1. SBIRT TRAINING: FIELD SUPERVISORS APPRECIATION R. Lyle Cooper, Ph.D. Assistant Clinical Professor University of Tennessee College of Social Work Project Director SBIRT Training Grant Meharry Medical College Department of Family and Community Medicine

2. W HAT IS SBIRT? An intervention based on “motivational interviewing” strategies Screening: Universal screening for quickly assessing use and severity of alcohol; illicit drugs; and prescription drug use, misuse, and abuse Brief Intervention: Brief motivational and awareness-raising intervention given to risky or problematic substance users Referral to Treatment: Referrals to specialty care for patients with substance use disorders Treatment may consist of brief treatment or specialty AOD (alcohol and other drugs) treatment.

3. An Example of an SBIRT Intervention http://www.bu.edu/bniart/sbirt-in-health-care/sbirt- educational-materials/sbirt-videos/

4. M EDICAL AND P SYCHIATRIC H ARM OF H IGH -R ISK D RINKING

5. Historic Response and Public Health Response to Substance Abuse Previously, substance use intervention and treatment focused primarily on substance abuse universal prevention strategies and on specialized treatment services for those who met the abuse and dependence criteria. There was a significant gap in service systems for at-risk populations.

6. P OLICY AND SBIRT In the Public Health Paradigm, Services are Aligned and Integrated Affordable Care Act: Calls for the integration of mental and physical health care. Mandates prevention, early intervention, and treatment. Includes mental health and substance abuse treatment as “an essential health benefit.” Mental Health Parity and Addiction Equity Act: Health insurers and group health plans must provide the same level of benefits for behavioral health as they do for primary care. In Summary, mental and behavioral health must be considered in providing health care, and providers can be reimbursed for it!* *See sbirttn.org for more information on billing in Tennessee.

7. GOAL The primary goal of SBIRT is to identify and effectively intervene with those who are at moderate or high risk for psychosocial or health care problems related to their substance abuse.

8. S EVERITY OF U SE Based on Findings from Screening Dependent Use Harmful Use At-Risk Use Low Risk

9. SBIRT S CREENING F LOW Client is given a screen with single question pre-screens Social Worker reviews pre-screen prior to taking the client to the office Positive Screen Social worker reviews screen results and delivers brief intervention Client asked to complete (is administered) AUDIT and/or DAST Client in need of TX Referral to TX made at that time Follow-up appointment scheduled Client session documented in record 75% Screen Negative This means more assessment YesYes No Yes

10. Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages ? NO YES AUDIT C: How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you have on a typical day? 3. How often do you have six or more drinks on one occasion? Male score of 4 or more, Female score 2 or more, complete full screen. Sensitivity/Specificity: Male: 86%/89% Female: 73%/91% Source: www.integration.samhsa.gov/images/res/tool_auditc.pdf‎ A LCOHOL P RESCREENING

11. H OW M UCH I S “O NE D RINK ”? 12-oz glass of beer (one can) 5-oz glass of wine (5 glasses in one bottle) 1.5-oz spirits 80-proof 1 jigger Equivalent to 14 grams pure alcohol

12. Determine the average drinks per day and average drinks per week—ask: On average, how many days a week do you have an alcoholic drink? On a typical drinking day, how many drinks do you have? ( Daily average ) Weekly average = days X drinks Recommended Limits Men = 2 per day/14 per week Women/anyone 65+ = 1 per day or 7 drinks per week > Regular limits = at-risk drinker P RESCREENING D RINKING L IMITS

13. A P OSITIVE A LCOHOL S CREEN = A T -R ISK D RINKER Binge drink (  5 for men or  4 for women/anyone 65+) Or patient exceeds regular limits? (Men: 2/day or 14/week Women/anyone 65+: 1/day or 7/week) YES Patient is at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT. NO Patient is at low risk.

14. Alcohol Use Disorders Identification Test AUDIT What is it? Ten questions, self-administered or through an interview; addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems Developed by World Health Organization (WHO)

15. AUDIT Q UESTIONNAIRE WHO, 1992

16. AUDIT D OMAINS WHO, 1992

17. S CORING THE AUDIT Dependent Use (20+) Harmful Use (16‒19) At-Risk Use (8‒15) Low Risk (0‒7)

18. SBI T RAINING Outline Motivational Interviewing Skills (Miller, Benefield, & Tonigan; r=.65) Responding to Change Talk Role Play

19. R ESISTANCE AND A MBIVALENCE Ambivalence Problems with Status quo Hopes for change CHANGESTATUS QUO Desired effects of status quo Fear of Change Counselor Behavior Ambivalence Maintains the Balance Counselor Behavior Assists in Resolving Ambivalence, OR Assists in Maintaining It!!!!!

