Screening, Brief Intervention, and Referral to Treatment

1. Screening, Brief Intervention, and Referral to Treatment MUSBIRT Lyn O’Connell, MA, IMFT Amy Saunders, MA

2. Acknowledgements • The material included in this course is based on previously funded SAMHSA grantees. • SBIRT is an evidence based model that originated in ER hospitals and residency programs. • A full bibliography is available by request or in the MUSBIRT blackboard course housed at Marshall.

3. Statement of the problem • National problem, with specific negative effects in Appalachia and WV regions • 22.5 Million Americans, 12 and older, are current drug users • 100,000 deaths annually are a result of substance use • $100 billion annual national cost • $27 billion due to lost of productivity • Healthy People 2010, a set of health objectives for the U.S. to achieve over the first decade of the 21st century, lists “Substance Abuse” as one of its main areas of focus. CDC 2010;2014; NIH; SAMSHA 2015

4. Prescription Drug Abuse • 2.1 million Americans suffer from a Substance Use Disorder related to prescription painkillers (opioids). • Every day, almost 7,000 people are treated in the ER for improper use of prescriptions and many are unaware of their improper use. • Deaths from prescription painkillers have quadrupled since 1999, killing more than 16,000 people in the U.S. in 2013. • 28.1% of the population of WV reported daily drug/medication use “to affect your mood or help you relax” which is the highest in the country • The next closest state is Rhode Island at 25.9% • The national average is 18.9%. • WV has the 3rd highest prescribing rate for opioid pain relievers at 137.6 pills per 100 persons and the highest prescribing rate for benzos at 71.9 per 100 persons. • WV has the highest drug overdose mortality rate in the nation. Gallup-HealthwaysWell-being Index for 2014 http://www.gallup.com/poll/182192/mood-altering-drug-highest-west-virginia-lowest-alaska.aspx; http://www.cdc.gov/drugoverdose/epidemic/index.html

5. Why SBIRT Matters in WV: Local Overdose Statistics • In 2015, there were at least 944 overdoses in Cabell County. • 72 have resulted in death. • Approximately 2.58 overdoses per day. • The average age of someone who has overdosed is 37 years. • The youngest overdose patient is 12 years old. The oldest overdose patient is 78. Mayor’s Office of Drug Control Policy Cabell County Drug Overdose Stats for 2015

6. Local Effects: Infectious Disease • WV has the 2nd highest rate of new Hepatitis C cases in the county and the highest rate of new Hepatitis B cases in the country. • The 4 biggest complications from IV drug use are: Hepatitis B & C (liver infection), Cellulitis (bacterial skin infection), Endocarditis (heart infection), and Osteomyelitis (bone infection). • The average lifetime medical cost for someone with Hepatitis can range from $65,000 to over $500,000. • Treatment often requires patient sobriety for 6 proceeding months. • According to the CDC, the cost of communicable diseases to the U.S. health care system is estimated to be as much as $15.9 billion annually. Cabell County Community Health Assessment Update: Regional Health Connect, 2015

7. Neonatal Abstinence Syndrome • 5x increase in the proportion of babies born with NAS from 2000 to 2012, 21,732 infants were born with NAS • Every 25 minutes, 1 baby is born suffering from opiate withdrawal. • Newborns with NAS stayed in the hospital for an average of 16.9 days compared to 2.1 days for those without NAS. • The hospital costs for newborns with NAS were $66,700 on average compared to $3,500 for those without NAS.

8. Factors Contributing to Use 1. Pain Scale 2. OxyContin In late 1996, Purdue Pharma introduced a new drug — OxyContin, a controlled-release version of the pain killer oxycodone. Designed for slow release, it contained more of its potent active ingredient OxyContin also had to unique components to its FDA-approval allowing it to state that it was “abuse resistant.” After recognizing abuse, a Black Box warning was issued however it stated “tablets are to be swallowed whole and are not to be broken, chewed, or crushed. Taking broken, chewed, or crushed tablets leads to rapid release and absorption of potentially fatal dose of oxycodone (June 2001)” Purdue Pharma has paid $634 million in fines since pleading guilty in 2007 to charges that they misrepresented the drug as “abuse resistant.” They were shown to have suppressed findings and created false “scientific charts” A reformulation making it harder to dissolved in water is linked to huge numbers of users, switching to heroin. • In 1999, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, which required VA doctors to ask patients about their pain — on a 0 to 10 scale — at all visits and the Joint Commission for Accreditation of American Healthcare Organizations followed suit. David Gutman 10/17/15 Charleston Gazette; FDA, April 2013 Press Release; opioids.com/oxycodone/oxycontin

