The ASOC Training Series (draft)

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)

28

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

30

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

58

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, Ph.D.larkins@ucla.edu

(310) 267-5376

&

Joy Chudzynski, Psy.D.joychud@ucla.edu