1. SBIRT Training The BNI-ART Institute Boston University School of Public Health Boston Medical Center, Dept. of Emergency Medicine Project Assert

3. Lead HPA: Ludy Young., HPAs: John Cromwell, Dan Heenen, Brent Stevenson,, & Moses Williams Adm Dir, Emma Riley; Med Dir., Dr. Edward Bernstein, Funded in 1993 SAMHSA/CSAT; 1998 line item in BMC ED Budget; a model for SBIRT in 2003 BMC Emergency Department’s Health Promotion Advocates : provide comprehensive care & prevention focus on substance abuse in context of other health and safety issues offer info & health resources with emotional support & advocacy; collaborates with staff to serve 5,000 + pts/yr

4. SBIRT is a comprehensive, integrated public health approach to the delivery of early intervention and treatment services to persons with at-risk and substance use disorders The primary goal of SBIRT is to identify and effectively intervene with those who are high risk for psycho-social or health care problems related to their substance use. Primary care centers, hospitals, EDs and other community settings provide excellent opportunity for early intervention What is SBIRT?

5. The S-BI-RT Screening to identify patients with high-risk or dependent drinking and drug use Brief Intervention: Conversation to motivate patients who screen positive to consider healthier decisions (e.g. cutting back, quitting, or seeking further assessment) Referral to Treatment: Actively link patients to resources when needed

6. Outline Why people use alcohol and drugs Different frameworks for viewing substance use ▫Moral failing ▫Biomedical model ▫Public health model ▫How SBIRT fits in Evidence for SBIRT Logistics of SBIRT in health care settings

7. Why do people use alcohol & drugs? Feels good/ not feel bad Socialize, hang out Feel outgoing, less shy Have fun, relax Celebrate Stay alert Tastes good

8. Why do people use alcohol & drugs? Environmental norms Work place Family, home Friends Peer pressure

9. Why do people use alcohol & drugs? Cope with stress Self-medicate Response to life trauma ACEs: Adverse Childhood Events Emotional, physical, sexual abuse; neglect; household dysfunction

10. How does society view… …Alcohol and drug use / users? In the past? Currently? In your community?

11. A Moral Failing Character flaw Sign of personal weakness Lacks values, strength Menace, danger to society Lazy, not contributing to society Drugs are bad, deviant, criminal Alcohol is acceptable up to a certain point To be avoided; “Just say no” Chose wrong path

12. Traditional Approaches War on Drugs, Just Say No Jail, prison, department of corrections Shame and blame confrontation Treat and street in medical encounter Stigmatization

13. Dr. Nora Volkow: NIDA Director “STIGMA” Addiction Science & Clinical Practice 2007; 4:1 In years past, science discovered the causes of epilepsy and leprosy and helped free the afflicted of stigma. “We are witnessing another instance of one of the great moral achievements of science: establishing the right of people who have been regarded as hopeless or untouchable to full consideration as human beings.”

17. Reward and Craving Pathways

18. Drugs can be “Imposters” of Brain Messages

19. Cocaine increases dopamine levels by blocking re-uptake into cells dopamine

20. Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997. Natural Rewards Elevate Dopamine Levels 0 50 100 150 200 060120180 Time (min) % of Basal DA Output NAc shell Empty Food Sex Box Feeding 100 150 200 DA Concentration (% Baseline) Sample Number 12345678 Female Present

21. ControlAddicted Dopamine D2 Receptors are Decreased by Addiction Functionally… DA D2 Receptor Availability Cocaine Alcohol Heroin Meth

23. Dopamine is only part of the story Scientific research has shown that other neurotransmitter systems are also affected: ▫Serotonin  Regulates mood, sleep, etc. ▫Glutamate  Regulates learning and memory, etc.

24. Volkow ND, Baler RD. Science 2012; 335:546. Addicted sibling Non addicted sibling Non addicted unrelated Risk factors Protective factors Risk factors Protective factors Risk factors Protective factors Stop impulse response Precuneus Amygdal a Striatum Orbitofrontal cortex Genetic, Developmental and Environmental Interaction Stop impulse response

25. Ability to stop an impulse to act is determined by the overall balance of risk factors and protective factors Maladaptive risk factors ▫high impulsivity, stress reactivity ▫novelty seeking, conditioning/habits ▫negative emotionality ▫poor reality awareness Adaptive protective factors ▫positive emotionality ▫robust inhibitory control and executive function ▫strong coping skills and good frustration management temper cues for potential reward

26. SAMHSA CSAT Jack B. Stein, MSW, PhD

27. Drug overdose deaths were second only to motor vehicle crash deaths among leading causes of unintentional injury death in 2007 in the United States. (27,658)

28. Addiction similar to other Chronic Illnesses <30% of patients adhere to prescribed medications & diet or behavioral changes 50% recurrence rate Substance abuse should be insured, monitored, treated and evaluated like other chronic diseases Diabetes Hypertension Asthma Addiction McLellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

29. Paradigm Shift = Innovative Approaches Shift from moral failing to addiction as a chronic and recurrent condition: Chronic disease management Integration with behavioral health Expanding treatment options ▫Medication assistance : suboxone, methadone, naltrexate ▫Intensive outpatient services ▫Sober housing ▫Drug court and treatment in prison

30. Treatment success depends on: A comprehensive model that considers Interpersonal relationships Employment options Housing options Mental health services Safety and support Human rights, dignity …and more

31. Saving lives & promoting recovery, cardiac & addiction require: community involvement, screening and access structural changes informed by evidence $ and monitoring of access & quality workforce development an integrated, coordinated, collaborative system public education, and advocacy & de-stigmatization Learning from Successful Examples: The Cardiac Care Chain of Survival ?

