FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
SBIRT in Primary Care Settings
Dr. Ginetta Salvalaggio MSc MD CCFP FCFP
Assistant Professor, University of Alberta Department of Family Medicine
Research Director, Inner City Health and Wellness Program, Edmonton, AB
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Faculty/Presenter Disclosure Faculty: Ginetta Salvalaggio
Relationship with commercial Interest
◦ None
Grant support
◦ Royal Alexandra Hospital Foundation (research lead)
◦ Alberta Innovates Health Solutions (principal investigator)
◦ Coalition Linking Action and Science for Prevention (co-investigator)
Affiliations
◦ Member of the BETTER coalition for chronic disease prevention and screening in primary care
◦ Member of the Alberta Research Network of the AHS Addiction and Mental Health Strategic Clinical Network
◦ Provincial SBIR champion as nominated by the ACFP, in partnership with the CFPC and the Canadian Centre on Substance Abuse
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Disclosure of Commercial Support
This session has not received financial support
This session has not received in-kind support
Potential for Conflicts of Interest:
◦ Dr. Salvalaggio has received research funding from Alberta Innovates—
Health Solutions to develop, implement, and evaluate SBIRT knowledge
translation resources
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Mitigating Potential Bias
Session content is derived from a comprehensive review of
the relevant literature
Recommendations are based on best available evidence
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Objectives
Learn how to screen for problematic alcohol and drug use in
various clinical settings
Learn how to discuss problematic use in a patient-centered
fashion and negotiate common goals using Brief Intervention
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
What is SBIRT?
Screening, Brief Intervention, and Referral to Treatment A public health measure that uses brief screening tools to identify those at risk
of developing alcohol or substance use disorders, accompanied by brief
counseling derived from motivational interviewing, and if needed, referral to
more intensive treatment
A three-step strategy that can be as brief as a few questions and some
feedback, or it can involve a more structured approach
A well validated approach to decrease overall alcohol consumption and
increase addiction treatment uptake and retention
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
SBIRT: Where?
Primary care office: solo, group or multidisciplinary practices
Emergency Department
Hospital Based Clinics
Jail medical departments
Community based clinics, drop-ins
Nursing stations
Prenatal care settings
Primary care settings provide an excellent opportunity for
screening and intervention
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
SBIRT: When?
Incorporated into preventive care
◦ Periodic health exam
◦ Pregnancy
◦ EMR reminder systems
Opportunistic screening
◦ Conditions where substances may play a role
◦ Poor response to treatment
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Canadian resources for SBIRT
www.sbir-diba.ca
Canada’s Low-Risk Alcohol Drinking Guidelines
A Clinical Guide: Alcohol Screening, Brief Intervention and Referral
http://knowledgex.camh.net/primary_care/toolkits/addictio
n_toolkit/pages/default.aspx
Practical tools for using SBIRT in the clinical setting
www.knowmo.ca
Knowledge mobilization website about addictions and mental health in
Alberta
Home page> Toward Patient Centered Addiction Care
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Where do I start? Screening….
"How many times in the past year have you had X or more
drinks in a day?" (where X is 5 for men and 4 for women)
“How many times in the past year have you used an illegal
drug or used a prescription medication for nonmedical
reasons?”
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Screening: one step further
AUDIT
CAGE
TICS
TACE / TWEAK in pregnancy
CRAFFT in adolescence
If the screen is positive: further questions
◦ Quantity: regular use, weekly amounts, maximum amount consumed in the past
month
◦ Consequences: medical, financial, social, legal
◦ Evidence of withdrawal, tolerance, use despite harm
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Now what? Brief Intervention
Negative screen: • Acknowledge healthy decisions
• Feedback on health effects of low risk drinking and drug use abstinence
Positive screen: FRAMES • Feedback: Give feedback on the risks
and negative consequences of alcohol and substance use. Seek the client's reaction and listen
• Responsibility: Emphasize that the individual is responsible for making his or her own decision about his/her alcohol or drug use
• Advice: Give straightforward advice on modifying alcohol and drug use
• Menu of options: Give menus of options to choose from, fostering the client’s involvement in decision-making
• Empathy: Be empathic, respectful, and non-judgmental
• Self-efficacy: Express optimism that the individual can modify his or her alcohol or substance use if they choose
Miller WR, Sanchez VC. Motivating young adults for treatment and lifestyle change. In G. Howard (ed.), Issues in Alcohol Use and Misuse in Young Adults. Notre Dame, IN: University of Notre Dame Press;1999.
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Assessing Readiness to Change
Readiness to change scale
Confidence to change scale
Prochaska & DiClemente. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice 1982:19,276-88
“On a scale from 0 to 10, where 0 is not at all ready and 10 is very ready, how ready are you to ______ your marijuana use right now?”
“Wow, so you are_______% ready, great”
0 1 2 3 4 5 6 7 8 9 10
Not at all Very
Ready Ready
15
“On a scale from 0 to 10, where 0 is not at all confident and 10 is very confident, how confident are you right now that you can meet your goal of ________ ?”
“What might take you from a ___to a____in your confidence?”
0 1 2 3 4 5 6 7 8 9 10
Not at all Very
Confident Confident
16
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Matching Brief Intervention to the Stage
of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Raise doubt- increase the patient’s perception of
the risks and problems with current behavior
Tip the balance- evoke reasons to change, risks of
not changing; strengthen the patient’s self efficacy
to change
Help the patient to determine the best course of
action to take in seeking change
Help the patient to take steps toward change
Help the patient to identify and use strategies
to prevent relapse
Support the patient through renewal
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Brief Intervention In Action
http://www.youtube.com/watch?v=1KNEKZu7PUY
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Referral to Treatment Outpatient treatment:
• Multidisciplinary team members
• Community addiction agencies
• 12 Step meetings
• Addiction Medicine consultation
• Pharmacotherapy
Intensive or Inpatient treatment:
• Day programs
• Inpatient programs
Web based resources
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
Engaging Your Patients
Asking permission
Thanking patient for disclosure
Consistent and comprehensive assessment
Partnership in care
Harm reduction basic principles
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
SBIRT Implementation
Barriers
◦ Time
◦ Complexity
◦ Remuneration
◦ Documentation
◦ Resources
◦ Follow-up
Facilitators
◦ Multidisciplinary team
◦ Understand your billing
codes
◦ EMR-embedded tools
FUNDAMENTALS COURSE
CSAM 2014 – OTTAWA
SBIRT: lots more questions……
Non-alcoholic substances
Non-primary care settings
Implementation strategies
Thank you!