1. Screening, Brief Intervention, Referral, and Treatment (SBIRT) Training Session OB/GYN 1. Review of the scope of problems due to alcohol 2. Review of screening and effective interventions 3. Break 4. Video demonstration of brief negotiated intervention (BNI) 5. Role playing sessions (small group) and discussion 6. Complete post-program quiz

2. Several Truths Practitioners are reluctant to screen and intervene Practitioners are reluctant to screen and intervene The primary care visit is an opportunity for intervention The primary care visit is an opportunity for intervention Treatment works! Treatment works! Timely referral is effective Timely referral is effective

3. Alcohol: Scope of the Problem Why should we care?

4. Alcohol is the most commonly used drug in the United States

5. Alcohol Fast Facts Alcohol related deaths 75,000/year Alcohol related deaths 75,000/year Annual economic cost$185 billion Annual economic cost$185 billion Homicides (alcohol involved)60-70% Homicides (alcohol involved)60-70% Suicides (alcohol involved)40% Suicides (alcohol involved)40% Fatal motor vehicle accident50% Fatal motor vehicle accident50% A risk factor for medical conditions A risk factor for medical conditions Hypertension, stroke, diabetes, liver, GI disease Hypertension, stroke, diabetes, liver, GI disease

6. Alcohol Fast Facts Major risk factor for all categories of injury Major risk factor for all categories of injury Problem drinkers Problem drinkers Injuries per year2x Injuries per year2x Hospitalizations for injuries4x hospitalizations for injury Hospitalizations for injuries4x hospitalizations for injury Even one alcohol-related visit predicts continued problem drinking Even one alcohol-related visit predicts continued problem drinking

7. Young Adults Alcohol use in the past month Alcohol use in the past month 8 th grade17% 8 th grade17% 10 th grade33% 10 th grade33% 12 th grade47% 12 th grade47% Binge drinking (>5drinks in a row) in last 2 weeks Binge drinking (>5drinks in a row) in last 2 weeks 8th grade11% 8th grade11% 10 th grade 21% 10 th grade 21% 12th grader 28% 12th grader 28% Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities Drivers between the ages of 16-25 account for 30% of alcohol-related fatalities Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org www.monitoringthefuture.org

8. Adults over 18 years 10 million (5%) dependent drinkers 10 million (5%) dependent drinkers 40 million (20%) high risk drinkers 40 million (20%) high risk drinkers 70 million (35%) moderate drinkers 70 million (35%) moderate drinkers 80 million (40%) abstain 80 million (40%) abstain National Longitudinal Alcohol Epidemiologic Survey, 1992

9. High risk “At-risk” drinkers

10. Issues unique to pregnancy Prevalence of alcohol use11% Prevalence of alcohol use11% Binge drinking in a previous month 2% Binge drinking in a previous month 2% Prevalence of use (age 18-44)-non pregnant55% Prevalence of use (age 18-44)-non pregnant55% Binge drinking in a previous month13% Binge drinking in a previous month13% Many not using contraception >50% Many not using contraception >50% Pregnancy is a unique time, where motivation to reduce alcohol use may be higher. Pregnancy is a unique time, where motivation to reduce alcohol use may be higher. 74% of women stop drinking during pregnancy. 74% of women stop drinking during pregnancy.

11. Issues unique to pregnancy No known safe levels of alcohol intake No known safe levels of alcohol intake No exact dose-response relationship No exact dose-response relationship Binge drinking may be more concerning than similar volumes over time. Binge drinking may be more concerning than similar volumes over time. Increased stillbirth rate Increased stillbirth rate <1 drink per week1.37 per 1000 births <1 drink per week1.37 per 1000 births >/=1 drink per week8.83 per 1000 births >/=1 drink per week8.83 per 1000 births Current U.S. recommendation: abstinence Current U.S. recommendation: abstinence

12. Fetal alcohol syndrome (most severe) Prevalence with heavy drinkers10-50% Prevalence with heavy drinkers10-50% Offspring issues: Offspring issues: Leading cause of developmental delay in the US. Leading cause of developmental delay in the US. Growth problems (<10% at any point in time) Growth problems (<10% at any point in time) Facial dysmorphia Facial dysmorphia Microcephaly Microcephaly Smooth philtrum, thin vermillion border, small palpebral fissures Smooth philtrum, thin vermillion border, small palpebral fissures Maxillary hypoplasia Maxillary hypoplasia Central nervous system abnormalities Central nervous system abnormalities Average IQ 63 Average IQ 63 Fine motor dysfunction Fine motor dysfunction

13. Ambulatory medical care survey Nation’s Public Health Agenda: Healthy People 2010 Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these problems in the emergency department

