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Screening, Brief Intervention, and Referral to Treatment (SBIRT). Training Overview. Our goal for this training is to instruct providers in specific SBIRT procedures and to develop participants’ skills to deliver SBIRT in their practices. . Resources. Activities. Outcomes. Participants

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Presentation Transcript
training overview
Training Overview

Our goal for this training is to instruct providers in specific SBIRT procedures and to develop participants’ skills to deliver SBIRT in their practices.

Resources

Activities

Outcomes

  • Participants
  • Educational materials from ATTCs and other centers
  • Trainers
  • Didactic learning
  • Role plays
  • Group discussions
  • Brief assessment
  • Links to additional training
  • Develop skills to deliver SBIRT
  • Discuss implementation challenges and possible solutions
  • Integrate SBIRT in practice (long-term outcome)
pre test
Pre-test

Please complete the pre-test.

Thank you!!

slide4
This course will teach you how to:

Administer screening

Deliver a brief intervention

Employ a motivational approach

Make referrals to specialized treatment

activity 1 reflection
Activity 1: Reflection

Take some time to think about the most difficult change that you had to make in your life.

How much time did it take you to move from considering that change to actually taking action?

sbirt review of key terms
SBIRT: Review of Key Terms

Screening: Very brief set of questions that identifies risk of substance use related problems.

Brief Intervention: Brief counseling that 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: Procedures to help patients access specialized care.

benefits of sbirt
Benefits of SBIRT

Substance abuse

SBI may reduce alcohol and drug use significantly

Morbidity and mortality

SBI reduces accidents, injuries, trauma, emergency departmentvisits, depression, drug-related infections and infectious diseases

Health care costs

Studies have indicated that SBI for alcohol saves $2 - $4 for each $1.00 expended

Other outcomes

SBI may reduce work-impairment, reduce DUIs, and improve neonatal outcomes

benefits of sbirt for practice
Benefits of SBIRT for Practice

Increases clinicians’ awareness of substance use issues.

Offers clinicians more systematic approach to addressing substance use (less of a “judgment call”).

slide9

Benefits of SBIRT for Practice

“I had a vague idea on how to assess substance use, but now I think I have a lot more knowledge in these other areas. I know what to look for and it is a way to give me a gauge to see if the person is at risk and how to approach them [about that risk].”

Mental health clinician, UCLA Counseling and Psychological Services

the key to successful interventions
The Key to Successful Interventions

Brief interventions are successful when clinicians relate patients’ risky substance use to improvement in patients’ overall health and wellbeing.

the key to successful interventions1
The Key to Successful Interventions

“I just kind of relate it by saying…there’s just a big connection with mood and substance use, so I talk about that more as they could be someone who is anxious and they’re drinking or smoking pot. The drug use could be intensifying as a problem even if they are not identifying their use as a problem. So just pointing that out to them in a motivational interviewing way by saying, why don’t you track this and see what’s happening with your depression. And it just opens another way of talking about it. Sometimes you can see them glaze over and think, ‘‘Oh here we go with the alcohol and drug part.’’ But when you start linking it with mood and anxiety then they are like ‘Oh OK’.”

Mental health clinician, UCLA Counseling and Psychological Services

candidates for routine screening
Candidates for Routine Screening

College students

Primary care patients

Mental health patients

Patients in infectious disease clinics

People with alcohol- or drug-related legal offenses (e.g., DUI)

activity 2 adoption of sbirt
Activity 2: Adoption of SBIRT

Can SBIRT work in your setting?

types of screening t ools
Types of Screening Tools

Self-report

Interview

Self-administered questionnaires

Biological markers

Breathalyzer testing

Blood alcohol levels

Saliva or urine testing

Serum drug testing

See reference list

characteristics of a good screening tool
Characteristics of a Good Screening Tool

Brief (10 or fewer questions)

Flexible

Easy to administer, easy for patient

Addresses alcohol and other drugs

Indicates need for further assessment or intervention

Has good “sensitivity” and “specificity”

benefits of self report t ools
Benefits of Self-Report Tools

Provide historical picture

Inexpensive

Non-invasive

Highly sensitive for detecting potential problems or dependence

how do we define risk
How do we define risk?

See reference list

pre screening
Pre-screening

Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief intervention.

Self-report, 1-4 questions

Biological, blood alcohol level test

pre screening example
Pre-screening Example

NIAAA 1-item for alcohol use

“How many times in the past year have you had X or more drinks in a day?”

