Los Angeles County Department of Mental Health with support from SAMHSA/CSAT Presents: Screening, Brief Intervention, and Referral to Treatment (SBIRT): How to Identify and Motivate for Change Patients with Substance Use Disorders - PowerPoint PPT Presentation

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Los Angeles County Department of Mental Health with support from SAMHSA/CSAT Presents: Screening, Brief Intervention, and Referral to Treatment (SBIRT): How to Identify and Motivate for Change Patients with Substance Use Disorders

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Title: Los Angeles County Department of Mental Health with support from SAMHSA/CSAT Presents: Screening, Brief Intervention, and Referral to Treatment (SBIRT): How to Identify and Motivate for Change Patients with Substance Use Disorders


1
Los Angeles County Department of Mental
Healthwith support from SAMHSA/CSAT
PresentsScreening, Brief Intervention, and
Referral to Treatment (SBIRT) How to Identify
and Motivate for Change Patients with Substance
Use Disorders
2
The ASOC Training Series (draft)
  • On-site SBIRT training at DMH directly operated
    ASOC programs
  • Encourage clinical supervisors and/or SBIRT
    champions to walk through their agency to
    determine implementation issues
  • Follow-up with clinical supervisors/ champions
    via webinar/telehealth network to consult on
    implementation

3
Why SBIRT and Why now?
  • The service population will be increasing
    greatly. Therefore efficiency of service is
    critical
  • ACA is expanding SUD benefit and there will be
    more specialty care services available
  • SBIRT can help to incorporate screening,
    intervention and referral for treatment for
    substance use into the overall clinic redesign
    plan for your clinic
  • Help in engaging in referring people more
    efficiently into appropriate EBPs
  • Screening will help with overall treatment
    planning and treating to target

4
Objectives
  • Describe the background and rationale for
    conducting SBI in medical settings
  • Describe screening procedures for identifying
    patients engaged in at-risk drinking
  • Review brief intervention strategies and
    techniques

5
Consider the patients that you treat
  • What are the characteristics of the ones
  • who are the most difficult?
  • who you see the most often?

6
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, mental
    health clinics and other community settings
    provide opportunities for early intervention with
    at-risk substance users
  • Before more severe consequences occur

7
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

8
SBIRT Goals
  • Increase access to care for persons with
    substance use disorders and those at risk of
    substance use disorders
  • Foster a continuum of care by integrating
    prevention, intervention, and treatment services
  • Improve linkages between mental health services,
    health care services and alcohol/drug treatment
    services

9
Screening in medical settings
  • Substance abuse problems are often unidentified
  • In one study of 241 trauma surgeons, only 29
    reported screening most patients for alcohol
    problems.
  • In a health study of 7,371 primary care patients,
    only 29 of the patients reported being asked
    about their use of alcohol or drugs in the past
    year.

(Sources Danielsson et al., 1999 DAmico et
al., 2005)
10
What is a standard drink?
11
Drinking Guidelines
  • Men No more that 4 drinks on any day and 14
    drinks per week
  • Women No more than 3 drinks on any day and 7
    drinks per week
  • Men and Women gt65 No more than 3 drinks on any
    day and 7 drinks per week

NIAAA, 2011
12
Is it really a problem?
  • Prevalence of problematic alcohol and other drug
    use

13
Public Health Challenge
20.9 Million People Need But Do Not Receive
Treatment For Illicit Drug or Alcohol Use
4.1 Felt they needed treatment and did NOT make
an effort
94.5 Did no feel that they needed treatment
1.4 Felt they needed treatment and DID make an
effort
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).
14
US Population 307,006,550 US Census Bureau,
Population Division July 2009 estimate
NSUDH, 2008
15
  • In treatment (2 Million)
  • Diagnosable problem with substance use
  • Referred to treatment by

Self/Family 37 Criminal Justice 25 Other
SUD Program 8 County Assessment Center
19 Healthcare 3 Other 8
Healthcare 3
Los Angeles County Data
16
  • In need of treatment (21 Million)
  • Reported problems associated with use
  • Not in treatment currently
  • 1.1 Made an effort to get treatment
  • 3.7 Felt they needed treatment, but made no
    effort to get it.
  • 95.2 Did not feel that they needed treatment

17
  • Using at risky levels (60-80 Million)
  • Do not meet diagnostic criteria
  • Level of use indicates risk of developing a
    problems.
  • Some examples

