overview screening and bni rhh 328...including the “brief negotiation interview” (bni),...
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Screening, Brief Intervention, and Referral to g, ,Treatment Core Skills Training
d b l f h f l h d bPrepared by JBS International, Inc., for the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment
Contract No. HHSS28320070000311HHSS28300002T
Forget Everything You Knowg y g
• About what constitutes a substance use problem.
• About how substance use problems are pidentified.
• About how to treat substance use problemsAbout how to treat substance use problems.
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A New Initiative
• Substance use screening, brief intervention, and referral to treatment (SBIRT) is a systems change initiative. As such, we are required to shift our view toward a new paradigm, and;– Re‐conceptualize how we understand substance use problems.
– Re‐define how we identify substance use problems.
– Re‐design how we treat substance use problems.4
HistoricallyHistorically
Society has viewed substance use as:Society has viewed substance use as: A moral problem An individual problemA f il bl A family problem
A social problem A criminal justice problem A combination of one or more
The solution to any problem must be driven by its presumed causeits presumed cause. If substance use is caused by a moral problem… ….what is its solution?
If substance use is caused by a criminal justice problem……what is its solution?
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Substance Use Is
A P bli H l h P bl6
A Public Health Problem
Learning from Public Healthg
• The public health system of care routinelyscreens for potential medical problemsscreens for potential medical problems (cancer, diabetes, hypertension, tuberculosis, vitamin deficiencies renal function) providesvitamin deficiencies, renal function), provides preventative services prior to the onset of acute symptoms and delays or precludes theacute symptoms, and delays or precludes the development of chronic conditions.
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Historicallyy
• Substance Use Services have been bifurcated, focusing on two areas onlyfocusing on two areas only:– Primary Prevention – Precluding or delaying the onset of substance useonset of substance use.
– Tertiary Treatment – Providing time, cost, and labor intensive care to patients who are acutely orlabor intensive care to patients who are acutely or chronically ill with a substance use disorder.
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T diti l T t tSubstance Dependent
Traditional Treatment
Abstinence
No Problem No Intervention
Primary Prevention
Drink Responsibly
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The Current ModelA C ti f S b t UA Continuum of Substance Use
Abstinence Responsible Use
Dependence
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An Outdated Model
• This model (paradigm) of substance use:– Fails to recognize a full continuum of substance use behavior.
– Fails to recognize a full continuum of substance bluse problems.
– Fails to provide a full continuum of substance use i t tiinterventions.
WHY?WHY?11
The outdated model defines a substance use problem as…
DependenceDependence
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By failing to recognize a full continuum of substance use behavior a full continuum ofsubstance use behavior, a full continuum of substance use problems, and not providing a full continuum of substance use interventionsfull continuum of substance use interventions the outdated model has failed to provide resources in the area of greatest needresources in the area of greatest need.
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The SBIRT model defines a substance use problem as…
Excessive UseExcessive Use
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Excessive Use Results InExcessive Use Results In
• Trauma and trauma recidivism.• Causation or exacerbation of health conditions.• Exacerbation of mental health conditions.• Alcohol poisoning.• DUI.• Domestic and other forms of violence.• Transmission of sexually transmitted diseases.• Unintended pregnancies.p g• Substance Dependence.15
By recognizing a full continuum of substance use behavior a full continuum of substance usebehavior, a full continuum of substance use problems, and by providing a full continuum of substance use interventions the SBIRTof substance use interventions the SBIRT model can provide resources in the area of
greatest needgreatest need.
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Substance DependentTraditional Treatment
Abstinence
Excessive UseBrief Intervention
Brief Therapy
No Problem Screening and Feedback
Drink Responsibly
Primary Prevention
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Drink Responsibly
The SBIRT ModelA C i f S b UA Continuum of Substance Use
AbstinenceSocial Use Abuse
Experimental Use
Binge Use
Dependence
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U.S. Population
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Dependentp
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Excessive
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4% DependentBrief Intervention and Referral for additional Services
25%
71%Low Risk orAbstinence
No Intervention or screening and Feedback71%
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Drinking Behavior Intervention Need
6666
1111
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The Costs of Substance Use
• The bulk of the societal, personal, and health care related costs are not a result of substance dependence but of excessive substance use. Until such time as we acknowledge this fact, g ,and address it appropriately, we are unlikelyto make significant progress towards a g p gsolution.
