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Screening, Brief Intervention and Referral to Treatment (SBIRT). A training for personnel from trauma centers, emergency departments and primary care settings. What is SBIRT?.

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screening brief intervention and referral to treatment sbirt

Screening, Brief Intervention and Referral to Treatment (SBIRT)

A training for personnel from trauma centers, emergency departments and primary care settings

what is sbirt
What is SBIRT?

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services

  • For persons with substance use disorders
  • Those who are at risk of developing these disorders

Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users

Before more severe consequences occur

sbirt core clinical components
SBIRT: Core Clinical Components
  • Screening: Very brief screening that identifies substance related problems
  • Brief Intervention: 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: Referral of those with more serious addictions
slide4

19.7

Any Illicit Drug

14.6

Marijuana

9.0

Any Illicit Drug, not marijuana

6.4

Psychotherapeutics

(non-medical use)

2.4

Cocaine

0.7

Crack

0.5

Ecstasy

0.5

Meth

0.6

Inhalants

0.1

Heroin

0.1

LSD

0

5

10

15

20

Substance Abuse Challenges: 19.7 Million Americans Are Current* Users of Illicit Drugs

(in millions)

*past month users

Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

slide5

Non-Medical Use of Psychotherapeutics

Substance Abuse Challenge:

substance abuse challenge prescription drug sources primarily friends or family
Substance Abuse Challenge:Prescription Drug Sources: Primarily Friends or Family

Sources of OpioidPain Relievers Used Non-Medically

28%

Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006

public health challenge
Public Health Challenge

Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are unaware of the problem or do not feel they need help.

Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

screening in action

Screening in action

Screening

Assessment

screening
Screening

Conducted with large numbersof people to identify the potentialthat a problem exists

Screening is intended to be broad scale and produce false positives

Screening leads to more in-depth assessment and intervention for people identified with a potential problem

benefits of screening
Benefits of screening
  • Provides opportunity for education, early intervention
  • Alerts provider to risks for interactions with medications or other aspects of treatment
  • Offers opportunity to engage patient further
  • Has proved beneficial in reducing high-risk activities for people who are not dependent

(Source: NCETA, 2004)

sbi procedures follow up action depends on score
SBI Procedures:Follow-up Action Depends on Score

Screening Score

Negative Screen

Positive screen

Positive Reinforcement

Moderate Use

Moderate/High Use

Abuse/Dependence

Brief Intervention

Brief Treatment

Referral to Treatment

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 & other drugs
  • Indicates need for further assessment or intervention
  • Has good sensitivity and specificity
menu of screening tools
Menu of Screening Tools
  • BAC/Drug Screen (biological measures)
  • CAGE(4 questions—alcohol only)
  • DAST (10 questions—drugs only)
  • AUDIT(10 questions—alcohol only)
  • AUDIT-C+ (5 questions—both alcohol and drugs—not well studied)
  • ASSIST (8 questions for each substance used— alcohol, drugs and tobacco—LONG)
mi the spirit 1 style
MI - The Spirit (1) : Style
  • Nonjudgmental and collaborative
  • based on client and clinician partnership
  • gently persuasive
  • more supportive than argumentative
  • listens rather than tells
  • communicates respect for and acceptance for clients and their feelings
the 3 tasks of a bi
The 3 Tasks of a BI

F

L

O

W

Avoid Warnings!

Warn

Feedback

Options Explored

Listen & Understand

(that’s it)

how you talk to the patient matters
How you talk to the patient matters

You’re not doing it right if you if you find yourself…

  • Challenging
  • Warning
  • Finger-wagging
  • Moralizing
  • Giving unwanted advice
  • Shaming
  • Labeling
  • Confronting
  • Being Sarcastic
  • Playing expert
the 3 tasks of a bi24
The 3 Tasks of a BI

F

L

O

Feedback

Options Explored

Listen & Understand

the first task feedback
The First Task: Feedback

Give Patient Feedback using:

  • R
  • A
  • N
  • G
  • E
  • Range
  • Anybody knows
  • Normal ranges
  • Give score
  • Elicit reaction
slide26

The First Task: Feedback

Give Patient Feedback: An Example

  • Range: “BAC can range from 0 (sober) to .4 (lethal)”
  • Anybody knows: “.08 defines drunk driving (heavy drinking)”
  • Normal: “Normal drinking is .03-.05
  • Give score: “Your level was …”
  • Elicit reaction: “What do you make of that?”
slide27

The First Task: Feedback

  • •Your job in F is only to deliver the feedback!
  • •Let the patient decide where to go with it.
slide28

The First Task: Feedback

To avoid this…

LET GO!!!

slide29

The First Task: 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 hear to convince you that you’re an alcoholic.
  • I’d just like to give you some information..
  • I’d really like to hear your thoughts about…
  • What you do is up to you.
slide30

The First Task: Feedback

Finding a Hook

  • Ask the client about their concerns
  • Provide non-judgmental feedback/information
  • Watch for signs of discomfort with status quo or interest or ability to change
  • You cannot know the truth; you were not there.
  • Let the patient decide.
  • Just asking the question is helpful.
  • Always ask this question: “What role, if any, do you think alcohol played in your getting injured?
the 3 tasks of a bi31
The 3 Tasks of a BI

F

L

O

Feedback

Options Explored

Listen & Understand

the second task listen and understand33
The Second Task: Listen and Understand
  • Change Talk
  • DESIRE: I want to do it.
  • ABILITY: I can do it.
  • REASON: I can’t afford to lose my job.
  • NEED: I have to do it.
  • COMMITMENT!!! I WILL DO IT.
the second task listen and understand34
The Second Task: Listen and Understand

