SBIRT and Public Health Practice: The Peer InReach Team Model bridging the gap between clinical medi

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SBIRT and Public Health Practice The Peer
In-Reach Team Modelbridging 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
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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

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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?

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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 high risk 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

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Past Year Need for Receipt of Tx for Illicit
Drug/ Alcohol Abuse among Persons Aged 12
2002-3
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Substance abuse resembles other chronic recurrent
illnesses a time for a paradigm shift

• lt30 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
2841689-1695.
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Intersection of Opportunity Need An
Emergency Department Perspective

• 7.6 /111 million ED visits are alcohol
  attributable (McDonald, 2004)
• 31 of urban ED pts gt 2 CAGE positive
  (Bernstein, 1996)
• 26 of ED patients high risk/dependent
  (Academic ED
  SBIRT Collaborative, 2005)

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

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ED BRIEF INTERVENTION THE FIRST CT

• Chafetz et al, 1961
• (n200)
• 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.
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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

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Brief MI for injured drinkers in the ED (n539)
Longabaugh et al. J Stud Alcohol 200162806-816

• AUDIT gt8, BAC gt 0.03 mg/dl, drinking 6hrs
  pre-injury
• 3 groups standard care (SC) vs MI vs MIbooster
• follow up at one year 84
• all 3 groups reduced days of heavy drinking
• MIbooster had fewer consequences (DrinC)
• 2.24 vs 2.4 (MI) and 2.52 (SC)
• MIbooster had fewer alcohol-related injuries
  than SC
• 0.456 (SC) vs 0.165 (MIbooster)

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• 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 199730181-189.

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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.
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Peer educators provide consultation to nurses and
physicians
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providing empathy and support
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offering resources
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From CSAT Demonstration Grant to Boston Medical
Center ED Budget Line ItemRESULTS 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

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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

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Brief Intervention in the Clinical Setting
Reduces Cocaine and Heroin Use Bernstein et al.
Drug Alcohol Dependence, 20047749-59

• 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

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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

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Academic Emergency Medicine SBIRT Collaborative
New England Med.
Boston Medical
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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.

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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 lt .05)
• almost ¾ of a drink less for maximum number of
  drinks per occasion than controls (B -.72 SE
  .32, p lt .05).
• Benefits of brief intervention were confined to
  those with at-risk drinking rather than dependent
  drinking patterns, as measured by the CAGE.

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THE PROBLEM DRINKERsource photo exhibit,
National Gallery
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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)gt14 drinks/week
  for men and gt7 drinks per week for women
• What is the maximum number of drinks you had on
  any given occasion during the last month?
• NIAAA Guidelines gt4 for men gt3 for women

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Remember that a standard drink consists of
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THE ED BRIEF NEGOTIATION INTERVIEW A
toolkit for enhancing motivation for changein
the clinical setting--developed with Stephen
Rollnick,1994
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Effective communication about alcohol and drugs.

• .approaching the drinking driver to facilitate
  behavior change

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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

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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.

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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
961769-70.
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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)
UNSURE (4 - 7)
NOT READY (1 - 3)
1 2 3 4
5 6 7
8 9 10
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INTERVENTION ALGORITHM adapted from DOnofrio,
Pantalon and DeGutis

• Hello, I am _____. Would you mind taking a few
  minutes to talk with me about your use of X?
  
• ltltPAUSE and LISTENgtgt
• 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.

• BNI STEPS
• 1. Raise subject
• 2. Provide feedback
• Review screen
• Assess connection
• For alcohol
• Show NIAAA guidelines norms

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• 3. Enhance motivation
• Explore Pros and Cons
• Use reflective listening
• Readiness to change
• Reinforce positives

• Ask pros and cons. Help me to understand what you
  enjoy about X?
• ltltPAUSE AND LISTENgtgt
• Now tell me what you enjoy less about X or
  regret about your use.
• ltltPAUSE AND LISTENgtgt
• On the one hand you said
• ltltRESTATE PROSgtgt
• On the other hand you said.
• ltltRESTATE CONSgtgt
• 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?

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• Whats 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 Ive heard you sayHeres 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

• 4. Negotiate advise
• Negotiate goal
• Reinforce resilience /resources
• Summarize
• Provide handouts
• Suggest PC f/u

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Applying the algorithmGetting to yes with a
high risk drinker

• Provider Clara Safi, NP
• www.ed.bmc.org/sbirt

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Connecting drinking Reason for Visit

• This is the patients 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 patients 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 hadnt
  while drinking?
• Give feedback empathetically, with no shame or
  blame.

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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
didnt you mark a lower number like a one or two?
1 2 3 4
5 6 7 8
9 10
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The pros and cons in action.

• Provider Ludy Young, Health Promotion Advocate
• www.ed.bmc.org/sbirt

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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?

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Provider advice and negotiation with the
dependent drinker.

• Provider Gail DOnofrio, MD
• www.ed.bmc.org/sbirt

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THE ROLE OF PROVIDER ADVICE

• meet people where they are at
• timing is importantthe patient should feel heard
  and respected before the physician weighs in
• conversational style mattersadvice should be
  brief, and non-judgmental
• advice should be based on fact and weave in
  medical events

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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?

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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

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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