1. SBIRT Screening, Brief Intervention, & Referral to Treatment
Carrie Jankowski, MSSW, LCSW
ANNE AND HENRY ZARROW SCHOOL OF SOCIAL WORK
CENTER FOR SOCIAL WORK IN HEALTHCARE

2. Who is SAMHSA?
The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
Since 2003, SAMHSA has supported SBIRT with more than 1.5 Million people screened

3. Screening, brief intervention, and referral to treatment IS :
a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services.
Persons with substance use disorders
Those whose use are at higher levels of risk
carried out at in primary care, hospitals, and other Health care and community settings.
based on Motivational Interviewing strategies , may result in Brief intervention or referral to Treatment

4. Goal of sbirt
to identify and effectively intervene with those who are at moderate or high risk for problems related to their Alcohol and other substance use.

5. Results of Hazardous alcohol and substance abuse
Injury/trauma
Contributes to many Acute and chronic diseases
Criminal justice involvement
Social problems
Mental health consequences (e.g. anxiety and depression)
Increased absenteeism and accidents in the workplace

6. Substance abuse: A Public Health Perspective
Significant gap in services…used to be only for people in dependent category but huge need for those in at-risk or binge category

7. Screening Stratifies Risk
The full alcohol and/or drug screens stratifies patients risk levels into zones of use. These zones inform the type of intervention to be delivered.

8. Making a Measurable Difference
Outcome data of SBIRT confirms a 40 percent reduction in harmful use of alcohol by those drinking at risky levels and a 55 percent reduction in negative social consequences.
Outcome data also demonstrate positive benefits for reduced illicit substance use.
Based on review of SBIRT GPRA data (2003−2011)
SBIRT cost effective as it reduces drinking beh and sub abuse before it costs higher rate of funds

9. SBIRT Is a Highly Flexible Intervention

10. Earlier Detection and Intervention are Key
By intervening early, SBIRT saves lives and money and is consistent with overall support for Patient wellness
Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed comorbid health conditions

11. Survey on medical patient Attitudes
PATIENTS ARE OPEN TO DISCUSSING THEIR SUBSTANCE USE TO IMPROVE THEIR HEALTH

12. Why Is It Important to do SBIRT in Primary Care and Other Health Care Settings?

13. SBIRT Decreases the Frequency and Severity of Alcohol and Drug Use
Primary care is one of the most convenient points of contact for substance issues. Many patients are more likely to discuss this subject with their family physician than a relative, therapist, or rehab specialist.

14. SBIRT Reduces Short and Long Term Health Care Costs
By intervening early, SBIRT saves lives and money and is consistent with overall support for patient wellness
Late-stage intervention and substance abuse treatment is expensive, and the patient has often developed comorbid health conditions

15. What are examples of common screens?
Step One: Screening
Universal Screening is the first step of the SBIRT process and determines the severity and risk level of the patient’s substance use.
The results allow the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient.
“a discussion aimed at raising an individual’s awareness of their risky behavior and motivating them to change their behavior” (Substance Abuse and Mental Health Services Administration, 2007).
Research shows that approximately 90% of substance use disorders go untreated
What are examples of common screens?
Cholesterol, mammogram, gestational diabetes

16. Universal Screening Results in earlier detection
Addresses the problem, which brings them to seek medical treatment
Reduces Risk of future injury or illness
Normalizes the Screening and subsequent discussion
Why? Drinking and drug use are common; each contribute to chronic and acute care issues; drinking and drug use often go undetected and people are more open to change than you would expect.

17. Key Points for Screening
Screen everyone
Use validated tools and processes
Prescreening is usually part of another health, stress or wellness survey
Usually self administered in waiting room- paper or electronic
VERY brief (in contrast to assessment (which is more in-depth)
Any positives (“red flags”) can be addressed in assessment
Assessment provides opportunity for more details, co-use of substances, or consequences of use

18. Screening in a Practice Setting

19. Screening for Alcohol Use
When Screening, It’s Useful To Clarify What One Drink Is!

20. What is a standard drink?

21. Screening, Brief Intervention, and Referral to Treatment
CATEGORIES OF DRINKING
LOW-RISK DRINKING LIMITS
Men
14 Drinks Per Week Drinks Per Day
Women
7 Drinks Per Week Drinks Per Day
All Age > 65
IV DEPENDENT: 5%
III HARMFUL: 8%
II RISKY: 9%
I HEALTHY: 78%

22. Evidence Behind the Numbers (SEE SBIRT CARD)
analyses reveal significant and rapid increases in the risks of—
injuries and resulting death
Being a target of aggression or Being aggressive
Alcohol use disorders
Unfavorable medical Concerns
work-related, legal, and social consequences
The more the individual exceeds the guidelines, the Greater the likelihood of one or more of the above.