14. SCREENING

15. Screening for Alcohol use and abuse ACOG Committee Opinion: Dec 2008 ACOG Committee Opinion: Dec 2008 “Obstetrician-gynecologists have an ethical obligation to learn and use a protocol of universal screening questions, brief intervention, and referral to treatment in order to provide patients with medical care that is state-of-the-art, comprehensive and effective. “Obstetrician-gynecologists have an ethical obligation to learn and use a protocol of universal screening questions, brief intervention, and referral to treatment in order to provide patients with medical care that is state-of-the-art, comprehensive and effective. Screening allows for early and effective treatment Screening allows for early and effective treatment Screening is cost-effective (saves $7 for every $ spent) Screening is cost-effective (saves $7 for every $ spent) Primary care visit is an ideal opportunity to screen and intervene as necessary Primary care visit is an ideal opportunity to screen and intervene as necessary

16. UNIVERSAL SCREENING WIDENS THE NET ABSTAINERS & MILD DRINKERS (70%) MODERATE (20%) at risk drinkers SEVERE (10%) Primary Prevention Brief Intervention Specialized Treatment

18. ASK Current Drinkers On average, how many days per week do you drink alcohol? On average, how many days per week do you drink alcohol? On a typical day when you drink, how many drinks do you have? On a typical day when you drink, how many drinks do you have? What is the maximum number of drinks you had on a given occasion last month? What is the maximum number of drinks you had on a given occasion last month?

19. Remember that a “standard drink” consists of:

20. Screen Positive: NIAAA Guidelines Pregnant women0 drinks Pregnant women0 drinks

21. ASK Current Drinkers CAGE C Cut Down A Annoyed G Guilty E Eye Opener

22. Detection and Referral Does it matter?

23. What do we do? ABSTAINERS & MILD DRINKERS (70%) MODERATE (20%) at risk drinkers SEVERE (10%) Primary Prevention Brief Intervention Specialized Treatment

24. Brief negotiated intervention (BNI): A motivational interview For the “At-risk drinker”

25. Principles of Motivational Interviewing Ask for permission to discuss problems Ask for permission to discuss problems Express empathy and avoid arguments Express empathy and avoid arguments Develop discrepancies Develop discrepancies Help patients understand the differences between their behavior and their goals Help patients understand the differences between their behavior and their goals Roll with resistance and provide personalized feedback Roll with resistance and provide personalized feedback “Reflective listening” “Reflective listening” Support self-motivation Support self-motivation

26. Motivational Interviewing: A Tool for Behavior Change ACOG Committee Opinion: Jan 2009 ACOG Committee Opinion: Jan 2009 The goal is to “help patients identify and change behaviors that place them at risk” The goal is to “help patients identify and change behaviors that place them at risk” “motivational interviewing to everyday patient interactions has been proved effective in eliciting “behavior change” “motivational interviewing to everyday patient interactions has been proved effective in eliciting “behavior change” “ACOG encourages the use of motivational interviewing as one approach to elicit behavior change.” “ACOG encourages the use of motivational interviewing as one approach to elicit behavior change.”

27. Fleming et al JAMA 1997 “ Brief physician advice for problem alcohol drinkers: a randomized control trial in community-based primary care practices” Randomized controlled trial 723 patients Randomized controlled trial 723 patients 17 practices with 64 physicians 17 practices with 64 physicians Intervention included: Intervention included: Educational workbook, Educational workbook, 15 minute visits one month apart x 2 15 minute visits one month apart x 2 Nurse follow-up calls x 2 (2 weeks after the visit) Nurse follow-up calls x 2 (2 weeks after the visit)

28. Fleming et al JAMA 1997 Results at 12 months (n=723) Results at 12 months (n=723) Alcohol consumption reduced with intervention: Intervention group 19.1 drinks/wk  11.5 Intervention group 19.1 drinks/wk  11.5 Control group 18.9 drinks/wk  15.2 Control group 18.9 drinks/wk  15.2 Episodes of binge drinking during prior 30 days: Intervention group5.7  3.1 Intervention group5.7  3.1 Control group5.3  4.2 Control group5.3  4.2

30. How do we do it? Brief Interventions are Effective… How do we do it?

31. Video: Scenario 1

32. Components of the Brief Negotiated Intervention 1. Raise the Subject 2. Provide Feedback 3. Enhance Motivation 4. Negotiate and Advise

34. Establish Rapport Establish Rapport Raise the subject of alcohol use Raise the subject of alcohol use Step 1: Raise the Subject

35. Step 1: Establish Rapport To understand the patient’s concerns and circumstances To understand the patient’s concerns and circumstances “That car accident must have been scary” “That car accident must have been scary” “Having your boyfriend hurt you must be awful” “Having your boyfriend hurt you must be awful” To explain the providers concern/role To explain the providers concern/role I am concerned regarding the effect alcohol may be having on you. I am concerned regarding the effect alcohol may be having on you. To avoid a judgmental stance To avoid a judgmental stance