9. Factors Risk Factors Protective Factors Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact. Protective factors may be seen as positive countering events. Individual-level protective factors might include positive self-image, self-control, or social competence. • Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes. • Variable risk factors include income level, peer group, adverse childhood experiences (ACEs), and employment status. • Individual-level risk factors may include a person’s genetic predisposition to addiction or exposure to alcohol prenatally. http://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/risk-protective-factors

10. Common Substance Abuse MYTHS • Myth #1: Drug addiction is a choice. Drug use is a choice, and prolonged use changes your body and brain chemistry. When that happens, the user no longer appears to have a choice—this is when use and misuse become addiction. • Myth #2: If you have a stable job and family life, you’re not addicted. You may still have a job or career, a loving spouse and kids, and still have a drug or alcohol problem. Just ask any physician in recovery—many of them practiced for years without anyone recognizing their drug addiction. Holding down a job doesn’t mean you’re not addicted—it could mean that you have a tolerant spouse or boss, or you are in a career that puts up with excessive drug or alcohol use. • Myth #3: Addicts are bad people. Addicts aren’t “bad” people trying to get “good,” they’re sick people trying to get well. They don’t belong to a particular race or exist only in certain parts of the country. They are lawyers, farmers, soldiers, mothers and grandfathers who struggle with drug dependence on a daily basis. They are proof that addiction doesn’t discriminate—but, thankfully, neither does recovery • Myth #4: More than anything else, drug addiction is a character flaw: Drug addiction is a brain disease. Every type of drug of abuse has its own individual mechanism for changing how the brain functions. But regardless of which drug a person is addicted to the effects are similar: they range from changes in the molecules and cells that make up the brain, to mood changes, to changes in memory processes and in such motor skills as walking and talking. The drug becomes the single most powerful motivator in a drug abuser's existence. This comes about because drug use has changed the individual's brain and its functioning in critical ways. • Myth #5: Detox is all you need. You aren’t addicted after you finish detox. They can just knock you out so you can detox while you sleep. Detox is difficult and it’s just the beginning. Detox is the first step towards recovery, but addiction is a chronic illness—like diabetes, asthma or hypertension, it needs to be managed throughout the lifespan. There is no “cure.” • Myth #6: You need to be religious in order to get sober. Sobriety doesn’t require you to believe in God or subscribe to any organized religion Treatment that meets the client’s needs is most effective. • Myth #7: You need to hit “rock bottom.” There is no such thing an universal “rock bottom.” Each person has different limits. This is a dangerous idea that keeps people using or avoiding help because “I haven’t him rock bottom” or allows family members to wait to intervene till someone “hits rock bottom.” Help can be obtained at any time and early intervention is best. DeniCarise, Ph.D. Chief Clinical Officer, Phoenix House See more at: http://www.phoenixhouse.org/news-and-views/our-perspectives/ten-popular-myths-drugs-addiction-recovery/#sthash.Ntly2mhz.dpuf and NIDA "Exploring Myths about Drug Abuse“ by Alan I. Leshner, Ph.D

11. Substance abuse is affecting our community http://www.c-span.org/video/?c4577876/cary-dixon

12. What we’ve been doing isn’t working… • Historically, treatment isn’t initiated until crisis and stigmatizing beliefs perpetuate the ideas of moral failings or a lack of will power. • SBIRT proposes a public health approach that doesn’t wait until someone is in medical or legal crisis, rather seeks to identify at-risk users early. • Intervene with a broad population with more diversely trained professionals. • Addiction should be treated like other chronic illnesses. • Substance abuse and addiction is an epidemic effecting communities all over the world, United States, and especially in our local community. • Drug use is on the rise, yet most people report not being asked about their substance usebut report being very willing to answer honestly • Early intervention is key to addressing the addiction epidemic and reducing stigma. Source: Adapted from SBIRT Curriculum

13. Patients Are Open To Discussing Their Substance Use To Help Their Health Source: Miller, P. M., et al. (2006). Alcohol & Alcoholism. Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum (www.sbirtoregon.org)

14. Mental Health & Substance Use Disorders: Co-Occurring Disorders Another important consideration…

15. Adverse Childhood Experiences (ACES) • Childhood experiences, both positive and negative, have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. • Adverse Childhood Experiences have been linked to • risky health behaviors, • chronic health conditions, • low life potential, and • early death • As the number of ACEs increases, so does the risk for these outcomes. CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study https://www.cdc.gov/violenceprevention/acestudy/about_ace.html

16. ACES Effects CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study https://www.cdc.gov/violenceprevention/acestudy/about_ace.html

17. Mental Health & Substance Use Disorders: Co-Occurring Disorders • The existence of both a mental health disorder and a substance use disorder is defined as a co-occurring disorder. • 8.9 million Americans have both a mental disorder and substance use disorder • Only 7.5% of those people enroll in a treatment program SAMHSA’s 2014 National Survey on Drug Use and Health

