1. 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

2. Objectives Describe the background and rationale for conducting SBI in medical settings Describe screening procedures for identifying injured patients engaged in at-risk drinking Review brief intervention strategies and techniques

3. Consider the patients that you treat What are the characteristics of the ones …who are the most difficult? …who you see the most often?

4. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with substance use disorders Those 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

5. 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

6. 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

7. 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.**

8. Is it really a problem? Prevalence of problematic alcohol and other drug use

9. 94.5% Did no feel that they needed treatment Public Health Challenge Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006). Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are unaware of the problem or do not feel they need help. 20.9 Million People Need But Do Not Receive Treatment For Illicit Drug or Alcohol Use 4.1% Felt they needed treatment and did NOT make an effort 1.4% Felt they needed treatment and DID make an effort

10. 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 Division July 2009 estimate *NSUDH, 2008

11. 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%

12. 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

13. 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 week Pregnant woman occasionally has a shot of vodka to relieve stress Adolescent smokes marijuana with his friends on weekends Occasionally takes one or two extra vicodin to help with pain These people need services, but will never enter the treatment system

14. Screening Score SBI Procedures: Follow-up Action Depends on Score Negative ScreenPositive screen Positive Reinforcement Brief Intervention Brief Treatment Referral to Treatment Moderate UseModerate/High UseAbuse/Dependence

15. Screening, Brief Interventions for Alcohol: Major Impact of SBI on Morbidity and Mortality StudyResults - conclusionsReference Trauma patients48% fewer re-injury (18 months) 50% less likely to re-hospitalize Gentilello et al, 1999 Hospital ER screening Reduced DUI arrests 1 DUI arrest prevented for 9 screens Schermer et al, 2006 Physician offices20% fewer motor vehicle crashes over 48 month follow- up Fleming et al, 2002 Meta-analysis Interventions reduced mortality Cuijpers et al, 2004 Meta-analysis Treatment reduced alcohol, drug use Positive social outcomes: substance-related work or academic impairment, physical symptoms (e.g., memory loss, injuries) or legal problems (e.g., driving under the influence) Burke et al, 2003 Meta-analysis Interventions can provide effective public health approach to reducing risky use. Whitlock et al, 2004

16. Screening, Brief Interventions for Alcohol: Saves Healthcare Costs Study Cost Savings Authors Randomized trial of brief treatment in the UK Reductions in one-year healthcare costs $2.30 cost savings for each $1.00 spent in intervention (UKATT, 2005) Project TREAT (Trial for Early Alcohol Treatment) randomized clinical trial: Screening, brief counseling in 64 primary care clinics of nondependent alcohol misuse Reductions in future healthcare costs $4.30 cost savings for each $1.00 spent in intervention (48-month follow-up) (Fleming et al, 2003) Randomized control trial of SBI in a Level I trauma center Alcohol screening and counseling for trauma patients (>700 patients). Reductions in medical costs $3.81 cost savings for each $1.00 spent in intervention. Gentilello et al, 2005)

17. 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 References provided in subsequent slides

18. 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. identify those at higher risk of abusing prescription drugs. identify abusers of prescription drugs or OTC drugs. have positive influence on social function.

19. Screening to Identify Patients at risk for Alcohol Problems How do we conduct the screening?

20. Alcohol Problems Among Trauma Patients Severe Problem Drinkers Hazardous & Harmful Drinkers Non-Drinkers or Low Risk Drinkers SBIRT

21. American College of Surgeons: Committee on Trauma The trauma center needs a mechanism to identify patients who are problem drinkers: Level I and II Trauma Centers The trauma center has the capability to provide an intervention for patients identified as problem drinkers: Level I Trauma Centers

22. Coding for Screening and Brief Intervention Reimbursement PayerCodeDescription Fee Schedule Commercial Insurance CPT 99408 SBI (15-30 minutes) $33.41 Commercial Insurance CPT 99409 SBI (Greater than 30 minutes) $65.51 MedicareG00396SBI (15-30 minutes) $29.42

23. Coding for Screening and Brief Intervention Reimbursement PayerCodeDescription Fee Schedule MedicareG0397SBI (Greater than 30 minutes) $57.69 MedicaidH0049Alcohol/drug screening (only) $24.00 MedicaidH0050SBI (per 15 minutes) $48.00

24. 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)

25. 25 Brief Intervention Effect Brief interventions can trigger change 1 or 2 sessions can yield much greater change than no counseling A little counseling can lead to significant change Brief interventions can yield outcomes that are similar to those of longer treatments

26. 26 The Concept of Motivation Motivation is influenced by the clinician’s style Motivation can be modified The 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

27. 27 The Concept of Ambivalence Ambivalence is normal Clients 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”

28. So… What is the best way to ask?

29. Single-Item alcohol screener Primary care setting Validated single item Primary care setting Validated single item 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)

30. 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)

32. Review: LAC DMH Assessment 32

35. Conducting the Brief Intervention FLO

36. The 3 Tasks of a BI Avoid Warnings! FLOW FeedbackListen & UnderstandWarnOptions Explored (that’s it)

37. How does it all fit together? Listen & Understand Explore Pros and Cons Explain ImportanceAssess readiness to change Feedback Setting the stage Tell screening results Options Explored Discuss change optionsFollow up

38. The 3 Tasks of a BI FLO FeedbackListen & UnderstandOptions Explored

39. Chronic Pain SUD Family anxiety Medical Issues Pain SUD

40. THE 2 ND TASK: LISTEN & UNDERSTAND Ambivalence is Normal

41. 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.

42. The Second Task: Listen and Understand Tools for Change Talk Pros and Cons Importance & Confidence Scales Readiness Ruler

43. HOW TO EXPLORE AMBIVALENCE Avoid questions that inspire a yes/no answer. The good things about ______ The not- so-good things about ____ The good things about changing The not-so- good things about changing Summarize both pros and cons… “On the one hand you said.., and on the other you said….

44. The Second Task: Listen and Understand Strategies for weighing the pros and cons… “What do you like about drinking?” “What do you see as the downside of drinking?” “What Else?” Summarize both pros and cons… “On the one hand you said.., and on the other you said….

45. 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

46. Sadness Social Isolation SUD Family Physical Problem Social Isolation Mental Health SUD

47. 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

48. The Advice Sandwich Ask permission Give Advice Ask for Response

49. The Third Task: Options for Change When to Give Advice Does 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)

50. Important Internet Sites www.uclaisap.org www.psattc.org http://sbirt.samhsa.gov/about.htm http://sbirt.samhsa.gov/trauma.htm http://www.saem.org/SAEMDNN/Portals/ 0/IGroups/PublicHealth/sbirt2008/SBIRT ResourceManual051608.doc http://www.saem.org/SAEMDNN/Portals/ 0/IGroups/PublicHealth/sbirt2008/SBIRT ResourceManual051608.doc

51. Thank you for your time! Thomas E. Freese, Ph.D. tfreese@mednet.ucla.edu (310) 267-5397