These people need services, but will never
enter the treatment system
18
SBI ProceduresFollow-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
19
Screening, Brief Interventions for Alcohol
Major Impact of SBI on Morbidity and Mortality
Study Results - conclusions Reference
Trauma patients 48 fewer re-injury (18 months) 50 less likely to re-hospitalize Gentilello et al, 1999
Hospital ER screening Reduced DUI arrests 1 DUI arrest prevented for 9 screens Schermer et al, 2006
Physician offices 20 fewer motor vehicle crashes over 48 month follow-up Fleming et al, 2002
Meta-analysis Interventions reduced mortality Cuijpers et al, 2004
Meta-analysis Treatment reduced alcohol, drug use Positive social outcomes substance-related work or academic impairment, physical symptoms (e.g., memory loss, injuries) or legal problems (e.g., driving under the influence) Burke et al, 2003
Meta-analysis Interventions can provide effective public health approach to reducing risky use. Whitlock et al, 2004
20
Screening, Brief Interventions for AlcoholSaves
Healthcare Costs
Study Cost Savings Authors
Randomized trial of brief treatment in the UK Reductions in one-year healthcare costs 2.30 cost savings for each 1.00 spent in intervention (UKATT, 2005)
Project TREAT (Trial for Early Alcohol Treatment) randomized clinical trial Screening, brief counseling in 64 primary care clinics of nondependent alcohol misuse Reductions in future healthcare costs 4.30 cost savings for each 1.00 spent in intervention (48-month follow-up) (Fleming et al, 2003)
Randomized control trial of SBI in a Level I trauma center Alcohol screening and counseling for trauma patients (gt700 patients). Reductions in medical costs 3.81 cost savings for each 1.00 spent in intervention. Gentilello et al, 2005)
21
Screening and Brief Interventions in Healthcare
Settings Work
  • Substance abuse
  • SBI may reduce alcohol and other drug use
    significantly
  • Morbidity and mortality
  • SBI reduces accidents, injuries, trauma,
    emergency dept visits, depression
  • 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 DUI,
    and improve neonatal outcomes, decrease mental
    health symptoms, improve quality of life
  • References provided in subsequent slides

22
SBI Could Have a Major Impact on Public Health
  • There are grounds for thinking SBI may
  • stem progression to dependence.
  • Prevent/improve mental health conditions
    exacerbated by substance abuse.
  • Prevent/improve medical conditions resulting from
    substance abuse or dependence.
  • reduce drug-related infections and infectious
    diseases.
  • improve response to medications.
  • have positive influence on social function.

23
Screening to Identify Patients at risk for
Alcohol Problems
  • How do we conduct the screening?

24
Alcohol Problems Among Trauma Patients
SBIRT
SBIRT
25
Coding for Screening andBrief Intervention
Reimbursement
Payer Code Description Fee Schedule
Commercial Insurance CPT 99408 SBI (15-30 minutes) 33.41
Commercial Insurance CPT 99409 SBI (Greater than 30 minutes) 65.51
Medicare G00396 SBI (15-30 minutes) 29.42
26
Coding for Screening andBrief Intervention
Reimbursement
Payer Code Description Fee Schedule
Medicare G0397 SBI (Greater than 30 minutes) 57.69
Medicaid H0049 Alcohol/drug screening (only) 24.00
Medicaid H0050 SBI (per 15 minutes) 48.00
27
What is screening?
  • A range of evaluation procedures and techniques
    to capture indicators of risk
  • A preliminary assessment that indicates
    probability that a specific condition is present
  • A single event that informs subsequent diagnosis
    and treatment

(Source SAMHSA, 1994)
28
Brief Intervention Effect
  • Brief interventions can trigger change
  • 1 or 2 sessions can yield much greater change
    than no counseling
  • A little counseling can lead to significant
    change
  • Brief interventions can yield outcomes that are
    similar to those of longer treatments

29
The Concept of Motivation
  • Motivation is influenced by the clinicians style
  • Motivation can be modified
  • The clinicians task is to elicit and enhance
    motivation
  • Lack of motivation is a challenge for the
    clinicians therapeutic skills, not a fault for
    which to blame our clients

30
The Concept of Ambivalence
  • Ambivalence is normal
  • Clients usually enter treatment with fluctuating
    and conflicting motivations
  • They want to change and dont want to change
  • Working with ambivalence is working with the
    heart of the problem