  • Identifies unhealthy alcohol use
  • Positive screen = 1 or more (provide BI)

5 for men

4 for women

See reference list

pre screening example1
Pre-screening Example

NIDA 1-item for illicit drug use

"How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”

Identifies overall drug use

Positive screen = 1 or more

See reference list

sbi decision tree

Alcohol:

Women = 0 – 2

Men = 0 – 4

Alcohol:

Women = 4+

Men = 5+

Other Drugs:

Any Yes

Other Drugs:

All Nos

Alcohol Screen Complete

Other Drug

Screen Complete

Administer the AUDIT

Administer the DAST

Mod/High Risk:

Alcohol = 16 – 19

Other drugs = 3 – 5

Low/No Risk:

Alcohol = 0 – 7

Other drugs = 0

At Risk:

Alcohol = 8 – 15

Other drugs = 1 – 2

High/Severe Risk:

Alcohol = 20 – 40

Other drugs = 6 – 10

Reinforce behavior;

Monitor

Brief Intervention

Goal: Lower Risk; Reduce use to acceptable levels

BI/Referral to tx/BT

Goal: Encourage pt. to accept a referral to tx, or engage in BT

Referral to tx.

Goal: Encourage pt. to accept referral to tx, or engage in BT

SBI Decision Tree

Complete Pre-Screen

review of the alcohol use disorders identification test audit
Review of the Alcohol Use Disorders Identification Test (AUDIT)

10-question alcohol use screening instrument

Target groups include:

Medical patients

Accident victims

DWI offenders

Mental health clients

Designed for primary health care workers

domains of the audit
Domains of the AUDIT

Hazardous Alcohol Use

Question 1: Frequency of Drinking

Question 2: Typical quantity

Question 3: Frequency of heavy drinking

domains of the audit cont
Domains of the AUDIT (cont.)

Dependence Symptoms

Question 4: Impaired control over drinking

Question 5: Failure to meet expectations because of drinking

Question 6: Morning drinking

domains of the audit cont1
Domains of the AUDIT (cont.)

Harmful Consequences of Alcohol Use

Question 7: Guilt after drinking

Question 8: Blackouts

Question 9: Alcohol-related injuries

Question 10: Others’ concerns about drinking

activity 3 audit practice
Activity #3: AUDIT Practice

I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients.

Your responses will be confidential.

These questions help me to provide the best possible care.

You do not have to answer them if you are uncomfortable.

See reference list

activity 3 audit practice1
Activity #3: AUDIT Practice

Feedback? Reactions?

enhancing accuracy of self report
Enhancing Accuracy of Self-Report

Self-reports are more accurate when people are:

Alcohol- or drug-free when interviewed

Told that their information is confidential

Asked clearly worded, objective questions

Provided memory aides (calendars, response cards)

See reference list

sbi decision tree1

Alcohol Screen Complete

Other Drug

Screen Complete

Administer the AUDIT

Administer the DAST-10

Mod/High Risk:

Alcohol = 16 – 19

Other drugs = 3 – 5

Low/No Risk:

Alcohol = 0 – 7

Other drugs = 0

At Risk:

Alcohol = 8 – 15

Other drugs = 1 – 2

High/Severe Risk:

Alcohol = 20 – 40

Other drugs = 6 – 10

Reinforce behavior;

Monitor

Brief Intervention

Goal: Lower Risk; Reduce use to acceptable levels

BI/Referral to tx/BT

Goal: Encourage pt. to accept a referral to tx, or engage in BT

Referral to tx.

Goal: Encourage pt. to accept referral to tx, or engage in BT

SBI Decision Tree
what are brief interventions
What Are Brief Interventions?

“Brief opportunistic interventions are short, face-to-face conversations regarding drinking, motivation to change, and options for change which are provided during a window of opportunity or potentially teachable moment occasioned by a medical event.”

See reference list

goal of brief interventions
Goal of Brief Interventions

Awareness of Problem

Motivation

Behavior Change

Presenting problem

Screening results

brief intervention effect
Brief Intervention Effect

Brief interventions trigger change.

A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min.

Research is less extensive for illicit drugs, but promising.

A randomized study with cocaine and heroin users found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls.

See reference list

four bi model options
Four BI Model Options

FLO (Feedback, Listen and understand, Options explored)

4 Steps of the BNI (Raise the Subject; Provide Feedback; Enhance Motivation; Negotiate and Advise)

Brief Negotiated Interview (BNI) Algorithm (Build Rapport; Pros and Cons; Information and Feedback; Readiness Ruler; Action Plan)

FRAMES (Feedback; Responsibility; Advice; Menu of options; Empathy; Self efficacy)

where do i start
Where Do I Start?

What you dodepends on where the patient is in the process of changing.

The first step is to be able to identify where the patient is coming from.

slide43

1. Precontemplation

Definition:

Not yet considering change or

is unwilling or unable to change.

Primary Task:

Raising Awareness

6. Recurrence

Definition:

Experienced a recurrence

of the symptoms.