18. Co-Occurring Disorders • Anyone can be affected by mental and substance use disorders. • They exist on a spectrum and may be common, recurrent, or very serious. • The major of mental disorders are treatable and many people recovery. • 3.6 million (18.1%) Americans ages 18 and up experienced some form of mental illness. • 20.2 million adults (8.4%) have a substance use disorder. SAMHSA’s 2014 National Survey on Drug Use and Health

19. Commonly overlapping MH disorders with SA SAMHSA’s 2014 National Survey on Drug Use and Health

20. Substances Associated with Co-Occurring Disorders SAMHSA’s 2014 National Survey on Drug Use and Health

21. Treatment • Treatment of a co-occurring disorders needs to treat both the substance use and the mental health disorder • Based on the level of substance abuse, substance abuse treatment may be the primary disease treated • For example – detox or sobriety may be necessary before mental health treatment would be effective SAMHSA’s 2014 National Survey on Drug Use and Health

22. What is SBIRT?

23. SBIRT Defined Screening Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated, public health approach, focused on the delivery of early intervention and treatment services. 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. Moderate/High Risk Affirm Low Risk BriefIntervention Follow Up: Risk Reduction Referral to Treatment Source: Adapted from SBIRT Curriculum

24. SBIRT is used to screen EVERYONE*for: moderate to higher levels of risk of developing a substance use disorder. a substance use disorders (SUD). *SBIRT promotes Universal Screening! Source: Adapted from SBIRT Curriculum

25. 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 use. Source: Adapted from SBIRT Curriculum

26. SBIRT is Effective & Widely Used • SBIRT saves lives and money and is consistent with overall support for patient wellness. • Since 2003, SAMHSA has supported SBIRT programs, with more than 1.5 million persons screened. • Outcome data confirm a 40 percent reduction in harmful use of alcohol by those drinking at risky levels and a 55 percent reduction in negative social consequences. Source: SBIRT Curriculum Based on review of SBIRT GPRA data (2003−2011)

27. SBIRTProcess Source: Adapted from SBIRT Curriculum

28. Frequently Asked Questions Q: Why is SBIRT important? A: We hope you will find your own personal reasons for integrating SBIRT into your practice based on the pervasive effects of substance use. Q: Does it require a lot of work/changes? A: There are a few challenges with starting up including getting trained and having materials on hand, but it can be made easy and routine. Q: Will my patients find this annoying? A: No, research indicates that 86% of people reported that they would not be annoyed by their physician asking them questions about use. 93% reported that their doctor should be asking them about use. Source: SBIRT Curriculum

29. Screening

30. Source: Adapted from SBIRT Curriculum

31. Step 1 • Pre-Screen • In the past 6 months, have you used 3 or more drinks containing alcohol on any one day? • In the past 6 months, have you used prescription medication more than prescribed or that was not prescribed to you? • In the past 6 months, have you used drugs other than those required for medical reasons? • In the past 6 months, have you used tobacco (cigarettes or any tobacco use)? • In the past 6 months have you felt down or depressed? • In the past 6 months have you felt anxious or helpless? If yes to any, complete appropriate Brief-Screen. If no, at this time, nothing further is necessary but affirm the client’s positive health decisions. Adapted from SBIRT Curriculum

32. Pre-Screen Common Prescreening Results • In the past 6 months, have you used 3 or more drinks containing alcohol on any one day? • In the past 6 months, have you used prescription medication more than prescribed or that was not prescribed to you? • In the past 6 months, have you used drugs other than those required for medical reasons? Adapted from SBIRT Curriculum

34. Step 2 • Brief-Screen • Alcohol – AUDIT (Alcohol Use Disorders Identification Test) • Prescription Medications and/or Illicit Drugs - DAST (Drug Abuse Screening Test) • For youth up to 21 years of age, you screen using the CRAFFT for either alcohol or drugs. • Tobacco – no brief screen – provide quit line information • Depression – PHQ-9 (Patient Health Questionnaire 9-item) • Anxiety – GAD-7 (Generalized Anxiety Disorder 7-item) Score based on scale instructions & provide brief intervention or refer to necessary services Adapted from SBIRT Curriculum

35. When Screening, It’s Useful To Clarify What One Drink Is! Recommended Limits • Men = 2 drinks per day/14 per week • Women/anyone 65+ = 1 drink per day or 7 drinks per week Binge drinking 5 for men or 4 for women/anyone 65+

36. AUDIT Questionnaire • Ten questions, self administered or via interview; addresses recent alcohol use, alcohol dependence symptoms, and alcohol-related problems • Developed by World Health Organization (WHO) • First 3 questions can be used as a pre-screen. • Remember it is always a good idea to refer to behavioral health care expert when you identify high risk behavior.

