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

2. Brief Intervention and Referral to Treatment IS :
Screening
Brief Intervention and
Referral to Treatment IS :
An evidence based, comprehensive, integrated approach to identify and provide brief and effective early intervention for:
Alcohol misuse
Substance use
Tobacco use
Depression/anxiety
Carried out at in primary care, specialty care, hospital E/D, and other Health care and community settings.
Based on Motivational Interviewing strategies

3. Goal of sbirt
to identify and effectively/efficiently intervene with those who are at risk for health problems related to one or more of those conditions.
Seeks to identify those in the ‘risky or harmful’ use categories
As well as those with dependency and in need of specialty referral/treatment.

4. A Public Health Perspective

5. Why SBIRT is being Adopted
Risky and harmful levels of drinking are very common
Alcohol is a contributing factors to many injuries as well as other chronic and acute care concerns.
Dependence usually be identified, but risky and harmful levels of alcohol use most often go unaddressed
People are more open to discussion and change than you might expect
It is efficient and effective
The drinking and drug use are very common. Increases risk for other issues.

6. Category
Increase
12 month alcohol use
11.2%
High-risk drinking
29.9%
DSM-IV AUD
49.4%
JAMA Psychiatry. 2017;74(9): doi: /jamapsychiatry Published online August 9, 2017.

7. Increases of these outcomes were greatest among Women Older adults
Racial/ethnic minorities
Individuals with lower educational level and family income
JAMA Psychiatry. 2017;74(9): doi: /jamapsychiatry Published online August 9, 2017.

8. Screening Universal Screening is the first step of SBIRT.
The result of a screen allows the provider to determine if a brief intervention or referral to treatment is necessary.

9. Universal Screening Results in earlier detection
Helps determine provider response
Normalizes the Screening and subsequent discussion
Ques the client/patient on importance
Often initiates reflection by the client/patient
Increases efficiency

10. Pre-Screening
The Audit-C is being used and information gathered by admitting nurse.
The Audit-C has been normed and found to be a valid and reliable tool in healthcare settings.
When a response is positive, further screening and/or discussion is indicated.
Best practice is to conduct a brief review of the screen with client/patient - even if there are no areas of concern.

11. Based on Findings of Initial or Pre- Screening
A positive response initiates a full screen-the Audit
The Audit –C and Audit supply valuable client/patient self-reported information that can be used as the basis for the brief intervention.
Often the process of screening sets in motion client/patient reflection on their substance use behavior.

12. AUDIT Questionnaire Never Monthly or Less 2-4 times a month1 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 one you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?

13. AUDIT Questionnaire (cntd.)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 guild 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

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

15. What is a standard drink?

16. 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

17. CATEGORIES OF DRINKING
Screening, Brief Intervention, and Referral to Treatment OU SBIRT Collaborative
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%

18. Brief intervention in Health care Settings
-Usually last from 5 to 15 minutes.
-Not intended to treat people with serious substance dependence.
-Motivational Interviewing skills are the underpinnings
ge.

19. 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

20. A Word about Best Outcomes from the SBIRT process
The likelihood of the client/patient taking steps to decrease alcohol consumption will be enhanced by a team approach.
The doctors, nurses, social work staff and clergy should seize opportunities to reinforce the work of the lead SBIRT professional.
Very brief-thirty seconds to three minutes
Use MI skills
Encourage and listen
Reinforce

22. During the Brief Intervention you help the client/patient to:
Find personal and compelling reasons to change
Build readiness to change
Make commitment to change

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

24. Initiating Reflective Discussion
Start the reflective discussion asking permission of our clients/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?”

25. Providing Feedback Review score Discuss Level of risk
Provide information about the risk
Share why you would hope to see a reduction
Dependent
Harmful
Risky
Healthy
Low Moderate High Very High

26. Evoking Personal Meaning
Reflective questions: From your perspective…..
Have you had any thoughts before today about the relationship between alcohol and your health? (or your blood pressure, diabetes, etc. )
What relationship might there be between drinking and ____?
What are your concerns About this?
What are the important reasons for you to decrease use of alcohol?
What are possible benefits you can see from cutting down?

27. Enhancing motivation
Uses skills to move client/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

28. Negotiating Commitment
PLAN
Simple
Realistic
Specific
Attainable
Follow-up/timeline

29. Follow Up Ideas: -Client/Patient discharge instruction sheets are useful
They should contain at minimum:
The agreed upon plan
Information regarding any referrals/resources
Tips on cutting back
-A follow up phone call after discharge in addition would be another useful reinforcer.

30. Motivational Interviewing: The Basics

31. Definition of Motivational Interviewing
“Motivational interviewing is a client-centered, method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

32. Benefits of Using MI E vidence based P atient centered
P rovides structure
R eadily adaptable

33. “People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.” —Blaise Pascal .

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

35. Rolling with Resistance
Example 1 :
Patient: I don’t plan to quit drinking anytime soon
Clinician: 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
Clinician: It sounds like he is concerned, but expresses it in a way that makes you angry

36. Remember
“Readiness to change”
State
Trait

37. Core MI
Open-ended questions
Affirmations
Reflections
Summaries

38. https://youtu.be/uL8QyJF2wVw
This video illustrates An effective discussion about overuse of alcohol with a Patient. Look for: -the steps of a Brief Intervention -Use of Motivational Interviewing skills

39. Referral to Treatment
Referral

40. Overview Substance abuse treatment works!
Following are strategies to realize the greatest likelihood of a successful treatment referral.

41. What Is Treatment? Treatment may include—
Counseling and Therapy on an outpatient basis
Various levels of inpatient/residential care
other psychosocial rehabilitation services
Medications
Involvement with self-help (AA, NA, Al-Anon)
Complementary wellness (diet, exercise, meditation)
Combinations of the above

42. What Is Treatment? (continued)
Treatment is provided within levels of care often available in multiple treatment settings.
Level of care is determined by severity: Is the client/patient a dependent or nondependent substance abuser, are they of danger to self or others, and are there medical or psychiatric comorbidities?
Inpatient treatment is reserved for those with more serious illness (dependence, Severe psychosis, Active suicidal/homicidal ideation).

43. Referral Guidelines for Greatest Success
Determine if client/patient is drug or alcohol dependent and needs medical detoxification (usually inpatient care).
Determine if client/patient is a serious threat to self or others.
A nondependent substance abuser is usually treated as an outpatient unless there are other risk factors.

44. A Strong Referral to Appropriate Treatment Is Key
When your client/patient is ready—
Make a plan with the client/patient.
You or your staff should actively participate in the referral process. The warmer the referral handoff, the better the outcome.
Decide how you will communicate with the provider to whom you are referring.
Confirm your follow-up plan with the client/patient.
Decide on the ongoing followup support strategies you will use.

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

46. NIAAA Treatment Navigator
Navigator home
Treatment finder
treatment/find-alcohol-treatment-programs 
Treatment toolkit page
treatment-navigator

47. Role Play

48. Tips for Being the Client/Patient
Do respond with information provided on the AUDIT
Do respond with your feelings related to how you believe the patient would
Don’t create extra “turns” or conflict in the case
Don’t break character

49. Contact information
Terrie Fritz
Katrina Meyers