Primary Task:

Cope with consequences and

determine what to do next

2. Contemplation

Definition:

Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:

Resolving ambivalence/

Helping to choose change

Stages of Change:Primary Tasks

5. Maintenance

Definition:

Has achieved the goals and is

working to maintain change.

Primary Task:

Develop new skills for

maintaining recovery

3. Determination

Definition:

Committed to changing.

Still considering what to do.

Primary Task:

Help identify appropriate

change strategies

4. Action

Definition:

Taking steps toward change but

hasn’t stabilized in the process.

Primary Task:

Help implement change strategies

and learn to eliminate

potential relapses

slide44

1. Pre-contemplation

2.

Contemplation

3.

Determination

4.

Action

5.

Maintenance

6.

Recurrence

slide45
“People are better persuaded by the reasons they themselves discovered than those that come into the minds of others”Blaise Pascal
ambivalence
Ambivalence

All change contains an element of ambivalence.

We “want to change and don’t want to change”

Patients’ ambivalence about change is the “meat” of the brief intervention.

motivational interviewing strategies
Motivational Interviewing Strategies

Use reflective listening and empathy

Avoid confrontation

Explore ambivalence

Elicit “change talk”

activity 4 video example 1
Activity 4: Video Example (1)

Young man is treated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video?

See reference list

activity 5 video e xample 2
Activity 5: Video Example (2)

Same scenario, but different doctor. What does this doctor do that is different? Does it work?

See reference list

reflective listening
Reflective Listening

Listen to both what the patient says and to what the person means

Show empathy and don’t judge what patient says

You do not have to agree

Be aware of intonation

Reflect what patient says with statement not a question, e.g., “You couldn’t get up for work in the morning.”

slide51

Levels of Reflection

Repeating – Repeating what was just said.

Rephrasing – Substituting a few words that may slightly change the emphasis.

Paraphrasing – Major restatement of what the person said. Listener infers meaning of what was said. Can be thought of as continuing the thought.

Reflecting Feeling – Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

activity 6 reflective listening
Activity 6: Reflective Listening

What change are you wanting to make?

What makes you want to change?

What are the good things about making this change? Not-so-good things?

avoid confrontation
Avoid Confrontation
  • Challenging
    • “What do you think you are doing?”
  • Warning
    • “You will damage your liver if you don’t stop drinking.”
  • Finger-wagging
    • “If you want to be a good student, you must stop drinking on school nights.”
explore ambivalence
Explore Ambivalence

Benefits of using drugs

Costs of change

Benefits of change

Costs of using drugs

how to explore ambivalence
How to Explore Ambivalence

Avoid questions that inspire a yes/no answer.

elicit change talk
Elicit “Change Talk”
  • Change talk consists of self-motivational statements that suggest:
  • Recognition of a problem
  • Concern about staying the same
  • Intention to change
  • Optimism about change
slide57

Conducting a BriefIntervenion: The 4 Steps of a BNI

1) Raise The Subject

2) Provide Feedback

3) Enhance Motivation

4) Negotiate And Advise

See Reference List

step 1 raise the subject
Step 1: Raise the Subject

Key Components

Be respectful

Ask permission to discuss use

Avoid arguing or being confrontational

Key Objectives

Establish rapport

Raise the subject

step 2 provide feedback
Step 2: Provide Feedback

What you need to cover.

1. Ask permission; explain how the screen is scored

2. Range of scores and context

3. Screening results

4. Interpretation of results (e.g., risk level)

5. Substance use norms in population

6. Patient feedback about results

feedback
Feedback

What do you say?

Range of score and context - Scores on the AUDIT range from 0-40. Most people who are social drinkers score less than 8.

Results - Your score was 18 on the alcohol screen.

Interpretation of results - 18 puts you in the high risk range. At this level, your use is putting you at risk for a variety of health issues and other negative consequences.

Norms - A score of 18 means that your drinking is higher than 70% of the U.S. adult population.

Patient reaction/feedback - What do you make of this?

the feedback sandwich
The Feedback Sandwich

Ask Permission

Give Feedback

Ask for Response

feedback1
Feedback

Handling Resistance

Look, I don’t have a drug problem.

My dad was an alcoholic; I’m not like him.

I can quit using anytime I want to.

I just like the taste.

Everybody drinks.

What would you say?

feedback2
Feedback

To avoid this…

LET GO!!!

feedback3
Feedback

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 have a problem/are an alcoholic.

I’d just like to give you some information.

I’d really like to hear your thoughts about…

What you decide to do is up to you.

slide65

SUD

Chronic Pain

Pain

Family

SUD

Con-fusion

Medical Issues

feedback4
Feedback

Finding a Hook

Ask the patient about their concerns

Provide non-judgmental feedback/information

Watch for signs of discomfort with status quo or interest or ability to change

Always ask this question: “What role, if any, do you think alcohol played in your (getting injured)?

