1. Screening, Brief Intervention and Referral to Treatment (SBIRT)

2. Training Objectives Describe the background and rationale for conducting SBI Briefly describe screening procedures for identifying patients engaged in at-risk drinking/use Teach brief intervention strategies and techniques

3. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with substance use disorders Those who are at risk of developing these disorders Primary care, mental health, AOD and other community settings provide opportunities for intervention with at-risk substance users Before more severe consequences occur

4. SBIRT: Core Clinical Components Screening: Very brief screening that identifies substance related problems Brief Intervention: Raises awareness of risks and motivates client toward acknowledgement of problem Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help Referral: Referral of those with more serious addictions

5. SBIRT Goals Increase access to care for persons with substance use disorders and those at risk of substance use disorders Foster a continuum of care by integrating prevention, intervention, and treatment services Improve linkages between health care services and alcohol/drug treatment services

6. SBI Could Have a Major Impact on Public Health There are grounds for thinking SBI may: stem progression to dependence. improve medical conditions exacerbated by substance abuse. prevent medical conditions resulting from substance abuse or dependence. reduce drug-related infections and infectious diseases. identify those at higher risk of abusing prescription drugs. identify abusers of prescription drugs or OTC drugs. have positive influence on social function.

7. Use of SBIRT Among At-Risk Patients Severe Problem Drinkers Hazardous & Harmful Drinkers Non-Drinkers or Low Risk Drinkers SBIRT

8. Substance Abuse Challenges: 19.7 Million Americans Are Current* Users of Illicit Drugs Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006). 0.1 0.6 0.5 0.7 2.4 6.4 9.0 14.6 19.7 05101520 LSD Heroin Inhalants Meth Ecstasy Crack Cocaine Psychotherapeutics (non-medical use) Any Illicit Drug, not marijuana Marijuana Any Illicit Drug (in millions) *past month users

9. Substance Abuse Challenge: Non-Medical Use of Psychotherapeutics Conclusion: Increase in non-medical use of prescription drugs among 18 – 25 year olds since 2002. Non-medical use of opioid analgesics is most significant contributor to the problem.

10. Substance Abuse Challenge: Prescription Drug Sources: Primarily Friends or Family Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006 Sources of Opioid Pain Relievers Used Non-Medically ( Accounts for 73% of prescription drug abuse)

11. 11 Brief Intervention Effect Brief interventions can trigger change 1 or 2 sessions can yield much greater change than no counseling A little counseling can lead to significant change Brief interventions can yield outcomes that are similar to those of longer treatments

12. Conducting the Brief Intervention FLO

13. FLO Brief Intervention Based on Motivational Interviewing (MI) Approach People are ambivalent about change People continue their drug use because of this ambivalence Resolving ambivalence in the direction of change is key element of motivational interviewing Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

14. “People are better persuaded by the reasons they themselves discovered than those that come into the minds of others” Blaise Pascal

15. MI: Principles 1. Empathy May be the most crucial principle Creates environment conducive to change, instills sense of safety, of being understood and accepted, and reduces defensiveness Sets the tone within which the entire communication occurs. Without it, other components may sound like mechanical techniques

16. MI: Principles 2. Develop Discrepancy Help client to become more aware of the discrepancy between their addictive behaviors and their more deeply-held values and goals Part of this is helping client to recognize and articulate negative consequences of use. More effective if the client does this, not the clinician Explore values and life goals and then ask client to reflect on how their addictive behavior fits into them

17. MI: Principles 3. Roll with resistance In general, it is unhelpful to argue with clients. Confrontation elicits defensiveness, which predicts a lack of change Particularly counter therapeutic for clinician to argue that there is a problem while client argues that there isn’t one Client does not need to accept diagnostic label (e.g. “addict” or “alcoholic”) for change to occur

18. MI: Principles 4. Support self-efficacy Can be conceptualized as a specific form of optimism, a “can-do” belief in one’s ability to accomplish a particular task or change. Crucial to help client see and experience their own ability to make positive changes. Part of this is the clinician believing in the client’s ability to change.

19. The 3 Tasks of a BI Avoid Warnings! FLOW FeedbackListen & UnderstandWarnOptions Explored (that’s it)

20. How does it all fit together? Listen & Understand Explore Pros and Cons Explain ImportanceAssess readiness to change Feedback Setting the stage Tell screening results Options Explored Discuss change optionsFollow up

21. How you talk to the patient matters You are singing off key if you find yourself… Challenging Warning Finger-wagging Moralizing Giving unwanted advice Shaming Labeling Confronting Being Sarcastic Playing expert

22. The 3 Tasks of a BI FLO FeedbackListen & UnderstandOptions Explored

23. Providing Feedback The Feedback Sandwich Ask permission Give Feedback Ask for Response

24. The First Task: Feedback Give Patient Feedback using: R A N G E Range Anybody knows Normal ranges Give score Elicit reaction

25. The First Task: Feedback Give Patient Feedback: An Example Range: “BAC can range from 0 (sober) to.4 (lethal)” Anybody knows: “.08 defines drunk driving (heavy drinking)” Normal: “Normal drinking is.03-.05 Give score: “Your level was …” Elicit reaction: “What do you make of that?”