23. Alcohol Prescreening
Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages? NO
YES
NIAAA Single Screener: How many times in the past year have you had five (men) or four (women or patients over age 65) drinks or more in a day?
If one or more affirmative answers, move on to full screen.
Sensitivity/Specificity: 82%/79%
Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. J Gen Intern Med 24(7), 783−788

24. Prescreening Drinking Limits
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 = 4 per day/14 per week
Women/anyone 65+ = 3 per day/ 7 drinks per week
> Regular limits = at-risk drinker

25. AUDIT
Alcohol Use Disorders Identification Test (AUDIT) [audit-C is shorter version]
10-Item Alcohol Screen
Developed by World Health Organization (WHO)
Can be self-administered or through an interview
addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems

26. Becoming familiar with the Audit
Take a minute to and complete the audit screen supplied.
(you can take it as yourself or someone else that you know)

27. AUDIT Questionnaire 1 2 3 4
1. How often do you have a drink containing alcohol?
Never
Monthly or Less
2-4 times a month
2-3 times a week
4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
0-2
3 to 4
5 to 6
7 to 9
10 or more
3. How often do you have four or more drinks on one occasion?
Less than monthly
Monthly
Weekly
Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?

28. AUDIT Questionnaire 1 2 3 4
6. How often in the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
9. Have you or someone else been injured by your drinking? No
Yes, but not in the last year
Yes, in the last year
10. Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down?
Yes, during the last year

29. Scoring the Audit Each question has a set of responses to choose from
Response Scores range from 0 to 4
Add score for questions 1 through 10

30. Scoring and interpreting the audit
Score
Zone
Action
0-3: Women
0-4 Men
I - Low Risk
Brief Education
4-12: Women
5-14: Men
II - Risky
Brief Intervention
13-19: Women
15-19: Men
III - Harmful
Brief Intervention or Referral to Specialized Treatment
20+: Women
20+: Men
IV - Severe
Referral to Specialized Treatment

31. AUDIT Domain

32. PreScreening & Screening for Drugs

33. Prescreening for drugs

34. A Positive Drug Screen

35. Evidence Based Screening
Dast (10)
10-item brief screening tool
Can be administered by clinician or self- administered
Yes or no responses
Can be used with adults and older youth

36. Using SBIRT and MI skills for other Behavioral Concerns
Depression, anxiety, and tobacco use are all common Behavioral issues that significantly impact health status
can Also be Addressed in an SBIRT format
PHQ-2 or PHq-9Depression
Gad-2 or gad-7anxiety
Also can address suicidality—high percentage of people had primary care visit within 30 days of death
Supported by public/private health fundors

37. Routine screener
Medical Practices are instituting electronic or paper screening tools that incorporate most or all of the above.
Often called a wellness-r stress screen
Medical Practices are adding mental health professionals in a collaborative integrated healthcare model.
Co-location or referrals not as effective-the vast majority of People do not make it to a Behavioral Health referral

38. Patient Stress Questionnaire
Over the last 2 weeks, how often have you been bothered by the following:
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Little interest or pleasure in doing things
4. Feeling down, depressed, or hopeless
5. Thoughts that you would be better off dead or of hurting yourself in some way
In the past year:
10. Have you been hit, kicked, punched, or otherwise hurt someone? (If so, by whom?)
In the past month, how much have you been bothered by:
11: Repeated, disturbing memories, thoughts, or images of stressful experience from the past?
12. Feeling very upset when something reminded you of a stressful experience from the past?
Alcohol/Drug use in the past year:
6. How often do you have a drink containing alcohol.
7. How many drinks of alcohol do you have on a typical day when you are drinking?
8. How often do you have five or more drinks on one occasion?
9. How many times in the last year have you used an illegal drug or used a prescription?

39. Based on Findings of Screening
The clinician has valid, patient self-reported information that is used in brief intervention.
Often the process of screening sets into motion patient reflection on their substance use behavior.