Let the patient decide.

Just asking the question is helpful.

role play
Role Play

Lets practice Feedback:

Give Feedback Using Completed Screening Tools

Establish rapport

Raise the subject

Give feedback results

Express concern

Substance use norms in population

Elicit patient feedback about the feedback

step 3 enhancing motivation
Step 3: Enhancing Motivation

Critical components:

Develop discrepancy

Reflective listening

Open-ended questions

Assess readiness to change

slide70

Enhancing Motivation

Ambivalence is Normal

enhance motivation
Enhance Motivation

Importance/Confidence/Readiness

On a scale of 1–10:

How important is it for you to change your drinking?

How confident are you that you can change your drinking?

How ready are you to change your drinking?

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

  • See reference list
enhance motivation1
Enhance Motivation

Strategies for Weighing the Pros and Cons

What do you like about drinking?

What do you see as the downside of drinking?

What else?

Summarize Both Pros and Cons

“On the one hand you said..,

and on the other you said….”

dig for change talk
Dig for Change Talk

I’d like to hear you opinions about…

What might you enjoy about…

If you decided to ____ how would you do it?

What are some things that bother you about using?

What role do you think ____ played in your ______?

How would you like your drinking/using to be 5 years from now?

What do you need to do in order to_____?

listen to understand dilemma don t give advice
Listen to Understand Dilemma. Don't Give Advice.

Ask:

Why do you want to make this change?

What abilities do you have that make it possible to make this change if you decided to do so?

Why do you think you should make this change?

What are the 3 best reasons for you to do it?

Give short summary/reflection of speaker’s motivation for change

Then ask: “So what do you think you’ll do?”

slide75

Role Play

Let’s practice Enhance Motivation:

Using Completed Screening Tool

Importance/Confidence/Readiness Scales

Pros and Cons

Develop Discrepancy

Dig for Change Talk

Summarize

slide76

Step 4: Negotiate and Advise

Critical components:

Negotiate a plan on how to cut back and/or reduce harm

Direct advice

Provide patient health information

Follow-up

negotiate and advise
Negotiate and Advise

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?

negotiate and advise1
Negotiate and Advise

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

negotiate and advise2
Negotiate and Advise

Offer a Menu of Options

Manage drinking/use (cut down to low-risk limits)

Eliminate your drinking/drug use (quit)

Never drink and drive (reduce harm)

Utterly nothing (no change)

Seek help (refer to treatment)

See reference list

negotiate and advise3
Negotiate and Advise

Giving Advice Without Telling Someone What to Do

Provide Clear Information (Advice or Feedback )

What happens to some people is that…

My recommendation would be that…

Elicit their reaction

What do you think?

What are your thoughts?

negotiate and advise4
Negotiate and Advise

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

negotiate and advise5
Negotiate and Advise

Closing the Conversation (“SEW”)

Summarize patients views (especially the pro)

Encourage them to share their views

What agreement was reached (repeat it)

role play1
Role Play

Let’s practice Negotiate and Advise

Ask about next steps, offer menu of options

Offer advice

Summarize patient’s views

Repeat what patient agrees to do

role play put t ing it all together
Role Play: Putting It All Together

Raise The Subject

Establish rapport

Raise the subject

Provide Feedback

Provide screening results

Relate to norms

Get their reaction

Enhance Motivation

Assess readiness

Develop discrepancy

Dig for Change

Negotiate and Advise

Menu of Options

Offer advise

encourage follow up v isits
Encourage Follow-Up Visits

At follow-up visit:

Inquire about use

Review goals and progress

Reinforce and motivate

Review tips for progress

See reference list

slide86

Enhancing Motivation for Change Inservice Training

Based Treatment Improvement Protocol (TIP) 35

Published by the Center for Substance Abuse Treatment

www.samhsa.gov

See reference list

referral to treatment
Referral to Treatment

Approximately 5% of patients screened will require referral to substance use evaluation and treatment.

A patient may be appropriate for referral when:

Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use.

These high risk patients will receive a brief intervention followed by referral.

See reference list

warm hand off approach to referrals
“Warm hand-off” Approach to Referrals

Describe treatment options to patients based on available services

Develop relationships between health centers, who do screening, and local treatment centers

Facilitate hand-off by:

Calling to make appointment for patient/student

Providing directions and clinic hours to patient/student

Coordinating transportation when needed

final activity wrap up
Final Activity : Wrap-Up

What I learned…

What I’d like to work on next…

thank you
Thank You!!!

Thank you for your participation!

For additional information on SBIRT or other training topics, visit:

www.attcnetwork.org

www.worldofsbirt.wordpress.com