1. How to Screen and Assess

2. Screening does not provide a
“It is important to recognize the difference between an assessment, which is intended to make a diagnosis, and a screen, which is intended to identify the potential for problems. Screening provides us with a quick heuristic about who is likely not at risk and who might benefit from a closer look. Once a likely risk is identified, assessment allows us to confirm that risk and determine the appropriate level of services.”

3. Role Play: Winging It Role Play: Winging It Break up into groups of 2
Client, provider
Use the 3 client roles provided
Provider: use your best judgment & clinical skills to screen the client for risky alcohol use &, if necessary, assess for severity & presence of an alcohol use disorder
2 minutes; rotate roles
Role Play: Winging It

4. Debriefing What went well? What was a challenge?
What tools would be helpful in this process?
Debrief
“How was that experience for you? What went well? What was a challenge? What tools would be helpful in this process?”
Debriefing

5. In minutes, a valid and reliable screening tool can…
“There are definitely some benefits to having standardized tools available to us in SBIRT. A good screening instrument can efficiently tell a great deal of information…”

6. Reliable screening tool
Immediately rule-out low/no risk users
Immediately identify level of risk
Provide context for a discussion about substance use
Provide information on the level of involvement in substance use
Offer insight into areas where substance use may be problematic
Identify clients who are most likely to benefit from brief intervention
Identify clients who are most likely in need of referral for further assessment
Reliable screening tool

7. 2 Ways of Administering Screens
Provider verbally administers screening instrument(s)
client completes screening instrument(s) on paper or electronically (e.g., tablet, laptop)

8. Client-Centered Screening Agenda Setting
Normalize
"We ask everyone these questions to help us provide the
best health services that we can."
Ask permission
"Would it be OK if I asked you some other health-related questions about alcohol use?"
Address confidentiality
"As with all of your health information, your responses to these questions are confidential."

9. Before Starting
I would like to ask you some personal questions that I ask all my clients. These questions will help me to provide you with the best care possible. As with all medical information your responses are confidential. If you feel uncomfortable just let me know.
This is an animated slide. Click to start the animation sequence
“This is an example of language that can be used to introduce the process of screening. Before starting, use an introduction such as this one which will help “normalize” this process (“I ask all my clients’), frame the questions as medical in nature, and highlight the confidentiality of the responses. It may help some clients if you frame these as “lifestyle” questions rather than “personal” questions.”
Option: “Take a few minutes to write an introduction that you feel covers the essentials and reflects your own style and approach to introducing screening.”
Share and discuss.

10. Special Note about Verbal Screens
Use the exact wording provided on the screening instrument - DO NOT PARAPHRASE
It is OK to clarify the meaning of an item or question.
‘When it comes to verbal screening instruments, it is important to remember that the questions should be asked exactly as they designed. As you’ll recall, these instruments were developed scientifically to be very specific predictors of clinical presentations our outcomes. When they are modified, they may lose their ability to accurately differentiate between levels of client risk.”

11. NIAAA Single Question Alcohol ScreenNO
YES
NIAAA Single Screener:
How many times in the past year have you had five (men) or four (women or clients over age 65) drinks or more in a day?
If one or more affirmative answers, move on to assessment
Sensitivity/Specificity: 82%/79%
Pre-screen: Do you sometimes drink beer, wine, or other alcoholic beverages?
“Here is an example of a validated and widely utilized verbal screening instrument develop by the National Institute on Alcoholism and Alcohol Abuse. There is a pre-screening questions which reads: Do you sometimes drink beer, wine, or other alcohol beverages? If the client endorses this question, then the single question screening question can be asked: How many times in the past year have you had five (men) / four (women or clients >65) drinks in a day? An answer of 1 or greater is considered a positive screen. This simple verbal tool is a good predictor of hazardous alcohol use. Although there are several good screening tools, this is the tool that we’ll be learning to do in the clinical protocol that we will be learning about in this training.”
(Smith, Schmidt, Allensworth-Davies, & Saitz, 2009)

12. Positive Screen = Risky Drinker
Daily limits
5 for men or 4 for women/anyone 65+
Weekly limits
Men: 14/week
Women/anyone 65+: 7/week
YES
client is at risk. Assess to determine drinking severity and presence of AUD. NO
client is at low risk.
“One benefit of the NIAAA single question screen is that it directly corresponds to recommended drinking limits, which may make the transition between screening and brief intervention easier. The NIAAA recommends that men not have more than 4 drinks in a day or 14 in a week. And women and people over 65 not have more than 3 in a day or 7 in a week. The NIAAA single question screen maps right onto the recommended daily drinking limit.”
Optional: “What do you make of these limits? Do they seem low or high?” 12

13. Screening
Based on previous experiences with SBIRT, screening will yield 75% negative responses.
Negative
“Based on drinking levels in the population, we can expect that if this screening instrument is administered in most settings, we will get a high negative screen rate. For example, in primary care settings, at least 3/4s of clients will likely screen negative, meaning they have not had any days in the past year in which they have exceed recommended drinking levels.

