Edward Bernstein MD Judith Bernstein RNC, PhD

1. SBIRT and Public Health Practice: The Peer In-Reach Team Model…bridging the gap between clinical medicine and public health Edward Bernstein MD Judith Bernstein RNC, PhD Dept. of Emergency Medicine Project Assert and the BNI-ART Institute NIAAA Youth Alcohol Prevention Center

2. SBIRT Workshop • Rationale and evidence for SBIRT • The Project ASSERT collaborative model • NIAAA Screening Guidelines • Motivational Interviewing Principles • The basic brief negotiation interview & referral skills • Practice SBIRT with case studies

3. The policy debate • Is addiction a moral failing/crime, best controlled by punishment (jail)? ( drug courts & reclaiming futures) • Is addiction a medical problem/chronic disease, best treated by broad efforts at detection and referral to substance abuse treatment services? • Is addiction a public health problem requiring access to universal or targeted screening, brief interventions and more specialized treatment and a system of comprehensive supports for individuals, families and communities and safeguards for human rights?

4. Treatment Works: NESARC study 2001-02 • 35.9% of U.S. adults with alcohol dependence that began more than one year ago are now in full recovery (18% abstainers, 17% low risk drinkers) • 27% are in partial remission (that is, exhibit some symptoms of alcohol dependence or alcohol abuse) • 12% are asymptomatic highrisk drinkers with no symptoms but whose consumption increases their chances of relapse • 25% with alcohol dependence who began treatment more than one year ago are still dependent

5. Past Year Need for & Receipt of Tx for Illicit Drug/ Alcohol Abuse among Persons Aged 12+: 2002-3

6. Substance abuse resembles other chronic recurrent illnesses: a time for a paradigm shift • <30% of patients with asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes and 50% experience yearly recurrence requiring medical care • as in other chronic diseases, poor adherence and relapse is predicted by low SES, co-morbid psych conditions and lack of family and social supports • substance abuse should be insured, monitored, treated and evaluated like other chronic diseases McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

7. Intersection of Opportunity & Need An Emergency Department Perspective • 7.6 /111 million ED visits are alcohol attributable (McDonald, 2004) • 31% of urban ED pts > 2 CAGE positive (Bernstein, 1996) • 26% of ED patients high risk/dependent (Academic ED SBIRT Collaborative, 2005)

10. SBIRT SCREENING WIDENS THE NET ABUSE & DEPENDENCE (8.5%) ABSTAINERS & MILD DRINKERS (71%) AT-RISK DRINKERS (20%) Specialized Treatment Brief Intervention Primary Prevention

11. Motivational Interviewing(Miller & Rollnick) Translating evidence based practice from psychology literature to the medical setting, using public health principles of evaluation for risk and resilience, community assessment and reliance on community health workers

12. ED BRIEF INTERVENTION: THE FIRST CT • Chafetz et al, 1961 • (n=200) • 65% of those receiving brief intervention in the MGH ED kept a subsequent appointment for specialized treatment compared to 5% of controls. • 40% kept 5 appointments. Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: 390-410.

13. Brief Intervention in the Trauma Center • 1153 (46%) of 2524 screened positive • Intervention n = 366 vs control n = 396 • at 6 months, decreases in both groups (NS) • at 12 months, alcohol consumption 54% f/u • down by 21.9 drinks per week in intervention group • down 6.7 drinks per week in control group • in injuries requiring ED or admission • down 47% in the intervention group vs controls (p=.07) Gentilello, Rivara et al. Ann Surg 1999; 230: 473-483

14. Brief MI for injured drinkers in the ED (n=539) Longabaugh et al. J Stud Alcohol 2001;62:806-816 • AUDIT >8, BAC > 0.03 mg/dl, drinking 6hrs pre-injury • 3 groups: standard care (SC) vs MI vs MI+booster • follow up at one year = 84% • all 3 groups reduced days of heavy drinking • MI+booster had fewer consequences (DrinC) • 2.24 vs 2.4 (MI) and 2.52 (SC) • MI+booster had fewer alcohol-related injuries than SC • 0.456 (SC) vs 0.165 (MI+booster)

15. Project ASSERT: Bringing down the barriers A Model for Brief Intervention in the ED 1993 SAMHSA –CSAT Critical Populations Demonstration Grant Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based intervention to increase access to primary care, preventive services and the substance abuse treatment system. Ann Emerg Med 1997;30:181-189.

16. Established with funding from CSAT in 1993 to empower patients to reduce substance abuse and other harmful health and social behaviors, and facilitate ED patient access to primary care, preventive services and substance abuse treatment.

