SBIRT in rural Primary Care and referral to Intensive METCBT services in Indian Country

1
SBIRT in rural Primary Care and referral to
Intensive MET/CBT services in Indian Country

• John W. Gastorf, Ph.D., FICPP
• Director, Cherokee Nation Behavioral Health
  Services

2
(No Transcript)
3





Clinics

H
H
IHS Hospitals
H
ß
RTC

H
Cherokee Heights
ß


4
Great Grandmother
Grandmother
Father
Gierere Farm Circa 1920
5
Acknowledgement

• Cook Inlet Tribal Councils Social Services
• 2006 IHS/SAMHSA Conference
• Screening, Brief Intervention, Referral to
  Treatment Within the Native Community

6
Problem

• High Rate of Substance Abuse in the Cherokee
  Nation
• Significant In-direct consequences
• High Recidivism rate
• Current Substance Abuse programs are not holistic
• Need for Evidence-Based practices
• Demand exceeds the capacity to treat

7
SA Visits
8
REFERRAL OUT OF SYSTEM
RESIDENTAL
INTENSIVE OUTPATIENT
INDIVIDUAL OUT PATIENT
MET/CBT PLUS
SCREENING
LEVELS OF TREATMENT
9
CHEROKEE HEIGHTS PROJECT

• Cooperative Effort of BHS, ICW, Marshall
  Services, Community Services, Tribal Court,
  Tribal Services, Help in Crisis, Education,
  Child Services.
• Located in a Cherokee Housing Addition
• Three bedroom Single Family Housing
• Coordinated effort to identify individuals and
  families who are at risk for substance abuse.
  PRIMARY PREVENTION

10
Total Collaborative Structure

• Common Screening tools
• Identical referral forms referral processes
• Shared equipment
• Co-location of staff
• Staff Sharing (No territoriality)
• Shared meeting facilities
• Establishment of Multi-Disciplinary Staffing Team
  (consistent treatment standards)
• Shared budget

11
CLINIC
SCREENING (AUDIT)
REFERRAL
RESIDENTIAL
INDIVIDUAL OUTPT.
RESIDENTIAL
TRADITIONAL or
CHEROKEE HTS.
CHEROKEE HTS.
INTENSIVE OUTPT.
INTENSIVE OUTPT.
MET/CBT Plus
CASE MANAGEMENT
6-12 month FU
12
AUDIT 1

• 10 item screen developed by World Health
  Organization
• High sensitivity valid pan-cultural brief
• Designed for PCP focus on current use
• Hazardous Use (1-2), Dependence (4-6), Harmful
  Use (7-10)
• When was the last time you had 5 or more drinks
  in one evening?

13
Brief Intervention

• Not serious addiction
• Still have some control to cut down without
  professional help
• 1-2 sessions (Modified FRAMES)
• Feedback
• Information
• Advice on Limits
• Establish Goals

14
Structured 12 Week Program

• Week 1- Intake NA-ASI Ssat/AI ASAM
• Weeks 2-3 Motivation Enhancement Therapy
  (Individual)
• Weeks 4-6 Cognitive Behavioral Therapy (Group)
• Weeks 7-12 PLUS (Positive Life Utility Skills -
  Group)
• Problem Solving
• Relationships
• Exercise/Nutrition
• Anger Management
• Cultural Issues
• Summary Session

15
MET/CBT PLUS

• Motivational Enhancement Therapy (development of
  self-refection an internal desire to change)
• Cognitive Behavioral Therapy
  (how to change ones behavior)
• Primary Life Utility Skills
• (how to maintain positive behaviors prevent
  relapse)

16
Motivational Enhancement Therapy

• Express Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy

17
Stages of ChangeProchaska DiClemente
18
Stages of Change
Increase awareness of risks (pro cons)
Elicit reasons for change
Support encourage the positives address relapse
Determination Decision
Help them take steps, encourage early attempts
Best course of action, timeline, id helpers.
19
What is Cognitive Behavioral Therapy?

• A form of psychotherapy that emphasizes the
  important role of thinking
• in how we feel
• and what we do.