36. Step 1: Raise the subject Get the patient’s agreement to talk about the alcohol or drug use Get the patient’s agreement to talk about the alcohol or drug use Do you mind if we just take a few minutes to talk about your alcohol/drug use? Do you mind if we just take a few minutes to talk about your alcohol/drug use? Talk about the pros and cons of their use/abuse Talk about the pros and cons of their use/abuse What is it that alcohol does for you? What is it that alcohol does for you? Re-state what they have said regarding the pros and cons Re-state what they have said regarding the pros and cons

37. Troubleshooting: What if the patient does not want to talk about their use/abuse ? “ Okay, I see you aren’t ready to talk about this today. Remember that we are here 24 / 7 if you change your mind”

38. Step 2:Provide Feedback Review patient’s drinking patterns Review patient’s drinking patterns “From what I understand you are drinking…” “From what I understand you are drinking…”

39. Step 2:Provide Feedback Make connection to the visit if possible Make connection to the visit if possible “What connection (if any) do you see between your drinking and this visit?” “What connection (if any) do you see between your drinking and this visit?” If the patient sees a connection: Reflect what they have just said. If the patient does not see a connection: Help make a connection with facts “Alcohol can slow your reflexes and predispose you to accidents” “Alcohol may impair your judgment and …..

40. Step 2:Provide Feedback Compare to National Norms and offer NIAAA guidelines (show them) Compare to National Norms and offer NIAAA guidelines (show them)

41. Step 3: Enhance Motivation: Assess the readiness for change “On a scale of 1-10 (1 being not ready and 10 being very ready) how ready are you to change any aspect your drinking patterns?” 1 2 3 4 5 6 7 8 9 10

42. Step 3: Enhance Motivation Develop Discrepancies If patient indicates she is ready for change:If patient indicates she is ready for change: > 2 : “Why did you choose that number and not a lower one? What are some reasons that you are so motivated to change.” If patient indicates she is not ready for change:If patient indicates she is not ready for change: < 1:“Have you ever done anything that you wish you hadn’t while drinking: What would make this a problem for you.” Discuss pros and cons

43. Step 3: Enhance Motivation Develop Discrepancy Explore Pros and Cons Help the patient identify the discrepancy between present behavior and important goals Help the patient identify the discrepancy between present behavior and important goals Use the discrepancy as a change motivator Use the discrepancy as a change motivator Let the patient name the problem and offer solutions Let the patient name the problem and offer solutions

44. The Ready Patient Help the patient to: Help the patient to: Name a solution for themselves Name a solution for themselves Choose a course of action Choose a course of action Decide how to achieve it Decide how to achieve it Encourage patient choice Encourage patient choice

45. Not Ready for Change Don’t Don’t Use shame or blame Use shame or blame Preach Preach Label Label Stereotype Stereotype Confront Confront Do Offer information, support and further contact Present feedback and concerns, if permitted Negotiate: “What would it take you to consider a change ?”

46. Not Ready for Change Avoid arguments Counter productive Counter productive Defending breeds defensiveness Defending breeds defensiveness Perceptions can be shifted Perceptions can be shifted Labeling is unnecessary Labeling is unnecessary Resistance is a signal to change strategies Resistance is a signal to change strategies Rolling with resistance Rolling with resistance

47. Unsure patients Don’t Don’t Jump ahead Jump ahead Give advice Give advice Expect argument about change Expect argument about change Do Explore pros & cons “help me to understand what alcohol does for you” “Are there things you don’t like about your alcohol use?”

48. Step 4:Negotiate and Advise Reinforce what the patient has stated are her goals. Reinforce what the patient has stated are her goals. “So… you would like to reduce your drinking to prevent….” “So… you would like to reduce your drinking to prevent….” Negotiate the goal/Elicit a response Negotiate the goal/Elicit a response “What is the next step?” “What is the next step?” Give advice Give advice “If you can stay within the limits you just mentioned you will be less likely to have a car accident..” “If you can stay within the limits you just mentioned you will be less likely to have a car accident..” Summarize Summarize “This is what I heard you say.. “This is what I heard you say..

49. Step 4:Negotiate and Advise Provide handouts Provide handouts Drinking agreements Drinking agreements Other support sources Other support sources

50. Step 4:Negotiate and Advise Suggest primary care follow up or referral Suggest primary care follow up or referral Social worker Social worker Psychiatric services Psychiatric services Discharge sheet of possible centers and / or programs and information Discharge sheet of possible centers and / or programs and information Thank patient for their time Thank patient for their time

51. Summary Alcohol problems are common, identifiable and treatable disorders Alcohol problems are common, identifiable and treatable disorders Knowledge and skills for screening and intervention can be learned Knowledge and skills for screening and intervention can be learned

52. VIDEO 2 nd and 3 rd scenario

53. Discussion To what degree do you discuss alcohol use with your patients?

54. Discussion Do you think you can incorporate SBIRT (Screening, Brief Negotiated Interview, and Referral to Treatment) into your practice? If so, why? What parts seem to work well? If not, why not? What barriers exist?

55. Small Groups