20. O PENING S TRATEGIES Micro Skills OARS PENQUESTIONSFFIRMINGEFLECTIVEUMMARIZING

21. A FFIRMATIONS Affirmations are closely tied to our values. What feels affirming to one person can be irrelevant to another. Think of a compliment you received recently that was deeply meaningful to you. Write it down. What made this affirmation personally meaningful to you?

22. L EVELS OF R EFLECTION Simple Reflection—stays close Repeating Rephrasing (substitutes synonyms) Example Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal. Clinician: So, at this moment you are not too concerned about your drinking.

23. L EVELS OF R EFLECTION ( CONTINUED ) LEVELS OF REFLECTION Complex Reflection—makes a guess Paraphrasing—major restatement, infers meaning, “continuing the paragraph” Examples Patient: “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint! Clinician: “It’s hard to imagine how I could possibly understand.” *** Patient: “I just don’t want to take pills. I ought to be able to handle this on my own.” Clinician: “You don’t want to rely on a drug. It seems to you like a crutch.”

24. L EVELS OF R EFLECTION ( CONTINUED ) LEVELS OF REFLECTION Complex Reflection Reflection of feeling—deepest Example Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me! Clinician: Her choosing not to attend today’s meeting was a big disappointment for you.

25. D OUBLE -S IDED R EFLECTIONS A double-sided reflection attempts to reflect back both sides of the ambivalence the patient experiences. Patient: But I can't quit smoking. I mean, all my friends smoke! Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you. Patient: Yes. I guess I have mixed feelings.

26. SBI T RAINING Change Talk Desire: wish, want, like Ability: can, could, able Reasons: ct gives reasons for change Need: need, should, got to, must Commitment Language Commitment: will, promise, intend Taking steps: ct expresses things they have done to change

27. SBI T RAINING Drumming for Change Talk I am going to read a series of statements You all listen, and if you hear change talk drum on your table or legs or something If you year commitment language, I want you to rub the pearl as it is precious in terms of change

28. BADGE CARD 0 10 III IV Low risk or Abstain: 78% Dependent: 5% II Harmful: 8% Risky: 9% Not at all Very Categories of drinking for patients 0 12345678910 III IV I Low risk or Abstain: 78% Dependent: 5% II Harmful: 8% Risky: 9% MEHARRY MEDICAL COLLEGE Low-risk drinking limits “If it’s okay with you, let’s take a minute to talk about the annual screening form you’ve filled out today.” Raise the subject “As your doctor, I can tell you that drinking (drug use) at this level can be harmful to your health and possibly responsible for the health problem you came in for today.” Provide feedback “On a scale of 0-10, how ready are you to cut back your use?” If >0: “Why that number and not a ____ (lower one)?” If 0: “Have you ever done anything while drinking (using drugs) that you later regretted?” Enhance motivation “What steps can you take to cut back your use?” “How would your drinking (drug use) have to impact your life in order for you to start thinking about cutting back?” Negotiate plan Zone of use: II - Risky III - Harmful IV - Dependent AUDIT score:Women: 4-12 Men: 5-14Women: 13-19 Men: 15-19Women and Men: 20+ DAST score:0-23-56+ Not at all Very INSERT REFERAL CONTACT INFORMATION HERE

29. SBI T RAINING SBIRT Badge Card Use the badge card to guide the conversation with the client in the following exercise.

30. SBI T RAINING Try it Out In groups of 3 you will be given a case study. One person will be the patient, one the social worker, and the third the observer. SW and observer, study the case study together and identify areas of interest for the interview. Patient, study your description. Use the AUDIT and/or DAST responses you have to start a motivational conversation about behavior change. Observer, use the BIOS to critique the work of the doc in your group.

31. References Miller, W.R., Benefield, G.S., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461. Burke, B.L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled drinking trials. Journal of Consulting and Clinical Psychology, 71, 843-861. Bertholet, N., Daeppen, J.B., Weitsbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: Systematic review and meta-analysis. Archives of Internal Medicine, 165(9), 986-985.