40. Linking Screening and Brief Intervention
MI strategies facilitate—
Finding personal and compelling reasons to change
Building readiness to change
Making commitment to change

41. Step two: Brief intervention
Brief interventions are designed to:
Low cost, effective public health intervention for harmful drinking
motivate individuals to change their behavior
help them understand how their substance use puts them at risk
Ultimately reduce or give up their substance use
Or encourage those with dependence to accept more intensive Care or treatment
Growing body of literature to show effectiveness of sbirt for risky drug use

42. Goal of Brief Interventions
Awareness of problem
Motivation
Behavior
change
Note: With this slide, you will use animation to highlight one idea at a time, starting first with the goal of behavior change, then awareness, and then motivation.
Click to animate in “Behavior change” box on far right We know the overall goal of brief interventions is to promote positive behavior change, such as reduced consumption and reduced harm.
To reach this goal, brief interventions work to
Click to animate in “Awareness of problem” box on far left
raise individuals’ awareness of their substance use and how it impacts their lives.
Click to animate in “Motivation” box in the middle
We then work to enhance individuals’ motivation to make changes regarding substance use.
Click to animate in “Presenting Problem.”
An individual’s presenting problem can be used to raise awareness if there is a possible connection with substance use.
Click to animate in “Screening Results.”
Likewise, the screening results can also raise awareness. To achieve our objectives in the brief intervention, it is necessary to use a motivational interviewing style. We will learn how to use this style later in this workshop.
Presenting problem
Screening results

43. Brief intervention in primary care
Usually last from 5 to 15 minutes of brief “advice”
are not intended to treat people with serious substance dependence.
Evidence-based implementation of motivational interviewing skills are the underpinnings of the Brief intervention. 

44. In the Brief Intervention we use MI Skills to…
Assess where the patient is currently in the cycle of change
and
Assist person to move through stages of change toward successful sustained change

45. Principles of Motivational Interviewing
MI is founded on five basic principles:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
Reference: Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism

46. MI: Tips for expressing empathy
Good eye contact
Responsive facial expression
Body orientation
Verbal and nonverbal “encouragers”
Reflective listening/asking clarifying questions
Avoid expressing doubt/passing judgment

47. Core MI
Open-ended questions
Affirmations
Reflections
Summaries

48. 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)
Involves listening and understanding the meaning of what the patient says
Accurate empathy is a predictor of behavior change

49. Summaries
Periodically summarize what has occurred in the Brief Intervention
Summary usages
Begin a session
End a session
Transition

50. Summaries (continued)
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.

51. Summaries (continued)
Examples of lead ins
“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.

52. Video Example (1)
Medical setting (ER): Young man is treated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video?
Note: Be sure to practice with the video ahead of time. If you have difficulty playing the video, see the trainer’s guide for alternate ways of accessing it.
We are going to watch two videos of doctors talking to a patient in an emergency room setting. The patient is a young man who had been drinking heavily and was involved in a bad car accident. These videos demonstrate different styles of talking to patients.
Hover over the video image to make the video controls appear. Click on the play button to show the “bad example” video. The video should display full screen.
Facilitate a 5-minute discussion with participants using the following questions:
What did you notice about the doctor’s approach. How did the patient react? Was it effective? Why or why not?
In the discussion, make sure that the following are covered: 
Angry and judgmental tone
Telling the patient what to do
Specific judgmental statement (e.g., “I know when someone is an alcoholic and I think that you have a serious drinking problem.” “Have some common sense.”)
Finger-wagging
Patient is frustrated, defensive, and just wants to get out of there

53. Video Example (2)
Same scenario, but different doctor. What does this doctor do that is different? Does it work?
The second video involves the same patient but a different doctor. Let’s look at how this doctor approaches the patient.
Hover over the video image to make the video controls appear. Click on the play button to show the “good example” video. The video should display full screen.
Facilitate a 5-minute discussion with participants using the following questions:
What did you notice about the doctor’s approach? What did the doctor do that worked well? How did the patient respond?
In the discussion, make sure that the following are covered:
The doctor style was respectful, nonjudgmental, and conversational
He explored the pros and cons of his drinking
Offered reflections of emotions and content
Involved the patient in the discussion and explored options
Offered options if his strategy to cut down did not work
Was encouraging about patient’s plan
Patient was willing to engage in discussion and generated solutions for behavior change

54. Five steps of Brief intervention
Negotiate commitment
Initiate reflective discussion
Provide feedback
based on screening/
assessment data
Evoke personal meaning
Enhance motivation

55. Initiating Reflective Discussion
Start the reflective discussion asking permission of our patients to have the conversation.
Example: “Would it be all right with you to spend a few minutes discussing the results of the wellness survey you just completed?”

