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
Not only those with dependency and in need of specialty referral/treatment.

4. A Public Health Perspective

5. Why SBIRT is being Adopted
Drinking, drug use, and depression are VERY common
They are Contributing factors to many chronic and acute care concerns
Drinking, drug use and depression often go undetected
People are more open to discussion and change than you might expect
SBIRT is efficient and effective
The drinking and drug use are very common. Increases risk for other issues.

6. 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.

7. Universal First Level Screening
Results in earlier detection
Reduces Risk of future injury or illness
Helps determine provider response
Normalizes the Screening and subsequent discussion
Cues the patient on importance
Often initiates reflection by the patient
Increases efficiency

8. 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 misused a prescription drug?

9. This tool incorporates:
For Anxiety – Gad-2
For Depression – PHQ-2
For suicidality – accepted single question
For Alcohol – Audit-C
For illicit and prescription drug abuse – Single question (prescreen)
A personal violence question
PTSD screen

10. More Points on Screening
The questions have been normed and have been found to be valid and reliable indicators when used in healthcare settings.
The tool is generally self administered using paper or electronic tool such as tablet.
When a response is positive to any question, further screening and/or discussion is indicated.
Best practice is to conduct a brief review of the screen with patient – even if there are no areas of concern.

11. Based on Findings of Initial or Pre-Screening
A positive response on any section will initiate a full screen
The clinician has valid, patient self-reported information that can be used as the basis for the brief intervention.
Often the process of screening sets in motion 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
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. Categories of Response
CATEGORIES OF DRINKING
ACTION
Refer to Assessment or Treatment
Brief Intervention or Refer to Assessment
Brief Intervention
Support and Education
IV DEPENDENT: 5%
III HARMFUL: 8%
II RISKY: 9%
I HEALTHY: 78%

19. Instructions
Get with your two neighbors in your triad/set
Review handouts for Low Risk Jill
Take turns being patient, provider, and observer.
Practice giving brief feedback to someone who is below the healthy drinking limits.
Give personal feedback
Use card
Ask their thoughts, any questions
Give brief information/education about how alcohol can play a role in many health conditions/illnesses
No more than one to two minutes
Twos start as provider, threes as patient and ones as observer, then rotate

20. 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

22. During the Brief Intervention you help the patient to:
Find personal and compelling reasons to change (NOT YOURS!)
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 by 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?”

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 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 time line

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

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

31. “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 .

32. Motivational Interviewing: The Basics

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

34. 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

35. Remember
“Readiness to change”
State
Trait

36. Core MI
Open-ended questions
Affirmations
Reflections
Summaries

37. Open-Ended Questions (continued)
Why open-ended questions?
They avoid the question/answer trap
Puts patient in an active role
Provides opportunity to explore ambivalence

38. Affirmations What is an affirmation?
Compliments or statements of appreciation and understanding
Praise
Support
Caveat – Must be done sincerely

39. Reflective Listening (
Involves listening and understanding the meaning of what the patient says
Accurate empathy is a predictor of behavior change
Demonstrates that you have accurately heard and understood the patient
Strengthens trust and the relationship

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

41. Using Rulers: I-C-R Confidence Readiness Importance
Readiness rulers can address—
Importance
Confidence
Readiness 41

42. Enhancing Motivation
Readiness Ruler

43. Short Video Shows many of the points I have made thus far
Is really pretty good, overall
Watch for
the five steps
the OARS
things you want to copy
things you might do differently

44. Five steps of Brief intervention
Negotiate commitment
Initiate reflective discussion
Provide feedback
based on screening/
assessment data
Evoke personal meaning
Enhance motivation
#1s will take 5-7
minutes to do steps
1, 2 and 3.
#2s will perform
3, 4 and 5

45. Practice
Brief intervention Part One (Jill Risky/Harmful)
Ones will be provider
Two will be patient
Threes will observe
5 to 7 minutes
Your objective is to do the first three steps of a brief intervention

46. Practice
Brief Intervention Part Two (Jill Risky/Harmful)
Twos will be provider
Threes will be patient
Ones will be observer
5-7 minutes
Objective is to review and augment step three and complete steps four and five.

47. Referral to Treatment
Referral

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

49. If a patient is a Category IV
You will either need to refer them to an assessment/evaluation service
Or directly to an inpatient or outpatient program

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

51. 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 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).

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

53. When the Patient falls into the Possibly dependent (or sometimes harmful) range on the audit, your goal for the brief intervention is to get the patient to obtain an assessment or treatment.

54. A Strong Referral to Appropriate Treatment Is Key
When your patient is ready—
Make a plan with the 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 interact/communicate with the provider.
Review your follow-up plan with the patient.
Decide on the ongoing followup support strategies you will use.

55. Practice Brief intervention-all parts! (Jill Possibly Dependent)
Threes will be provider
Ones will be patient
Twos will observe
10 to 12 minutes
Your objective is to do a brief intervention with the goal of enhancing motivation to accept a referral for further assessment.

56. 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

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

58. Readings (before Didactic)
SBIRT White Paper
Medical Consequences of Alcohol Abuse
Alcohol SBI in Primary Care Recommendation
Brief Negotiated Interview and Active Referral to Treatment Provider Training Algorithm
Videos (after Didactic, before Simulation
Introduction to SBIRT
Brief Intervention with Jill
Brief Intervention with Steve
At Risk Alcohol Brief Intervention
Possibly Dependent Alcohol Brief Intervention
Follow Up Brief Intervention for Possibly Dependent Alcohol Use

59. Wrap Up Discussion
Questions?????

60. Contact information
Terrie Fritz
Katrina Meyers