“The administration will continue to promote the integration of SBIRT in to mainstream health care, disseminate informationabout SBIRT to a wide variety of health care settings, highlightmodel programs that are using SBIRT, and encourage training opportunities for the allied health professions.” -2012 National Drug Control Strategy
Support for SBIRT• The Joint Commission• The American College of Surgeons Committee on Trauma• The U.S. Preventive Services Task Force• The American Congress of Obstetricians and Gynecology• The Emergency Nurses Association• The Office of National Drug Control Policy• The Centers for Medicare and Medicaid Services• The Center for Substance Abuse Treatment• Health Resources and Services Administration• National Institute on Alcohol Abuse and Alcoholism• National Institute on Drug Abuse
Brief Screen1. How many drinks do you have per week?2. When was the last time you had 4/5 or more drinks in one day?3. In the past year, have you used or experimented with an illegal drug or prescription drug for nonmedical reasons?4. Do you currently smoke or use any form of tobacco products?
Screening InstrumentsUse for follow-up in those who test positive on the brief screen:• ASSIST: Alcohol, Smoking, and Substance Involvement Screening Test• AUDIT: Alcohol Use Disorders Identification Test• DAST-10: Drug Screening Test (not including alcohol)• CRAFFT: Adolescent drug and alcohol screening
What is Brief Intervention?• A brief motivational conversation• Single 3-5 minute to multiple 15-30 minute sessions have led to decreased use• Most effective with at-risk clients who are not addicted• Educating clients about the health risks of their substance use has led to behavior change• BIs are low cost, quick, client friendly, easy to do
Motivational InterviewingWilliam Miller and Steven RollnickAmbivalence as central constructPersuasion elicits resistanceAlternative to direct persuasion and it works! Source: William Miller (2002)
Examples of MI StrategiesOpen-ended questionsAffirmationReflective listeningSummarizing Goal is to elicit change talk!!!
Don’t Assume• Patient ought to change• Patient wants to change• Patient’s health motivates him/her• Now is the right time for patient to change• Tough approach is best
Brief InterventionStep 1: Raise the SubjectStep 2: Provide FeedbackStep 3: Enhance MotivationStep 4: Negotiate and Advise
Step 1: Raise the SubjectRaise the subject of substance use “Would you mind taking a few minutes to talk with me about your substance use?”
Step 2: Provide FeedbackDiscuss health risks of alcohol and other substances “At this level of consumption, you are at increased risk for health and other consequences such as…”Review drinking guidelines “The recommended guidelines for healthy women/men are…
Step 4: Negotiate and AdviseElicit response: “What are some of your thoughts regarding our discussion?Negotiate a goal: “Why are you a 5 and not a 7?” and “What are some steps you could take?”Assist in developing a plan: “What will be challenging for you to meet this goal? What is your plan for overcoming these challenges?”Summarize: “What I heard you say is…”
Closing the InterventionShow appreciation to your clientAffirm positive behaviorsRespect client’s decisionsOffer informationArrange for follow up
Referral to Brief Therapy and Treatment• If patient scores high on assessment• What is brief therapy?• Know your resources!
Sustainability• Identify an internal champion• Flexibility in how SBI can be implemented• Best to combine with other health screening and education to enhance integrated care• Involve the entire team• Train nursing students and residents to establish SBI as a routine practice
References• The National Center on Addiction and Substance Abuse at Columbia University. The Cost of Substance Abuse to America’s Health Care System. Report 2: Medicare Hospital Costs. May 1994. Available at http://www.casacolumbia.org/articlefiles/379- Cost%20of%20Substance%20Abuse%20Report%202.pdf.• Mokdad A, Marks J, Stroup D, Gerberding J. Actual causes of death in the United States, 2000. JAMA 2004;291:1238--45.• Substance Abuse and Mental Health Services Administration. (2006) Results from the 2005 National Survey on Drug Use and Health: National findings Rockville (MD): Office of Applied Studies.• Maciosek, MV, Coffield, AB, Edwards, MS, et al. Priorities Among Effective Clinical Preventive Services. Results of a Systematic Review and Analysis. Am J Prev Med 2006; 31 (1) 52-61. Available at http://www.prevent.org/data/files/initiatives/prioritiesamongeffectiveclinicalpreventivesvcsresultsofreviewandanalysis.pdf.• D’Onofrio G, Pantalon MV, Degutis LC, et al. The Yale Brief Negotiated Interview Manual. Yale University School of Medicine. 2005. Available at http://www.ihs.gov/nonmedicalprograms/nc4/documents/appendix_a_yale_bni_manual.pdf.• William Miller, Rollnick Steven. Motivational Interviewing, Second Edition: Preparing People for Change. 2002.