37. AUDIT Scoring Scoring the AUDIT: Use the number at the top of the column (0-4) to total the individual’s score. For each item selected assign it the necessary points (from the top column) and total those for the final score. Column 1 responses = 0 points each, column 2 responses = 1 point each, column 3 = 2 points, column 4 = 3 points, and column 5 = 4 points. Severe/Dependent Use (20+) Risky/Harmful Use (16‒19) At-Risk/Moderate Use (8‒15) Abstinent/Low Risk (0‒7)

38. Common Prescription Drug Misused • Opioids: Substance that act on the nervous system. (Ex. morphine, tramadol, oxycodone, hydrocodone, fentanyl, methadone) • Benzodiazepines: Sedative, anxiolytic, or anticonvulsant medications. (Ex. Valium, Xanax, Klonopin) • Stimulants: Psychoactive drugs to improve mental or physical functions (Ex. Ritalin, Concerta, amphetamine, dextroamphetamine, methylphenidate • Sleep aids (zolpidem, zaleplon, eszopicione) • Other assorted including clonidine (sedative), carisoprodol (muscle relaxant), & Neurontin (gabapentin). CDC 2015

39. DAST(10) Questionnaire • Shortened version of DAST 28, containing 10 items, completed as self-report or via interview. • Screening questions for at-risk drug use • Developed by Addiction Research Foundation, now the Center for Addiction and Mental Health • Yields a quantitative index of problems related to drug misuse • Strength: Sensitive screening tool for at-risk drug use • Weakness: Does not include alcohol use • Remember it is always a good idea to refer to behavioral health care expert when you identify high risk behavior.

40. DAST(10) Scoring Score 1 point for each questions answered “yes,” except for question 3, for which “no” receives 1 point. High/Severe Risk (6+) Harmful/Risky Use (3‒5) Hazardous/At-Risk Use (1‒2) Abstinent/Low Risk (0) Yudko et al., 2007

41. CRAFFT (<21 Alcohol & Drug Screen)CRAFFTis a mnemonic acronym of first letters of key words in the six screening questions. The questions should be asked exactly as written. The first 3 questions are considered the pre-screen. • SCORING INSTRUCTIONS: • Each “yes” response in Part B scores 1 point. • A total score of 2 or higher is a positive screen, indicating a need for additional assessment.

42. Mental Health Screening Tools Screen for Depression & Anxiety as potential co-occurring disorders

43. PHQ-9Patient Health Questionnaire 9-item Brief evidence-based screening instrument for depression. Only certified and/or licensed mental health clinicians can diagnose an individual with depression. Use this scale, like others as a tool for intervention. • Remember it is always a good idea to refer to behavioral health care expert when you identify high risk behavior.

44. GAD-7Generalized Anxiety Disorder 7-item Brief evidence-based screening instrument for anxiety. Only certified and/or licensed mental health clinicians can diagnose an individual with anxiety. Use this scale, like others as a tool for intervention. • Remember it is always a good idea to refer to behavioral health care expert when you identify high risk behavior.

45. Suicide Prevention Training If you are interested in receiving detailed training on how to screen and intervene around suicidal behavior or suicidal ideation that training can be made available to you.

46. Key Points for Screening • Screen everyone. • Don’t pre-screen if you are seeing someone who you know is in active addiction. Rather assess for overall use to make referral source or intervention decisions (depending on profession). • Prescreening can be included in another health and wellness survey. • Could be built into Home Care screening procedures or outpatient intake screens • Screen for bothalcohol and drug use including prescription drug abuse and tobacco. • Remember: People may not thinking they are taking prescriptions drugs incorrectly (too many or crushing). • Sharing is common in this community and in Appalachian culture (they mean well). • Explore each substance; many patients use more than one. • Use a validated tool (AUDIT, DAST, CRAFFT) • Follow up positives or "red flags" by assessing details and consequences of use. • Use your MI skills and show nonjudgmental, empathic verbal and nonverbal behaviors during screening. Adapted from SBIRT Curriculum

47. Screening: Summary • Screening is the first step of the SBIRT process and determines the severity and risk level of the client/patient’s substance use. • The result of a screen allows the provider to determine if a brief intervention (reduce risk- top of green/bottom range of orange in diagram below) or referral to treatment (top range of orange/red in diagram below) is the necessary next step.

48. Where Do We Go From Here? Next training is on the Motivational Interviewing skills necessary to conduct a Brief Negotiated Interview (BNI) Adapted from SBIRT Curriculum

49. Questions?

50. Motivational Interviewing Skills Learning the necessary basic skills and techniques from the evidence-based practice of Motivational Interviewing in order to apply them to clients/patients in the next step of SBIRT (Brief Intervention).