1. How To Do…
Screening

2. Screening: Why do SBIRT? “Who are the addicts?”
Slide 21: The Alcoholic
Screening: Why do SBIRT? “Who are the addicts?”
So where do we start? Nobody can predict which individual will become dependent on alcohol or other drugs. We must do universal screening in the ED. 2

3. Screening: Why screen universally?
Drinking and drug use…
are common
often go undetected
can increase risks to safety and health problems
Routine screening for other potential medical problems (e.g. cancer, diabetes, hypertension). Why not for alcohol and drug use?
*People are more open to change than we might expect.

4. Criteria for Screening
Significant morbidity/mortality
High prevalence
Long asymptomatic period
Valid, feasible screening test
Early intervention better (than later)
Available and effective treatments

5. Screening: Benefits
Detect current health problems related to at-risk alcohol and drug use
Detect alcohol and drug use patterns that can increase risk of future injury/illness
Intervene and educate about risky alcohol and drug use
Prevent medical and prescribing errors

6. Targeted Intervention

7. Drinkers who screen positive may meet criteria for…
Alcohol Misuse (at-risk drinking)
hazardous drinking (no consequences yet)
harmful drinking (consequences experienced)
Alcohol Abuse
Alcohol Dependence

8. What is Alcohol Dependence?
DSM-IV-TR Criteria
Evidence of tolerance or symptoms of withdrawal
Sweating, increased pulse rate, hand tremor, anxiety, nausea
A prior patient history that includes a pattern of compulsive use, high levels of alcohol intake, and increased alcohol-related problems
Devoting substantial periods of time to obtaining and consuming alcohol
Often drinking more than intended to
Unsuccessful efforts to cut-down or control intake
Some patients abuse alcohol without being alcohol dependent. DSM-IV-TR criteria for alcohol abuse include a pattern of use leading to major impairments or distress within the past 12 months, including one or more of the following: failure to fulfill role obligations, recurring use of alcohol in hazardous situations, recurring alcohol-related legal problems, continued alcohol use despite repeated interpersonal problems.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Test Revision (DSM-IV-TR). Arlington, VA: American Psychiatric Association, 2000.

9. What is Alcohol Abuse? DSM-IV-TR Criteria
Diagnosed after the absence of alcohol dependence as been established
A maladaptive pattern of use leading to significant clinical impairments within the past 12mos., including one or more of the following:
Failure to fulfill role obligations
Recurring use of alcohol in hazardous situations
Recurring alcohol-related legal problems
Continued alcohol use despite recurrent interpersonal problems
Some patients abuse alcohol without being alcohol dependent. DSM-IV-TR criteria for alcohol abuse include a pattern of use leading to major impairments or distress within the past 12 months, including one or more of the following: failure to fulfill role obligations, recurring use of alcohol in hazardous situations, recurring alcohol-related legal problems, continued alcohol use despite repeated interpersonal problems.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Test Revision (DSM-IV-TR). Arlington, VA: American Psychiatric Association, 2000.

10. The medical setting is a good home for screening & intervention
Alcohol & drug use contributes to injury & illness
Alcohol & illicit drugs interact with prescribed medications
Alcohol & drug use affects families & communities
Early intervention may reduce health consequences and save health care dollars
For many patients, SBI alone may be sufficient 10

11. Disagree/Strongly Disagree
Patients Are Open to Discussing Their Substance Use to Help Their Health
Survey on Patient Attitudes:
Agree/Strongly Agree
“If my doctor asked me how much I drink, I would give an honest answer.”
92%
“If my drinking is affecting my health, my doctor should advise me to cut down on alcohol.”
96%
“As part of my medical care, my doctor should feel free to ask me how much alcohol I drink.”
93%
Disagree/Strongly Disagree
“I would be annoyed if my doctor asked me how much alcohol I drink.”
86%
“I would be embarrassed if my doctor asked me how much alcohol I drink.”
78%
Contrary to popular belief – patients are open to discussing use with clinicians
Source: Miller, PM, et al. Alcohol & Alcoholism; 2006
Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum (

12. Introduction to Screening
Hello, I’m ______, a Health Promotion Advocate here at ____.
As a part of your medical team, my job is to ask all patients some personal questions to help you get the best care possible.
You do not have to answer them if you feel uncomfortable.

13. It’s Useful to Clarify What is One Drink!

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

16. NIAAA Definitions for Unhealthy Drinking
At-risk for increase in illness & injury
men: >14 drinks/wk or 5+ drinks/occasion
women: >7 drinks/wk or 4+ drinks/occasion
elders (+ 65): >7 drinks/week or 2+ drink/day
pregnant women: any use of alcohol

17. Brief Alcohol and Drug Screening Questions
Alcohol: Frequency
On average, how many days per week do you drink alcohol? (beer, wine, liquor)
Alcohol: Quantity
On a typical day when you drink, how many drinks do you have?
Heavy Episodic Drinking (HED)
In the last month: What is the maximum number of drinks you had in a 2-hour period?
Drugs: Any Use
In the past year: How many times have you used an illegal drug, or used a prescription medication for nonmedical reasons?

18. Let’s go over this together….in binder….

19. Validated Screening Instruments
Reimbursement requires using validated screening instruments
AUDIT, AUDIT-C
DAST

20. The AUDIT Developed by WHO Evaluated over 20 yrs
Accurate measure of risk across gender, age, & cultures
3 domains of drinking
Scores 8 > indicate risky drinking (give BNI)
Scores 20 > may indicate need for treatment
Assesses 3 domains of drinking: Hazardous us, Dependence symptoms, Harmful use

21. AUDIT-C (shorter version)

22. The DAST
One point for yes – except 3 which is reversed scored…

23. More or less if any “Yes” – then there is something to learn about

24. Enter scores into electronic medical records for billing
Include in medical record
Enter scores into electronic medical records for billing

25. Transition to Brief Intervention
Thanks so much for answering those questions. I was wondering if it would be okay if we talked a little bit more about _____?