14. Negative Screen Affirm Advise Open Door Rescreen Annually
“For the majority of clients who screen negative, it is recommended that we affirm their safe drinking choices, advise them of the recommended limits and encourage them to stay below them, remind them that we are available if alcohol use ever becomes a concern, and that we rescreen annually.”

15. Screening
If you get a positive screen, you should ask further assessment questions.
Positive
“For clients who screen positive, we want to invest further clinical energy to get more specific information about where they are at in terms of their drinking.”

16. Positive Screen
Assess further

17. Assess for Severity Quantity, frequency (explain standard drink)
Could you tell me a little more about your drinking patterns?
Reflect
Follow-up with closed-ended questions if needed
“As you all have highlighted, some pieces of information that can be helpful in assessing the severity of alcohol use, may include drinking quantity, or how much a person drinks, and drinking frequency, or how often a person drinks. In the protocol that we are learning it is recommended that we first try to gather this information in an open-ended fashion and then follow up with closed-ended questions as needed. Weaving in reflective listening statement and summaries can make the assessment seem less interrogating.”

18. Assess for SUDs
“It is also important to determine whether a client has an alcohol or drug use disorder.”

19. DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale
d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5.
Source: Am J Psychiatry. 2013;170(8):

20. 2 Item Scale Recurrent drinking in hazardous situations
In the last 12 months, have you been intoxicated on alcohol (or drugs) where you could have hurt yourself or others?
Drinking more than intended
In the last 12 months, how often did you drink (or use) more than you intended?
Assessing for the presence of a substance use disorder can be time consuming. Luckily, there are two DSM criteria that are pretty good predictors of whether or not someone has an alcohol use disorder. If clients endorse etiher of these questions, it is likely that they do have an alcohol use disorder, and if they don’t endorse either, it is likely that they don’t. If you a providing SBIRT in a time-limited situation, you may want to rely on these questions to make your determination regarding severity.

21. 2-Item test characteristics for current AUD in positive screens
Sample N
Sensitivity
Specificity
Acute injury in ED,
959
95%
77%
Random digit dialing
494
94%
62%
Five family medicine practices in Georgia,
280
66%
National Epidemiologic Survey on Alcohol and Related Conditions,
7,890
86%
18-20 year olds in ED
181
88%
90%
This slide show the sensitivity and specificity of these two questions in identifying persons with with an alcohol use disorder.”
Vinson D, Kruse RL, Seale JP. Alcohol Clin Exp Res ;31(8):1392–1398
Kelly TM, et al. Addict Behav. 2009;34(8):
(Kelly et al., 2009; Vinson et al., 2007)

22. Decision Rule No Use / Non-risky use >>> Affirmation
Risky Use / Mild SUD >>> Brief Intervention
Moderate or Severe SUD >>> Medical Management and/or Referral to Treatment
“So, as a reminder, the purpose of screening and assessment is to determine the appropriate level of services for a client. clients with no use or non-risky use identified from screening should be affirmed and rescreened annually. For those identified as risky during screening, further assessment is needed. Then, those without a substance use disorder or with only a mild substance use disorder are appropriate for brief intervention, while those with a moderate or severe substance use disorder should be referred for medically management or referral to treatment.”

23. Role Play: Single Question Screen
Break up into groups of 3
client, provider, observer
Use the 3 client roles provided
Provider: use the single question screen to determine whether the client is a risky drinker
If client is risky, assess severity, and use the 2 question SUD scale
3 minutes; rotate roles
“In this activity you will have the opportunity to practice screening and assessment. Break up into groups of three. Everyone will have the opportunity to be the client, the provider, and an observer. Use the standardized client examples provided to you. Providers, you job is to complete the first several steps of the SBIRT protocol. Screen your client. If screening is positive, assess severity and try to determine whether the client has a substance use disorder.”

24. Debriefing What went well? What was a challenge?
How was it helpful to have a tool?
Debriefing

25. Single Question Screen 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 had)
If response is, “None,” screening is complete
If response contains suspicious clues, inquire further
“Similar to the single-question alcohol screen, there is also a single question drug screen available. This one-item drug question has good sensitivity and specificity for drug use, and is easy to score. If a client answers “1 or more” they are considered a risky user and should be assessed further.”
Citation: McNeely J, Cleland CM, Strauss SM, Palamar JJ, Rotrosen J, Saitz R. Validation of Self-Administered Single-Item Screening Questions (SISQs) for Unhealthy Alcohol and Drug Use in Primary Care clients. J Gen Intern Med May 19.
Sensitivity/Specificity: 100%/74%
(Smith et al., 2010)

26. A Positive Drug Screen
Ask which drugs the client 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 pre-screen question puts the
client 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.
“Just like with alcohol, if a client endorses risky drug use, further questions should be asked to determine severity. These might include questions about types of drugs, quantity and frequency, and potential negative impacts.”

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