Download presentation
Presentation is loading. Please wait.
Published byAnn-Christin Olofsson Modified over 5 years ago
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-9Depression Gad-2 or gad-7anxiety 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 rulers
10 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
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.