32. Biomedical Model Isn’t Enough Chronic illness model doesn’t take high-risk use into account o Many people who use alcohol and drugs do not meet criteria for dependence o Intervention still needed for preventing future injury, illness, or possible dependence Substance use doesn’t happen in a vacuum o cost society over $600 billion annually o have far-reaching implications for family, workplace, community, and health care system

33. SBIRT Addresses Both Continuum of Use o Low-risk use o High-risk / unhealthy use o Abuse and dependence (substance use disorders) Continuum of Care o Brief intervention, action plan o Wrap-around services o Detox, treatment types

34. SBIRT: Part of a Public Health Solution It attempts to identify those who are high-risk for psycho-social or health care problems related to their substance use It attempts to effectively intervene in a nonjudgmental, empathic, and motivational way It offers an opportunity for finding and connecting to additional services It’s a holistic way of addressing the many ways the individual affects and is affected by its environment/society

35. Does SBIRT work? Evidence

36. Research Demonstrates Effectiveness A growing body of evidence about SBIRT’s effectiveness, including cost-effectiveness, has demonstrated its positive outcomes. The research shows that SBIRT is an effective way to reduce alcohol and drug related health and social/ legal problems.

37. Making a Measurable Difference Since 2003, SAMHSA has supported SBIRT programs with over 1.5 million persons screened. Outcome data confirm a 40% reduction in harmful use of alcohol by those drinking at risky levels and a 55% reduction in negative social consequences. Outcome data also demonstrate positive benefits for reduced illicit substance use. Based on review of SBIRT GPRA data (2003-2011).

38. Brief Intervention in the Clinical Setting Reduces Cocaine and Heroin Use Testing the ASSERT Model- Randomized Control Trial in Heroin-Cocaine Users Intervention group more likely to be abstinent at 6 months (n=778 + hair at baseline) follow-up rate 82%  cocaine alone (22.3% vs 16.9%)  heroin alone (40.2% vs 30.6%)  both drugs (17.4% v s 12.8%)  adjusted OR of 1.51-1.57 Cocaine levels in hair reduced  29% intervention group vs 4% control group Bernstein et al. Drug & Alcohol Dependence, 2005;77:49-59

39. Academic Emergency Medicine SBIRT Collaborative Boston Medical New England Med. Charles Drew Univ. Univ. of Southern California Cooper Health Howard Univ. Univ. of Michigan. Denver Health Medical Univ. of California Yale Univ. Univ. of Virginia Univ. of New Mexico Rhode Island Hospital Emory University 26% screened positive for at risk drinking

40. Patient Response to SBIRT at 3 month F/U Summary (n=1173) At 3 months, controlling for baseline drinking levels, patients receiving the intervention 2x as likely to drink within the NIAAA low risk guidelines as the controls (39% vs. 19%). had 3 fewer ‘typical number of drinks per week’ than controls providers reported greater utilization of SBIRT in their practice

41. Meta-analyses of BI and MI Alcohol only ▫Kaner et al. (Cochrane), 2007  I vs C ↓ 4 drinks/wk ▫Vasilaki et al, 2006  aggregate.18,.60 at 3 months ▫USPSTF, 2004  69% vs. 57% drinking risky amts; 38 grams/wk Alcohol/drugs ▫Dunn et al, 2001 ▫Hettema et al, 2005 (.30 at 1 yr)

42. A Ten Minute Brief Negotiated Interview By Practitioners Reduces Hazardous and Harmful Drinking Among ED Patients ( Donofrio et al. Ann of Emerg Med. 2012) N=889 Mean # drinks/ past 7 days BNI BL 19.8 12 mo 14.3 SC BL 20.9 12 mo 17.6 # Binge drinking days/past 28 BNI BL 7.5 12 mo 4.7 SC BL 7.2 12 mo 5.8 Driving after >3 drinks BNI BL 38% 12 mo 29% SC BL 43% 12 mo 42%

43. Recognizing the treatment gap and the need for prevention with a nationwide movement to a standard of care US Preventive Services Task Force Level I and II Trauma Centers Millions in federal SBIRT funding for state & residency training programs NIH funding Joint Commission hospital SBIRT standards reimbursement codes - Centers for Medicare & Medicaid Services; the AMA (CPT codes) and E&M codes

44. What does SBIRT look like? Screening Brief Intervention Referral to Treatment

45. Screening What NIAAA Qs, NIDA Qs, DAST, AUDIT-C, AUDIT, CRAFFT, ASSIST, Health Needs History When Triage, while patient awaits medical attention Who Health promotion advocate (HPA), health educator, medical assistant, triage nurse, social worker, doctor Where Triage, bedside, waiting room, private room/office

46. Brief Intervention = the BNI What BNI = Brief Negotiated Interview (5-steps) When Patient screens positive for risky alcohol/drug use Who Health promotion advocate (HPA), health educator, nurse, doctor, social worker, medical assistant Where Bedside, private room/office

47. 5 Steps of the BNI 1.Build rapport ▫Bringing up the topic, being nonjudgmental 2.Pros & Cons ▫Ask what is liked/disliked about the behavior 3.Information & Feedback ▫Give facts and feedback about the behavior, ask for thoughts 4.Readiness Ruler ▫Assess readiness to make any changes (to be healthier, safer) 5.Prescription for Change ▫Ask for action steps, create a plan together

48. Referral to Treatment (or other services) What Calling service providers, getting medical clearance (for detox), calling about insurance, arranging transportation, giving information: handouts, brochures, contact info., safety supplies When Patient wants (and is good match for) additional services Who Health promotion advocate (HPA), health educator, social worker, nurse, doctor, medical assistant Where Bedside, private room/office

49. Next, we'll break it down...