Consider ThisConsider This24
IfIf
We could provide a 100% cure to everyWe could provide a 100% cure to every substance dependent person in the United
States we wouldn’t be close to solving most ofStates we wouldn t be close to solving most of the substance related problems in our
countrycountry.
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The SBIRT ModelA Continuum of InterventionsA Continuum of Interventions
Primary Prevention – Precluding or delaying the onset of substance use.
Secondary Prevention and Intervention – Providing time, cost, and labor sensitive care to patients who are at riskfor psycho‐social or healthcare problems related to theirfor psycho‐social or healthcare problems related to their substance use choices.
Tertiary Treatment Providing time cost and labor Tertiary Treatment – Providing time, cost, and labor intensive care to patients who are acutely or chronically ill with a substance use disorder.
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Primary Goaly
• The primary goal of SBIRT is not to identify those who are dependent and need higher levels of carewho are dependent and need higher levels of care.
• The primary goal of SBIRT is to identify those who are at moderate or high risk for psycho‐social orare at moderate or high risk for psycho social or health care problems related to their substance use choices.
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NIAAA Definitions
L Ri k Low Risk: Healthy Men < 65
≤ 4 drinks per day AND ≤ 14 drinks per week
Healthy Women & Men ≥ 65 ≤ 3 drinks per day AND ≤ 7 drinks per week
Hazardous: Pattern that increases risk for adverse consequences.q
Harmful: Negative consequences have already occurred.
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The SBIRT Conceptp
SBIRT bli h lth h t i l i• SBIRT uses a public health approach to universal screening for substance use problems.– SBIRT provides:
• Immediate rule out of non‐problem users;• Identification of levels of risk;Id tifi ti f ti t h ld b fit f• Identification of patients who would benefit from brief advise;
• Identification of patients who would benefit from higher levels of care, and;
• Progressive levels of clinical interventions based on need and motivation for change. g
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The Moving Partsg
Pre screening (universal) Pre‐screening (universal). Full screening (for those with a positive pre‐screen). Brief Intervention (for those scoring over the cut offBrief Intervention (for those scoring over the cut off point).
Extended Brief Interventions or Brief Treatment or (f th h h d t i k hi h i k b(for those who have moderate risk, high risk, abuse, or dependence, would benefit from ongoing, targeted interventions, and are willing to engage).
Traditional Treatment (for those who are dependent and are willing to engage).
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Let’s Review
h• SBIRT is a systems change initiative requiring us to re‐conceptualize, re‐define, and re‐design our entire approach to substance use problems and services.p
• SBIRT uses a public health approach.• The current model defines the problem as dependence.• The SBIRT model defines the problem as excessive use.• SBIRT recognizes a continuum of substance use behavior, a
continuum of substance use problems and a continuum ofcontinuum of substance use problems, and a continuum of substance use interventions.
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Prescreening Strategyg gy
Use brief yet valid screening questions:
• Based on previous experiences with SBIRT, screening will Negativescreening questions:
• The NIAAA Single
gyield 75−80 percent negative responses.
g
Question Screener
• The Single Question • If you get a positive The Single Question Drug Screener
screen, you may ask further assessment questions.
Positive
Prescreening for Alcohol
P D i d i k bPrescreen: Do you sometimes drink beer, wine, or other alcoholic beverages?
NO YES
NIAAA Single Screener: How many times in the past year have you had five drinks (for men) or four drinks (for women or clients
over age 65) or more in a day?
If you get one or more affirmative answers, move on to full screen.
Sensitivity/Specificity: 82%/79%
Source: Smith, P. C., Schmidt, S. M., Allensworth‐Davies, D., & Saitz, R. (2009). Primary care validation of a single‐question alcohol screening test. J Gen Intern Med, 24(7), 783−788.
When Screening, It Is Useful To Clarify What Constitutes One Drink!What Constitutes One Drink!
How Much Is “One Drink”?