56. Providing Feedback Review Score Level of risk Risk behaviors
Normative behavior
Substance use risk
Based on your AUDIT screening—
Score: 17
You are here
Low Moderate High Very High

57. Evoking Personal Meaning
Reflective questions: From your perspective…..
What relationship might there be between your drinking and ____?
What are your concerns regarding use?
What are the important reasons for you to choose to stop or decrease your use?
What are the benefits you can see from stopping or cutting down?

58. Enhancing motivation
Uses skills to move patient along in the change process
Increases the likelihood of taking next steps
Relies on tools such as:
Highlighting Change talk
Developing discrepancy
Readiness assessment

59. What is developing discrepancy?
Discrepancy is the distance between the patient’s current behavior and one ore more change goals
Often involves identifying one’s personal goals
Professionals can ask patient what is good about behavior and what is not so good about same behavior

60. Develop Discrepancy: Examples
How will things e for you a year from now if you continue to ______?
Example 2:
How do you think your life would be different if you were not drinking?

61. Avoid Argumentation
Resistance to change is strongly affected by your response
Normalize to patient that having difficulties while changing is not uncommon

62. Rolling with resistance
What doesn’t work
Persuasion
Righting reflex
What does work
Expressing empathy
Develop discrepancy
Support self—efficacy
Use change talk

63. Rolling with Resistance
Example 1 :
patient: I don’t plan to quit drinking anytime soon
provider: You don’t think that abstinence would work for you right now
Example 2:
patient: My husband often brings up my drinking— He says I drink too much. It really bothers me
provider: It sounds like he is concerned, but expresses it in a way that makes you angry

64. Enhancement Strategies Most Commonly Used in Brief Intervention
Change talk
Decisional balance
Readiness ruler

65. Change, Confidence, & Importance rulers10 9 8 7 6 5 4 3 2 1
Change, Confidence, & Importance rulers
Change Ruler
Rating scale (0-10) Used to assess a patient’s motivation for a particular change
Confidence Ruler
Rating scale (0-10), patients are asked to rate their level of confidence in their ability to make a particular change
Importance Ruler
Rating scale (0-10), Clients are asked to rate the importance of making a particular change

66. Increasing Change Talk
Change talk is at the heart of MI. Through our conversations, listen for—
Desire – I wish/want to…
Ability – I can/could…
Reasons – It’s important because…
Need – I have to…                        

67. Developing Discrepancy: Supporting change
Highlights the individual’s ambivalence (maintaining versus changing a behavior)
Leverages the costs versus the benefits

68. Developing Discrepancy
Accept all answers.
Explore answers.
Note both the benefits and costs of current behavior and change.
Explore costs/benefits with patient’s goals and values.
Answers 68

69. Readiness Rulers: I-C-R
Confidence
Readiness
Importance
Readiness rulers can address—
Importance
Confidence
Readiness 69

70. Summarizing Motivation for Change
Motivation is an intrinsic process.
Ambivalence is normal.
Motivation arises out of resolving discrepancy.
“Change talk” facilitates change.

71. Negotiating Commitment
Simple
Realistic
Specific
Attainable
Follow-up time line
Negotiating a
PLAN

72. Step three: Referral to Treatment

73. What Is Treatment?
Counseling and other psychosocial rehabilitation services
Medications
Involvement with self-help (AA, NA, Al-Anon, celebrate recovery)
Complementary wellness (diet, exercise, meditation)
Inpatient treatment/ residential treatment/ day treatment/outpatient treatment
Combinations of the above
Level of care is determined by severity of illness: Is the patient a dependent or nondependent substance abuser, and are there medical or psychiatric comorbidities?
Inpatient treatment is reserved for those with more serious illness (dependence, comorbidity

74. A Strong Referral to Appropriate Treatment Provider Is Key
When the patient is ready…
1. Make a plan with the patient.
2. You or your staff should actively participate in the referral process. The “warmer” the referral handoff, the better the outcome.
3. Decide how you will interact/communicate with the provider.
4. Confirm your follow-up plan with the patient.
5. Decide on the ongoing follow-up support strategies you will use.

75. Common Mistakes To Avoid
Rushing into “action” and making a referral when the patient isn’t interested or ready
Referring to a program that is full or does not take the patient’s insurance
Seeing the patient as “resistant” or “self-sabotaging” instead of having a chronic disease

76. Resources 211: http://www.211oklahoma.org/
SAMHSA SBIRT:
SAMHSA Website:
Behavioral Health Treatment locator:
Suicide prevention lifeline:
National helpline:
Disaster distress helpline: distress-helpline

77. Sbirt: er setting with female college student

78. Contact information
Carrie Jankowski
Terrie Fritz or Page Miller