20
CBT How Does it Work?

• Elicit thoughts and behaviors
• Examine thoughts and behaviors
• Test thoughts and behaviors
• Challenge thoughts and behaviors
• Modify thoughts and behaviors

21
Successful Treatment Programs

• Emphasize self-reflection regarding ownership of
  decision-making
• Emphasize awareness of how ones behavior impacts
  others
• More contact ( 4 hrs/wk) and longer duration (
  20 hrs/wk)
• Multiple learning sources
• Addressing their entire social needs

22
CASE MANAGEMENT(Individual Family)

• Human Services
• Education/Literacy
• Vo-Rehabilitation
• Medical/Dental
• Legal Aid/Marshall Services
• Career Services
• Family First (Preventative ICW)
• Environmental
• Food Distribution

23
Expected Outcomes

• Increased rates of treatment completion
• Increased abstinence/greater harm-reduction
• Decreased in indirect consequences
• Higher employment rates
• Decreased family trauma
• Re-integration back into the non-drug community

24
(No Transcript)
25
CSAT GPRA Pre-measures

• Drug Use (last 30 days)
• Alcohol 15
• Intoxicated (4 drinks at sitting) 11
• High (4 or less drinks at a sitting) 4
• Illegal drugs 11
• Alcohol Drugs same time 7
• Illegal Drug use
• Cannabis 11 Meth 6 Benzos 6 Pain 3
  Cocaine 2

26

• Living Conditions (last 30 days)
• Home 9
• Institutions 3
• Prison 1
• Treatment Center 2
• Shelter 2
• Streets 1
• Parental rights terminated 3
• Education (highest)
• 8-11th 8
• 12th or more 3

27

• Employment (last 30 days)
• Employed 9 (6FT 3 PT)
• Looking for work 4
• Disabled 2
• Source of Income (last 30 days)
• Wages 8
• Spouse/family 4
• Public Assistance 2
• Non-Legal 1

28

• Criminal Justice System (last 30 days)
• Arrested 4
• Drug related 3
• Awaiting Trial 1
• Social Connection
• Support Groups
• AA 5
• Church 2
• Who do you most turn to in trouble?
• Family 6
• Friends 3
• Clergy 2
• ER Physician 1
• No One 3

29

• Physical Health (last 30 days)
• In-patient hospitalization 2
• Out-patient physician 5
• ER physician 7
• Mental health (last 30 days)
• Serious depression 12
• Serious anxiety 15
• Cognitive problems 4
• Violent Behaviors 9
• Suicidal Behaviors 2
• Domestic only 2 Non-Domestic only 4 both 3

30
CSAT GPRA Measures at 6 weeks

• Drug Use (last 30 days) (Pre)
• Alcohol 12 (15)
• Intoxicated (4 drinks at sitting) 5 (11)
• High (4 or less drinks at a sitting) 7 ( 4)
• Illegal drugs 7 (11)
• Alcohol Drugs same time 7 ( 7)
• Illegal Drug use
• Cannabis 2 Meth 1 Benzos 3 Pain 1 Cocaine
  0

DRAFT
31

• Living Conditions (last 30 days)
• Home 12 ( 9)
• Institutions 0 ( 3) Tx
• Prison 1
• Treatment Center 2
• Shelter 3 ( 2)
• Streets 0 ( 1) HO
• Education (highest)
• Interested in GED 6 (12 needed)

DRAFT
32

• Employment (last 30 days)
• unchanged
• Source of Income (last 30 days)
• unchanged
• Criminal Justice System (last 30 days)
• Arrested 0 (4)
• Drug related 0 (3)
• Awaiting Trial 1 (1)
• deferred pending treatment
• 2 picked up but released without arrest
  (HO)

DRAFT
33

• Social Connection
• Support Groups
• AA 8 (5)
• Church 5 (2)
• Who do you most turn to in trouble?
• Family 5 (6)
• Friends 1 (3)
• Clergy 4 (2)
• ER Physician 0 (1)
• No One 0 (3)
• Group/Therapist 5 ---

DRAFT
34
(No Transcript)