggestions, reinforce change and provide support MaintenanceFirm commitment to change Patient works to consolidate change and gains from change “I’m glad I quit drinking. I wasn’t sure I could, but I made it.” Support continued change and help with relapse prevention

22. T IPS FOR MOTIVATIONAL INTERVIEWING Spirit (3) Collaboration Evocation Autonomy Principles (4) Express empathy Develop discrepancy Support self- efficacy Roll with resistance Techniques (4) Open-ended questions Affirmations Reflective listening Summarizing

23. R ESISTANCE ANDA MBIVALENC E Problems with Status quo Hopes for change CHANGESTATUS QUO Desired effects of status quo Fear of Change Counselor Behavior Ambivalence Maintains the Balance Counselor Behavior Assists in Resolving Ambivalence, OR Assists in Maintaining It!!!!!

24. MICROSKILLS:O PENING S TRATEGIES OARS PENQUESTIONSFFIRMINGEFLECTIVEUMMARIZING

25. CHANGE TALK  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

26. V IDEO D EMONSTARATION  I am going to show a brief video of a physician conducting an SBIRT intervention  Watch the video and use the BIOS to critique the MD’s performance  We will discuss after

27. R EFERENCES  http://www.talkingalcohol.com/files/pdfs/WHO_audit.pdf http://www.talkingalcohol.com/files/pdfs/WHO_audit.pdf  http://www.cdc.gov/chronicdisease/overview/index.htm http://www.cdc.gov/chronicdisease/overview/index.htm  http://www.cdc.gov/media/releases/2014/p0501-preventable-deaths.html http://www.cdc.gov/media/releases/2014/p0501-preventable-deaths.html  http://www.cdc.gov/ncbddd/fasd/alcohol-screening.html http://www.cdc.gov/ncbddd/fasd/alcohol-screening.html  http://www.who.int/substance_abuse/activities/sbi/en/ http://www.who.int/substance_abuse/activities/sbi/en/  http://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf http://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf  http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6b.pdf http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6b.pdf  http://www.cdc.gov/workplacehealthpromotion/evaluation/topics/substance-abuse.html http://www.cdc.gov/workplacehealthpromotion/evaluation/topics/substance-abuse.html  Miller, W.R., Benefield, G.S., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.  Burke, B.L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled drinking trials. Journal of Consulting and Clinical Psychology, 71, 843-861.  Bertholet, N., Daeppen, J.B., Weitsbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: Systematic review and meta-analysis. Archives of Internal Medicine, 165(9), 986-985