31
SoWhat is the best way to ask?
32
Single-Item alcohol screener
  • Primary care setting Validated single item
  • Single item recommended by NIAAA
  • How many times in the past year have you had 5/4
    or more drinks in a single setting?
  • Smith, P., Schmidt, S., Allensworth-Davies, D.,
    Saitz, R. (2009)

33
Single-Item drug screener
  • "How many times in the past year have you used an
    illegal drug or used a prescription medication
    for non-medical reasons?"
  • A response of at least 1 time was considered
    positive for drug use
  • Smith, PC, Schmidt, SM, Allensworth-Davies, D,
    Saitz, R. (2010)

34
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35
Review LAC DMH Assessment
36
(No Transcript)
37
(No Transcript)
38
Conducting the Brief Intervention
39
Example of the Directing Style
40
The 3 Tasks of a BI
F
L
O
W
Warn
Feedback
  • Avoid Warnings!

Options Explored
Listen Understand
(thats it)
41
How does it all fit together?
42
Example of the Guiding Style
43
The 3 Tasks of a BI
F
L
O
Feedback
Options Explored
Listen Understand
44
The First Task Feedback
  • Your job in F is only to deliver the feedback!
  • Let the patient decide where to go with it.
  • Ask for Permission explicitly
  • Theres something that concerns me.
  • Would it be ok if I shared my concerns with you?
  • Provide direct feedback
  • The results of your screening form suggest that

45
SUD
Anxiety
Family
SUD
Pain
Medical Issues
46
Providing Feedback
  • Elicit (ask for permission)
  • Give feedback
  • Elicit again (the persons view of how the advice
    will work for him/her)

47
The 2nd Task Listen Understand
Ambivalence is Normal
48
The Second Task Listen and Understand
  • Change Talk
  • DESIRE I want to do it.
  • ABILITY I can do it.
  • REASON I cant afford to lose my job.
  • NEED I have to do it.
  • COMMITMENT!!! I WILL DO IT.

49
The Second Task Listen and Understand
  • Tools for Change Talk
  • Pros and Cons
  • Importance Confidence Scales
  • Readiness Ruler

50
How to Explore Ambivalence
Avoid questions that inspire a yes/no answer.
Summarize both pros and cons On the one hand
you said.., and on the other you said.
51
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.

52
The Second Task Listen and Understand
  • Importance/Confidence/Readiness
  • On a scale of 110
  • 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 didnt you give it a lower number?
  • What would it take to raise that number?

1 2 3 4 5 6 7
8 9 10
53
SUD
SUD
Physical Problem
Family
Social Isolation
Mental Health
54
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)
55
The Third Task Options for Change
  • The Advice Sandwich

Ask permission Give Advice Ask for Response
56
The Third Task Options for Change
  • When to Give Advice
  • Does the client already know what I have to say?
  • Have I elicited the clients knowledge regarding
    this information?
  • Is what Im about to say going to be helpful to
    the client (i.e., reduce resistance and/or
    increase change talk)

57
Meet Mike
  • Mike, is a 32-year-old with a history of drug
    use and depression. He has a recent DWI charge
    and was in jail for a domestic disturbance. Mike
    has been in and out of various jobs over the past
    few years and his current employment status is
    unclear. He is married and has one child, age 8.
    He lives with his wife and child, but they have a
    troubled relationship and he often leaves home
    for several days at a time. Mike was recently
    hospitalized for a suicide attempt and is now
    receiving mental health services. He was also
    referred to treatment by the court in lieu of
    jail, but he is not happy about it.

58
Activity Role Play
  • Lets practice F - L - O Feedback, Listen,
    Options
  • Using the COD Assessment Form
  • Provide Feedback Focus the conversation
  • Pros and Cons/Decisional Balance
  • Importance/Confidence/Readiness Scales
  • Develop Discrepancy
  • Dig for Change Talk
  • Explore Options and Menus of Change

59
Important Internet Sites
  • www.uclaisap.org/dmhcod
  • 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/Publ
    icHealth/sbirt2008/SBIRTResourceManual051608.doc

60
Thank you for your time!
  • Sherry Larkins, Ph.D.
  • larkins_at_ucla.edu
  • (310) 267-5376Joy Chudzynski, Psy.D.
  • joychud_at_ucla.edu
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