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
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
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
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
Consider the patients that you treat
What are the characteristics of the ones •…who are the most difficult?•…who you see the most often?
What is SBIRT?
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment servicesFor persons with substance use disordersThose 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
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
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
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.*
(Sources: *Danielsson et al., 1999; **D’Amico et al., 2005)
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.**
What is a standard drink?
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 >65: No more than 3 drinks on any day and 7 drinks per week NIAAA, 2011
Drinking Guidelines
285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 3.5 oz 1.5 oz
Is it really a problem?
Prevalence of problematic alcohol and other drug use
2M people (0.8%) receiving treatment*
21M people (7%) have problems needing treatment, but not receiving it*
≈ 60-80M people (≈20-25%) using at risky levels
US Population:307,006,550
US Census Bureau, Population DivisionJuly 2009 estimate
*NSUDH, 2008
In treatment (2 Million)
• Diagnosable problem with substance use• Referred to treatment by:*
*Los Angeles County Data
Self/Family 37%
Criminal Justice 25%
Other SUD Program 8%
County Assessment Center 19%
Healthcare 3%
Other 8%
Healthcare 3%
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
Using at risky levels (60-80 Million)
• Do not meet diagnostic criteria• Level of use indicates risk of developing
a problems.• Some examples…
Drinks 3-4 glasses of wine a few times per weekPregnant woman occasionally has a shot of vodka to relieve stressAdolescent smokes marijuana with his friends on weekendsOccasionally takes one or two extra vicodin to help with pain
These people need services,
but will never enter
the treatment system
Screening Score
SBI Procedures:Follow-up Action Depends on Score
Negative Screen Positive screen
Positive Reinforcement
Brief InterventionBrief Treatment
Referral to Treatment
Moderate Use Moderate/High Use Abuse/Dependence
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,
improvequality of life
References provided in subsequent slides
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.
Screening to Identify Patients at risk for Alcohol Problems
How do we conduct the screening?
Alcohol Problems Among Trauma Patients
SBIRT
SBIRT
Coding for Screening andBrief Intervention Reimbursement
Payer Code Description
Fee
ScheduleCommercial
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
Coding for Screening andBrief Intervention Reimbursement
Payer Code Description
Fee
ScheduleMedicare G0397 SBI (Greater
than 30 minutes)
$57.69
Medicaid H0049 Alcohol/drug screening
(only)
$24.00
Medicaid H0050 SBI (per 15 minutes)
$48.00
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)
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Brief Intervention Effect
Brief interventions can trigger change1 or 2 sessions can yield much greater
change than no counselingA little counseling can lead to significant
changeBrief interventions can yield outcomes
that are similar to those of longer treatments
29
The Concept of Motivation
Motivation is influenced by the clinician’s style
Motivation can be modifiedThe clinician’s task is to elicit and
enhance motivation“Lack of motivation” is a challenge for
the clinician’s therapeutic skills, not a fault for which to blame our clients
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The Concept of Ambivalence
Ambivalence is normalClients usually enter
treatment with fluctuating and conflicting motivations
They “want to change and don’t want to change”
“Working with ambivalence is working with the heart of the problem”
So…What is the best way to ask?
Single-Item alcohol screener
Primary care setting Validated single Primary care setting Validated single itemitem
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)
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)
Review: LAC DMH Assessment
35
Conducting the Brief Intervention
Example of the Directing Style
The 3 Tasks of a BI
Avoid Warnings!
F L O WFeed
back
Listen
& U
nd
erstand
Warn
Op
tion
s Exp
lored
(that’s it)
How does it all fit together?
Example of the Guiding Style
The 3 Tasks of a BI
F L OFeed
back
Listen
& U
nd
erstand
Op
tion
s Exp
lored
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 There’s 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…
SUD
Family
Pain Medical Issues
Anxiety
SUD
Providing Feedback
Elicit (ask for permission)
Give feedback
Elicit again (the person’s view of how the advice will work for him/her)
THE 2ND TASK: LISTEN & UNDERSTAND
Ambivalence is Normal
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 Understand
Tools for Change Talk
• Pros and Cons
• Importance & Confidence Scales
• Readiness Ruler
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….
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
Sadn
ess
Social Isolation
SU
D
Family
Physical Problem
Social Isolation Mental
Health
SUD
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 Change
The Third Task: Options for Change
The Advice Sandwich
Ask permission
Give Advice
Ask for Response
The Third Task: Options for Change
When to Give AdviceDoes 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)
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.
Meet Mike
Activity: Role Play Activity: Role Play
Let’s practice F - L - O: Feedback, Listen, OptionsUsing 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
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Important Internet Sites
www.uclaisap.org/dmhcodwww.uclaisap.orgwww.psattc.orghttp://sbirt.samhsa.gov/about.htmhttp://sbirt.samhsa.gov/trauma.htmhttp://www.saem.org/SAEMDNN/Portals/
0/IGroups/PublicHealth/sbirt2008/SBIRTResourceManual051608.doc
Thank you for your time!
Sherry Larkins, [email protected]
(310) 267-5376
&
Joy Chudzynski, [email protected]