26. The First Task: Feedback Your job in F is only to deliver the feedback! Let the patient decide where to go with it.

27. The First Task: Feedback Handling resistance… Look, I don’t have a drinking problem My dad was an alcoholic; I’m not like him I can quit anytime I want to I just like the taste If you lived in Forks, WA, you’d drink too What would you say?

28. To avoid this… LET GO!!! The First Task: Feedback

29. Easy Ways to Let Go… I’m not going to push you to change anything you don’t want to change I’m not here to convince you that you’re an alcoholic. I’d just like to give you some information.. I’d really like to hear your thoughts about… What you do is up to you.

30. The First Task: Feedback Finding a Hook Ask the client about their concerns Provide non-judgmental feedback/information Watch for signs of discomfort with status quo or interest in or ability to change Always ask this question: “What role, if any, do you think alcohol/drugs played in you being here?” Let the patient decide Just asking the question is helpful

31. The 3 Tasks of a BI FLO FeedbackListen & UnderstandOptions Explored

32. The Second Task: Listen and Understand Ambivalence is Normal

33. 33 The Second Task: Listen and Understand Change Talk is Happening When the Client Makes Statements that Indicate: Recognition of a problem A concern about the problem Statements indicating an intention to change Expressions of optimism about change

34. The Second Task: Listen and Understand Change Talk DESIRE: I want to do it. ABILITY: I can do it. REASON: I can’t afford to lose my job. NEED: I have to do it. COMMITMENT !!! I WILL DO IT.

35. The Second Task: Listen and Understand Listen for the change talk… Maybe drinking did play a role in what happened If I wasn’t drinking this would never have happened It’s not really much fun anymore I can’t afford to be in this mess again The last thing I want to do is hurt someone else I know I can quit because I’ve stopped before Summarize, so they hear it twice!

36. The Second Task: Listen and Understand Dig for change talk… I’d like to hear your opinions about… What are some things that bother you about your drinking/use? What role do you think alcohol/drugs played? How would you like your drinking/use to be 5 years from now?

37. The Second Task: Listen and Understand Tools for Change Talk Pros and Cons Importance & Confidence Scales Readiness Ruler

38. The Second Task: Listen and Understand Strategies for weighing the pros and cons… “What do you like about drinking/using?” “What do you see as the downside of drinking/using?” “What Else?” Summarize both pros and cons… “On the one hand you said.., and on the other you said….

39. The Second Task: Listen and Understand Importance/Confidence/Readiness On a scale of 1–10… How important is it for you to change your drinking/use? How confident are you that you can change your drinking/use? How ready are you to change your drinking/use? For each ask… Why didn’t you give it a lower number? What would it take to raise that number? 1 2 3 4 5 6 7 8 9 10

40. The 3 Tasks of a BI FLO FeedbackListen & UnderstandOptions Explored

41. What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next? The Third Task: Options for Change

42. Offer a Menu of Options Manage your use (cut down to low-risk limits) Eliminate your use (quit) Never drink/use and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment) The Third Task: Options for Change

43. During MENUS You can also explore previous strengths, resources and successes “Have you stopped drinking/using drugs before?” “What personal strengths allowed you to do it?” “Who helped you and what did you do?” “Have you made other kinds of changes successfully in the past?” “How did you accomplish these things?” The Third Task: Options for Change

44. When to Give Advice Does the client already know what I have to say? Have I elicited the client’s knowledge regarding this information? Is what I’m about to say going to be helpful to the client (i.e., reduce resistance and/or increase change talk)

45. The Third Task: Options for Change The Advice Sandwich Ask permission Give Advice Ask for Response

46. The Third Task: Options for Change Giving Advice Without Telling Someone What to Do Ask for Permission explicitly There’s something that concerns me. Would it be ok if I shared my concerns with you? Preface advice with permission to disagree This may or may not be helpful to you.

47. The Third Task: Options for Change Giving Advice Without Telling Someone What to Do Provide Clear Information or Feedback The results of your test suggest that… What happens to some people is that… My recommendation would be that… Elicit their reaction What do you think? What are your thoughts?

48. The Third Task: Options for Change Closing the Conversation S E W S E W Summarize patients views (especially the pro) Encourage them to share their views What agreement was reached (repeat it)

49. Putting it all together Feedback Range Pros and Cons Importance/Confidence/Readiness Scales Summary Options Explored Listen and Understand Menu of Options

50. Important Internet Sites www.uclaisap.org www.psattc.org http://sbirt.samhsa.gov/about.htm http://sbirt.samhsa.gov/trauma.htm http://www.saem.org/SAEMDNN/Portals/ 0/IGroups/PublicHealth/sbirt2008/SBIRT ResourceManual051608.doc http://www.saem.org/SAEMDNN/Portals/ 0/IGroups/PublicHealth/sbirt2008/SBIRT ResourceManual051608.doc

51. Thank you for joining us! Schedule of upcoming Webinars in fall 2009 Follow-up Webinar Series December 9 th (1pm PST) – SBIRT January 7 th (10am) and 13 th (1pm) – Cognitive Behavioral Therapy February 4 th (10am) and 10 th (1pm) – Motivational Incentives (contingency management)