1. SBIRT New Staff Training Pam Pietruszewski The National Council for Behavioral Health November 12, 2015

2. What is SBIRT? S creening to identify patients at-risk for developing substance use disorders. B rief I ntervention to raise awareness of risks, elicit internal motivation for change, and help set healthy goals. R eferral to T reatment to facilitate access to specialized services and coordinate care between systems for patients with highest risk. 2

3. SBIRT Work Flow Follow-up Low Risk Reinforce healthy choices

4. Screening A systematic way of identifying potential for problems using a standardized, reliable and valid tool 4

5. We use this information so we can help you with your needs and goals. As part of our commitment to your overall health and well- being, we have a set of questions we ask everyone.

6. Brief Screen (Pre-Screen) During the past 12 months, did you: 1. Drink any alcohol (more than a few sips)? 2. Smoke any marijuana or hashish? 3. Use anything else to get high? 6 If any “YES” ask full CRAFFT questions If all “NO” just ask CAR question

7. Full Screen: CRAFFT 7 1. Have you ever ridden in a car driven by someone (including yourself) who was “high” or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? 3. Do you ever use alcohol or drugs while you are by yourself, or alone? 4. Do you ever forget things you did while using alcohol or drugs? 5. Do your family or friends ever tell you that you should cut down on your drinking or drug use? 6. Have you ever gotten into trouble while you were using alcohol or drugs?

8. CRAFFT Scoring If 1+ provide brief intervention If 2+ also consider referral to treatment. Low RiskModerate RiskHigh Risk AbstinenceCRAFFT Score 1CRAFFT Score 2+ Source: American Academy of Pediatrics, 2011

9. Your Message Here How might you: Introduce yourself & your role Say “why” you’ll be asking questions Describe confidentiality

10. 1.Raise the subject 2.Provide feedback 3.Enhance motivation 4.Develop a plan Brief Intervention The Brief Negotiated Interview Format

11. 1.Raise the subject 2.Provide feedback 3.Enhance motivation 4.Develop a plan Brief Intervention

12. Rapport & Relationship I’d like to review the forms you filled out today. Would that be ok with you? What is most important to you? Thank you for being so open with me.

13. What is ONE drink? 12 oz beer 8.5 oz malt liquor 5 oz table wine 1.5 oz hard liquor (brandy, gin, vodka, whiskey) NIAAA Cocktail Calculator http://rethinkingdrinking.niaaa.nih.gov/Tools/Calculators/ Cocktail-Calculator.aspx

14. National Survey on Drug Use and Health, SAMHSA https://www.healthypeople.gov

17. Marijuana is all natural Marijuana may also contain harmful contaminants. Many natural substances are known to harm human health. Marijuana helps with stress and anxiety It is important to identify underlying causes of stress and anxiety. Explore alternatives to marijuana. Heavier users of marijuana may experience improved mental clarity and motivation when they stop using. It’s legal. So why quit, or how could it be a problem? Other legal substances such as tobacco, alcohol, and prescription narcotics cause significant harm. Marijuana is associated with serious, long-term negative health effects. SBIRT Colorado: www.healthteamworks.orgwww.healthteamworks.org Addressing Marijuana Myths

18. Raise the Subject & Provide Feedback Elicit: What do you know about… Advise: That’s partially correct…in addition… Elicit: What do you think? Where does that leave you?

19. 1.Raise the subject 2.Provide feedback 3.Enhance motivation 4.Develop a plan Brief Intervention

20. Some Motivational Interviewing Principles 1.Motivation is not static. 2.Ambivalence is normal to the change process. 3.Pushing too hard for will evoke resistance to change. 4.Evoking patient’s own change talk will enhance behavior change.

21. MI Spirit Partnership Evocation Compassion Acceptance

22. “MI appears to be a good fit with adolescents’ developmental need to exert their independence and make decisions for themselves, while it respects their heightened levels of psychological reactance and coincides with the development of their decision-making skills.” Motivational Interviewing for Adolescent Substance Use: A Review of the Literature Barnett, et al. Addict Behav 2012

23. Sustain Talk Change Talk Ambivalence

24. “What are the good things about pot? “What are the not so good things about pot?” Pros Cons Developing Discrepancy

25. Tool: Decisional Balance Good Not so good No change Change 12 43

26. 1.Raise the subject 2.Provide feedback 3.Enhance motivation 4.Develop a plan Brief Intervention

27. Example Planning Sheet Pros of use: _______________________________________ Cons of use: _______________________________________ What I’ll do differently before the next appointment: _________________________________________________ What could get in the way: ____________________________ Options: __________________________________________ Follow-up date: _____________________________________

28. What would need to happen for you to want to make a change? How would you do it if you decided? What are the three best reasons? What’s most important to you? What could you do differently? What might be your next step? The Road to Change

29. Readiness Rulers –On a scale of 0 to 10, how important is it for you to do something different? –On a scale of 0 to 10, how confident are you that you can do something different?

30. Find alternatives Abstinence challenge Reduce risks Cut back Measure & count Pace & space Plan for triggers The Cafeteria Plan

31. Close on Good Terms S ummarize the patient’s statements in favor of change. E mphasize the patient’s strengths. W hat agreement was reached? CDC, 2014

32. Pam Pietruszewski pamp@thenationalcouncil.org Thank You