12‐oz glass of beer (one can)5‐oz glass of wine g ( )(5 glasses in one bottle)
1.5‐oz spirits1.5 oz spirits 80‐proof1 jigger Equivalent to 14 grams pure alcohol
THE ALCOHOL, SMOKING AND SUBSTANCE INVOLVEMENTSUBSTANCE INVOLVEMENT
SCREENING TEST (ASSIST)(ASSIST)
The ASSIST
• Developed under the auspices of the World Health Organization (WHO)
• A group of addiction researchers and clinicians developed the ASSIST to address the overwhelming public health burden associated with psychoactive substance use worldwide.
The ASSIST continued
• The ASSIST (version 3.1) is an 8 item questionnaire designed to be administered byquestionnaire designed to be administered by a health worker to a client using paper and pencilpencil
• Takes about 5‐10 minutes to administerASSIST d i d t b lt ll t l• ASSIST was designed to be culturally neutral
The ASSIST
• screens for use of the following substances:– tobacco products
alcohol– alcohol– cannabis– cocaine– amphetamine‐type stimulants (ATS)– sedatives and sleeping pills (benzodiazepines)– hallucinogensg– inhalants– opioids
other drugs– other drugs
ASSIST Q 1‐4Q
Q i 1 (Q1) k b hi h b h b d i• Question 1 (Q1) asks about which substances have ever been used in the client’s lifetime.
• Question 2 (Q2) asks about the frequency of substance use in the past three months, which gives an indication of the substances which are most relevant to current health status.
• Question 3 (Q3) asks about the frequency of experiencing a strong Q (Q ) q y p g gdesire or urge to use each substance in the last three months.
• Question 4 (Q4) asks about the frequency of health, social, legal or financial problems related to substance use in the last three monthsfinancial problems related to substance use in the last three months.
See ASSIST screen handout
ASSIST Q 5‐8Q
Q i 5 (Q5) k b h f i h hi h f h• Question 5 (Q5) asks about the frequency with which use of each substance has interfered with role responsibilities in the past three months.
• Question 6 (Q6) asks if anyone else has ever expressed concern about the client’s use of each substance and how recently that occurred.
• Question 7 (Q7) asks whether the client has ever tried to cut down or Q (Q )stop use of a substance, and failed in that attempt, and how recently that occurred.
• Question 8 (Q8) asks whether the client has ever injected any substance• Question 8 (Q8) asks whether the client has ever injected any substance and how recently that occurred.
See ASSIST screen handout
Scoring of the ASSISTg
• The ASSIST screening questions provide an indication of the level of risk associated with the client’s substance use, and whether use is hazardous and likely to be causing harm(now or in the future) if use continues.
ASSIST Scoringg
A) ASSIST risk score for tobacco (range 0 – 31)
B) ASSIST risk score for alcohol (range 0 – 39)
C) ASSIST risk score for cannabis (range 0 – 39)C) ASSIST risk score for cannabis (range 0 39)
D) ASSIST risk score for cocaine (range 0 – 39)
E) ASSIST risk score for amphetamine‐type stimulants (range 0 – 39)
F) ASSIST risk score for inhalants (range 0 – 39)
G) ASSIST risk score for sedatives or sleeping pills (range 0 – 39)
H) ASSIST risk score for hallucinogens (range 0 39 )H) ASSIST risk score for hallucinogens (range 0 – 39 )
I) ASSIST risk score for opioids (range 0 – 39)
J) ASSIST risk score for “other” drug (range 0 – 39 )
ASSIST Levels of RiskASSIST Levels of Risk
Questions/Discussion About Screening
BREAK
SBIRT Brief Intervention Based on MI
• There are several examples for brief intervention, including the “Brief Negotiation Interview” (BNI), originally developed by Gail D’Onofrio MD Edoriginally developed by Gail D Onofrio, MD, Ed Bernstein, MD; and Steven Rollnick, MD.
The BNI is a semistructured interview process basedThe BNI is a semistructured interview process based on MI that is a proven evidence‐based practice and can be completed in 5−15 minutes.can be completed in 5 15 minutes.
Goals of Brief Intervention
• For the at‐risk user: The goal is to negotiate a reduction in use to lower risk levels. F h h h b• For the person who appears to have a substance use disorder: The goal is to negotiate a treatment referral for full assessment and a level of intervention to befor full assessment and a level of intervention to be determined.
Starting Off….