18. Peer educators provide consultation to nurses and physicians

19. …providing empathy and support

20. …offering resources

21. From CSAT Demonstration Grant to Boston Medical Center ED Budget Line Item…RESULTS FROM PROJECT ASSERT • 17,495 patients received screening and BNI from 2001-2005 • 16,114 total referrals made to SA treatment, AA/NA, social service, behavioral health and primary care. • 5,607 patients sent to detox often by taxi • 1608 beds detox unavailable • 1708 SA outpatient • 1,656 appointments made for primary care

22. Project Link1998 - 2002 A randomized, controlled trial to test the effectiveness of a peer delivered SBIRT in an Urgent Care setting NIDA Notes, November 2005

23. Brief Intervention in the Clinical Setting Reduces Cocaine and Heroin Use Bernstein et al. Drug & Alcohol Dependence, 2004;77:49-59 • 23,669 patients screened • 1175 enrollees (follow-up rate 82%) • among 778 with positive hair at baseline • intervention group more likely to be 30 days abstinent than the control group • cocaine alone (22.3% vs 16.9%) • heroin alone (40.2% vs 30.6%) • both drugs (17.4% v s 12.8%), with adjusted OR of 1.51-1.57 • cocaine levels in hair reduced • 29% for intervention group vs 4% control group

24. THE IMPACT OF ED Provider SBIRT ON PATIENTS’ ALCOHOL USE Funded in part by NIAAA R21 AA015123 and 14 RO3s AA 01511-14 with collaborative funding from SAMHSA

25. Univ. of Michigan. Rhode Island Hospital Yale Univ. Denver Health Medical Cooper Health Univ. of Southern California Univ. of Virginia Charles Drew Univ. Howard Univ. Univ. of California Univ. of New Mexico Emory University Academic Emergency Medicine SBIRT Collaborative New England Med. Boston Medical

26. SBIRT Alcohol Education Project • Exposure to an interactive SBIRT curriculum increased self reported competency, responsibility, & utilization and improve outcomes for patients with alcohol-related problems. • Training effects observed at 3 months persisted but were not completely sustained at 12 months.

27. Patient Response to SBIRT at 3 month F/U Summary • At 3 months, controlling for baseline drinking levels, patients receiving the intervention reported • 3.25 fewer ‘typical number of drinks per week’ than controls (B= -3.25 SE= 1.16, p < .05) • almost ¾ of a drink less for ‘maximum number of drinks per occasion’ than controls (B= -.72 SE= .32, p < .05). • Benefits of brief intervention were confined to those with at-risk drinking rather than dependent drinking patterns, as measured by the CAGE.

28. THE PROBLEM DRINKERsource: photo exhibit, National Gallery

29. Screening Questions • Do you smoke? Do you drink? Do you use drugs? • On average, how many days per week do you drink alcohol ( beer, wine, liquor )? • On a typical day when you drink, how many drinks do you have? • NIAAA Guidelines (risky drinking):>14 drinks/week for men and >7 drinks per week for women • What is the maximum number of drinks you had on any given occasion during the last month? • NIAAA Guidelines: >4 for men & >3 for women

30. Remember that a “standard drink” consists of:

31. THE ED BRIEF NEGOTIATION INTERVIEW A toolkit forenhancing motivation for changein the clinical setting--developed with Stephen Rollnick,1994

32. Effective communication about alcohol and drugs…. ….approaching the drinking driver to facilitate behavior change

33. NEGOTIATING BEHAVIOR CHANGEPrinciples of Good Practice • Respect the autonomy of clients and their choices • Set an agenda for change together • Offer information in a neutral, non-personal manner • Make clear from the start that the client is the active decision maker

34. OTHER PRINCIPLES OF MOTIVATIONAL INTERVIEWING • Ask open-ended questions. • Practice reflective listening to encourage patients to talk about their drinking and the barriers to change. • Accept resistance as a normal response. • Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.

35. NEGOTIATING BEHAVIOR CHANGEPrinciples of Good Practice “Motivational interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change.” Stephen Rollnick, PhD Addiction 2001; 96:1769-70.

36. THE BRIEF NEGOTIATION INTERVIEW • establish rapport & ask permission to raise subject • provide feedback • enhance motivation • explore pros and cons • assess readiness to change and sources of resilience • explore discrepancies between actual state & goals • develop action plan, using strengths/resources • referral to primary care and tx if indicated READY (8 - 10) NOT READY (1 - 3) UNSURE (4 - 7) 1 2 3 4 5 6 7 8 9 10

