1. Opening Pandora’s Box Professional attitudinal barriers to implementing practice nurse-led SBIRT in general practice Jock Mackenzie Project Officer Reducing Risky Drinking Project Southcity Clinic Bayside Medicare Local

2. Reducing Risky Drinking Project  Southcity Clinic - Bayside Medicare Local - July 2012  Substance dependent and DD clients w complex needs  Training, consultancy and support services  Reducing Risky Drinking Project RRDP  Practice nurse-led SBIRT in general practice  Barriers and Facilitators Report & Recommendations  Professional attitudinal barriers  Research questions

3. Opening Pandora’s Box

4. Design and Methods  Exploration of reasons for low rates of SBIRT  Literature review on barriers to SBIRT  Focus group with practice nurses and nurse mentor  Key informant survey of steering group members  Delphi technique  Quantitative screening outcomes data

5. NICS Barriers Tool  the innovation itself (and its implementation)  the health professional level  the patient level  the organizational context  the economic and political context NICS (2006) Identifying Barriers to Evidence Uptake. National Institute of Clinical Studies http://www.nhmrc.gov.au/nicshttp://www.nhmrc.gov.au/nics

6. Some Interesting Findings  Poor acceptance of NHMRC Alcohol Guidelines  Influence of clinician’s personal drinking habits  Lack of confidence in managing patient resistance  Over-estimation and over-generalization of patient resistance  Differential patient resistance by level of risk

7. Addressing Risky Drinking in General Practice

8. Addressing harms in General Practice  Harms well known & occur to drinkers and others  Most harms avoidable and SBIRT effective response  GP and PN well placed to detect and treat  Most risky drinkers won’t seek help or consider an issue  Risky drinking goes unrecognized & unaddressed  Unless obvious or client raises as an issue  Many reasons but PRIMARY reason is clinicians avoid

9. What is SBIRT?  Screening, BI and Referral to Treatment (& follow ups)  Non-treatment seeking risky drinkers in primary care  Aim to encourage and initiate behaviour change  Different evidentiary support, resources barriers and enablers  Very important stage precedes - Engagement  Failure to engage is the KEY barrier to SBIRT

10. Evidence for SBIRT  Short term evidence strong (Babor et al., 2007)  Long-term population health simulation models promising  Collins & Lapsley (2008) reduce risky drinking by 50%, avoid 2,000 early deaths and directly save $6 billion  SIPS Study UK - just attempting screening beneficial  Brief feedback has same impact as more extended BIs  Simply raising question initiates dialogue - active ingredient  Follow the latest research! tinyurl.com/findingsSBIRTtinyurl.com/findingsSBIRT Ashton, M. (2012) Alcohol screening and brief interventions in primary health care. Drug Findings http://findings.org.uk/

11. Barriers to SBIRT in General Practice  Lack of time, awareness, training, funding & access to AOD  Competing priorities, scepticism, confusion re guidelines, lack of role security  Fear of offending and losing rapport  Most patients not seeking help for drinking  Challenging risky drinking taboo in many cultures  More a clinician drinks, the less they engage patients  Professional anxiety is THE main barrier to SBIRT

12. Perceptions of Resistance  Clinicians overstate and overgeneralise patient resistance  Patients consider appropriate, important, not embarrassed  While some do object and a few may not come back  Worried patients appreciate a chance to discuss and those not worried are usually open to information and advice  Resistance does happen and confidence to manage is KEY Johnson, et al (2010). Barriers and enablers to implementing SBIRT: Systematic review of qualitative evidence J Public Health (2011) 33(3): 412-421

13. Perception of Resistance

15. Tips and Tricks for Engaging  Engaging not easy when no obvious link w presentation  Non-routine clinical context health checks or registration  Many different strategies for creating opportunity  Includes screening in ‘Patient Information Update Form’  Take the focus off patient, refocus on the process itself  Framing screening as health promotion campaign  Link presentation e.g. diabetes/ anxiety/insomnia to drinking  Appeal to pride in managing good health  Acknowledge questions may seem odd which may defuse refusal  Be creative!  All of these are contained in the Clinical Protocol

16. Products from the Project  Web resource at bml.org.au search for SBIRT  This will contain:  The Barriers and Enablers Report “Opening Pandora’s Box”  Newletter articles about the project  The Clinical Protocol  Training materials  Online E3 Learning Module with APNA March 2013

17. Further research ideas  Compare self-reported resistance of patients vs perceived resistance  Attitudes of patients to engagement  By demographics, by CALD, by risk level, by Stage of Change  Perceived resistance as outcome measure  Is there a compliant middle ground  Differential effectiveness of components of SBIRT in initiating and maintaining therapeutic conversations

18. References Please visit http://www.bml.org.au and search for SBIRT or emailhttp://www.bml.org.au jmackenize@southcityclinic.org.au