Listen for the change talk…

Maybe drinking did play a role in what happened

If I wasn’t drinking this would never have happened

It’s not really much fun anymore

I can’t afford to be in this mess again

The last thing I want to do is hurt someone else

I know I can quit because I’ve stopped before

Summarize, so they hear it twice!

the second task listen and understand35
The Second Task: Listen and Understand
  • Dig for change talk…
  • I’d like to hear your opinions about…
  • What are some things that bother you about drinking?
  • What role do you think alcohol played in your injury?
  • How would you like your drinking to be 5 years from now?
the second task listen and understand36
The Second Task: Listen and Understand
  • Tools for Change Talk
  • Pros and Cons
  • Importance & Confidence Scales
  • Readiness Ruler
the second task listen and understand37
The Second Task: Listen and Understand
  • 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….
the second task listen and understand38
The Second Task: Listen and Understand
  • 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

the second task listen and understand39
The Second Task: Listen and Understand

Let’s practice L: Role Playing Listening and Understanding

  • Pros and Cons
  • Importance/Confidence/Readiness Scales
  • Summary
the second task listen and understand40
The Second Task: Listen and Understand

Let’s practice L: Role Playing Listen and understand (Interviewer)

  • Begin with a structuring statement that ends with an open question
  • There is no need to fix or change the interviewee’s opinion
  • Listen empathically: use reflections and open ended questions as much as possible
  • After 10 minutes or so bring the interview to a close by offering a summary
the second task listen and understand41
The Second Task: Listen and Understand

Let’s practice L: Role Playing Listen and Understand (Patient)

  • Pick something that you feel two ways about but would like to change
  • Pick something that you are comfortable sharing but has some meaning for you
  • Say as much or as little as seems natural to you
  • Expect to converse for about ten minutes
the 3 tasks of a bi42
The 3 Tasks of a BI

F

L

O

Feedback

Options Explored

Listen & Understand

the third task options for change
The Third Task: Options for Change

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?

the third task options for change44
The Third Task: Options for Change

Offer a Menu of Options

Manage your drinking (cut down to low-risk limits)

Eliminate your drinking (quit)

Never drink and drive (reduce harm)

Utterly nothing (no change)

Seek help (refer to treatment)

the third task options for change45
The Third Task: Options for Change
  • During MENUS 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?”
the third task options for change46
The Third Task: Options for Change

The Advice Sandwich

Ask permission

Give Advice

Ask for Response

the third task options for change47
The Third Task: Options for Change

When to Give Advice

  • Does the client already know what I have to say?
  • Have I elicited the client’s knowledge regarding this information?
  • Is what I’m about to say going to be helpful to the client (i.e., reduce resistance and/or increase change talk)
the third task options for change48
The Third Task: Options for Change

Giving Advice Without Telling Someone What to Do

  • Ask for Permission explicitly
    • There’s something that concerns me.
    • Would it be ok if I shared my concerns with you?
  • Preface advice with permission to disagree
    • This may or may not be helpful to you
the third task options for change49
The Third Task: Options for Change

Giving Advice Without Telling Someone What to Do

  • Provide Clear Information or Feedback
    • The results of your test suggest that…
    • What happens to some people is that…
    • My recommendation would be that…
  • Elicit their reaction
    • What do you think?
    • What are your thoughts?
the third task options for change50
The Third Task: Options for Change

Closing the Conversation

S E W

  • S
  • E
  • W
  • Summarize patients views (especially the pro)
  • Encourage them to share their views
  • What agreement was reached (repeat it)
putting it all together
Putting it all together

Feedback

Range

Listen and Understand

Pros and Cons

Importance/Confidence/Readiness Scales

Summary

Options Explored

Menu of Options

research on brief treatment
Research on Brief Treatment

Research on effectiveness of brief vs. longer term therapies for a variety of presenting complaints is mixed.

  • Evidence suggests that brief therapies are often as effective.
  • Outcomes depend on clinician skills, comprehensive assessments, and selective criteria for eligibility.
  • Since many clients will not meet its eligibility requirements.
research on brief treatment54
Research on Brief Treatment
  • Brief therapy should notbe considered a standard of care for all populations.
  • Well suited for clients unwilling/unable to expendthe significant personal and financial resources for more intensive, longer term treatments.
  • Individuals who are functioning in society but have patterns of excessive substance may respond well to briefer approaches.
components of effective brief therapy
Components of Effective Brief Therapy
  • Problem focused or solution focused
  • Target the symptom and not what is behind it.
  • Defined goals related to a specific change or behavior.
  • Understandable to both client and clinician.
  • Designed to produce immediate results.
  • Require rapid establishment of a strong working relationship between client and therapist.
components of effective brief therapy56
Components of Effective Brief Therapy
  • Therapeutic style: highly active, empathic, directive.
  • Responsibility for change is placed on the client.
  • Enhance self-efficacy and confidence that change is possible.
  • Termination is discussed from the beginning.
  • Outcomes are measurable.
important internet sites
Important Internet Sites
  • www.uclaisap.org
  • www.psattc.org
  • http://sbirt.samhsa.gov/about.htm
  • http://sbirt.samhsa.gov/trauma.htm
  • http://www.saem.org/SAEMDNN/Portals/0/IGroups/PublicHealth/sbirt2008/SBIRTResourceManual051608.doc