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38. BNI STEPS 1. Raise subject 2. Provide feedback Review screen Assess connection For alcohol… Show NIAAA guidelines & norms Hello, I am _____. Would you mind taking a few minutes to talk with me about your use of [X]? <<PAUSE and LISTEN>> From what I understand you are using [insert screening data]… We know that drinking above certain levels and/or use of illicit drugs can cause problems, such as [insert medical info]… I am concerned about your use of [X]. What connection (if any) do you see between your use of [X] and this ED visit? If pt sees connection: reiterate what pt has said. If pt does not see connection, suggest one, using medical info. These are what we consider the upper limits of low risk drinking for your age and sex. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines. INTERVENTION ALGORITHM adapted from D’Onofrio, Pantalon and DeGutis

39. 3. Enhance motivation Explore Pros and Cons Use reflective listening Readiness to change Reinforce positives Develop discrepancy between ideal and present self Ask pros and cons. Help me to understand what you enjoy about [X]? <<PAUSE AND LISTEN>> Now tell me what you enjoy less about [X] or regret about your use. <<PAUSE AND LISTEN>> On the one hand you said… <<RESTATE PROS>> On the other hand you said…. <<RESTATE CONS>> So tell me, where does this leave you? [show readiness ruler] On a scale from 1-10, how ready are you to change any aspect of your use of [X]? Ask: Why did you choose that number and not a lower one like a 1 or a 2? How does this fit with where you see yourself in the future?

40. 4. Negotiate & advise Negotiate goal Reinforce resilience /resources Summarize Provide handouts Suggest PC f/u Thank patient What’s the next step? What do you think you can do to stay safe? If you can stay within these limits you will be less likely to experience illness, injury or other harmful effects? What have you succeeded in changing in the past? How? Could you use these methods? This is what I’ve heard you say…Here’s an agreement I would like you to fill out, reinforcing your new goals. This is really an agreement between you and yourself. Provide agreement and information sheet Suggest Primary Care f/u to discuss/support carrying out plan Thank patient for his/her time

41. Applying the algorithm…Getting to ‘yes’ with a high risk drinker Provider: Clara Safi, NP www.ed.bmc.org/sbirt

42. Connecting drinking & Reason for Visit • This is the patient’s chance to name the problem. • If there is resistance or lack of awareness of a connection, the provider can help the patient see the connection. • Listen carefully for the patient’s own concerns to make the link. • Use open ended questions to explore: • What would make this a problem for you? • How might you prevent that from happening? • Have you ever done anything you wished you hadn’t while drinking? • Give feedback empathetically, with no shame or blame.

43. ASSESSING READINESS TO CHANGE On a scale of 1-10, ten meaning ‘most ready’ and one ‘least ready’, please mark on the ruler where you are now on your readiness to change your use of alcohol and/ or drugs? You marked five, which indicates you are fifty percent ready to make a change, so tell me, why didn’t you mark a lower number like a one or two? 1 2 3 4 5 6 7 8 9 10

44. The pros and cons in action…. Provider: Ludy Young, Health Promotion Advocate www.ed.bmc.org/sbirt

45. Exploring the Pros and Cons • exploring the pros and cons can help you understand where the patient is coming from and obstacles to change • pros and cons strategy • ask, “What do you like about your use of [X]?” • acknowledge that you have heard what they say • elicit statements about consequences by asking • “What do you like less or regret about your use?” • repeat and affirm statements that lead to change • summarize briefly: on the one hand you said.., and on the other you said…. • ask, “Where does that leave you?” On a scale of 1-10, how ready are you to make some changes?

46. Provider advice and negotiation with the dependent drinker…. Provider: Gail D’Onofrio, MD www.ed.bmc.org/sbirt

47. THE ROLE OF PROVIDER ADVICE • meet people where they are at • timing is important—the patient should feel heard and respected before the physician weighs in • conversational style matters—advice should be brief, and non-judgmental • advice should be based on fact and weave in medical events

48. IN NEGOTIATING A PLAN, 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?” or • “Have you made other kinds of changes successfully in the past?” • “How did you accomplish these things?”

49. Developing and Using a Referral Network • Provider expectations: setting realistic goals for change in a chronic disease • http://findtreatment.samhsa.gov • www.ed.bmc.org/sbirt

50. BNI-ART Education Faculty • Lisa Allee; MSW, Boston Medical Center • Katherine Brown, Youth Alcohol Prevention Center, Boston University School of Medicine • Dr. James A Feldman, Department of Emergency Medicine , Boston University School of Medicine • Andrea Hall, LISW Boston Medical Center/ BEST Team • Patricia M Mitchell, RN; Department of EM, Boston University School of Medicine • Brenda E Rodriquez, MBA, BNI-ART Institute, BU School of Public Health • Dr. Benjamin Shelton; Chief Resident, Emergency Medicine Residency Program, Boston Medical Center • Luann Sweeney, RN, Boston Medical Center • Ludy Young, Licensed LADC II, Project ASSERT Boston Medical Center