How Not To Intervene video example
http://www.bu.edu/bniart/sbirt‐in‐health‐care/sbirt‐http://www.bu.edu/bniart/sbirt in health care/sbirteducational‐materials/sbirt‐videos/
Steps in the Brief Negotiation Interview (BNI)Brief Negotiation Interview (BNI)
1. Build rapport—raise the subject.
Di h d f— Discuss the pros and cons of use.
2. Provide feedback.
3. Build readiness to change.
4. Negotiate a plan for change.
1. Build Rapport—Raise the Subject
1. Begin with a general conversation.
2. Ask permission to talk about alcohol or drugs:
– Would you mind taking a few minutes to talk with me about your use of alcohol (or X)?y f ( )
– What’s a normal day look like for you, and where and how does alcohol fit?
Discussing the Pros and Cons of UseDiscussing the Pros and Cons of Use
1. Help me understand through your eyes. What are the good things about using alcohol?
2. What are some of the not‐so‐good things about using alcohol?
3. Summarize using a decisional balance… – So on the one hand “PROS ” and on the otherSo on the one hand PROS, and on the other hand “CONS.”
2 Provide Feedback2. Provide Feedback
k f1. Ask permission to give information:– I have some information about guidelines for low ‐risk drinking; would you mind if I shared them with you?drinking; would you mind if I shared them with you?
– We know that 4 or more drinks (for a female), 5 or more drinks (for a male) in one sitting, or more than 7 (for a
/female), 14 (for a male) in a week, and/or use of illicit drugs can put a person at risk for illness or injury and other problems.p
2. Discuss screening findings. 3. Link use behaviors to any known consequences.4. Elicit a reaction, facilitate a reflective discussion.
3 Build Readiness To Change3. Build Readiness To Change
• So could we talk for a few minutes about your interest in making a• So could we talk for a few minutes about your interest in making a change?
• On a scale from 1 to 10, with 1 being not ready at all and 10 being completely ready, how ready are you to make any changes in your alcohol use?
• You marked (or said)___. That’s great. That means you are ___ % ( )___ g y ___ready to make change.
• Why did you choose that number and not a lower one like a 1 or a 2? Sounds like you have some important reasons for change2? Sounds like you have some important reasons for change.
4 Plan for Change4. Plan for Change
• A plan for reducing use to low risk levels OR
• An agreement to follow up with specialty treatment services
How To InterveneHow To Intervene
BNI Vid D t tiBNI Video Demonstration
http://www.bu.edu/bniart/sbirt‐in‐health‐care/sbirt‐educational‐materials/sbirt‐videos/
BNI Practice SessionBNI Practice Session
• Roles• Patient• Interviewer• Observer• Observer
Process: Role‐PlayProcess: Role‐Play
Closing Discussion
Why might you choose to implement SBIRT?Why might you choose to implement SBIRT?
Questions?
Additional Information on SBIRT
Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, brief intervention, and referral to treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse 28, 7‒30.
Center for Substance Abuse Treatment. (2007). Alcohol Screening and Brief Intervention (SBI) for trauma patients: Committee on Trauma Quick Guide. Substance Abuse and Mental Health Services Administration, HHS. Publication No. (SMA) 07‐4266. Washington, DC: U.S. Government Printing Office. Available at http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf
D’Onofrio , G., Bernstein, E., & Rollnick, S. (1996). Motivating patients for change: A brief strategy for negotiation. In E. Bernstein and J. Bernstein (Eds), Case studies in emergency medicine and the health of the public (pp. 295‒303). Boston: Jones and Bartlett,.
D’Onofrio , G., Pantalon , M. V., Degutis , L. C., Fiellin, D. A., & O’Connor, P. G. (2005). Development and implementation of an emergency practitioner‐performed brief intervention for hazardous and harmful drinkers in the emergency department. Academy of Emergency Medicine 12, 249‒256.
National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: A clinician’s guide. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
World Health Organization. Brief intervention for substance use: A manual for use in primary care. (n.d.). http://wwwwho int/substance abuse/activities/en/Draft Brief Intervention for Substance Use pdfhttp://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf
Acknowledgementg
We wish to thank Gail D’Onofrio, MD, Ed Bernstein, MD; and Steven Rollnick, MD for granting permission to useand Steven Rollnick, MD for granting permission to use materials developed at the Boston University Medical Center and the Yale University School of Medicine.