Professor Carmel Clancy Screening, Brief Intervention and Referral for Treatment (SBIRT) Inter professional Symposium

For persons with substance use disorders What is SBIRT? Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for substance use disorders (SUDs) For persons with substance use disorders Those at risk of developing these disorders Primary care centres, trauma or A/E centres, Maternity Services and other community settings provide opportunities for early intervention with at-risk substance users

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 Referral to Treatment: Referral of those with more serious SUDs

Provides opportunity for education, early intervention Benefits of Screening Provides opportunity for education, early intervention Alerts provider to risks for interactions with medications or other aspects of treatment Offers opportunity to engage patient further Has proved beneficial in reducing high-risk activities for people who are not dependent

Distribution of Alcohol (or Drug) Problems

Engagement – the first stage What is engagement? Building a working relationship Showing that you care (do you?) Working towards mutual acceptable goal Building rapport Building trust Analysing any ‘counter-transference’ that may occur and detaching from any instinctive feelings, if necessary.

explain[and provide] confidentiality Interview individually How to Engage People explain[and provide] confidentiality Interview individually Appropriate setting Flexible approach Be non-confrontational Be non-judgmental Be yourself

Getting onto the Subject…. Broad to narrow General to specific Giving permission

ASSIST http://www.who.int/substance_abuse/activities/assist/en/ The ASSIST (version 3.1) is an 8 item questionnaire designed to be administered by a health professional or generic worker to a client using paper and pencil, and takes about 5-10 minutes to administer. It is culturally neutral and useable across a variety of cultures to screen for use of the following substances: tobacco products Alcohol Cannabis cocaine amphetamine-type stimulants (ATS) sedatives and sleeping pills, (e.g benzodiazepines) hallucinogens Inhalants opioids ‘other’ drugs

Assist ASSIST obtains information from clients about lifetime use of substances, and use of substances and associated problems over the last 3 months. It can identify a range of problems associated with substance use including acute intoxication, regular use, dependent or ‘high risk’ use and injecting behaviour.

ASSIST It determines the risk score for each substance which is used to start a discussion (brief intervention) with clients about their substance use. The score obtained for each substance falls into a ‘lower‘, ‘moderate’ or ‘high’ risk category. The low to high score determines the most appropriate intervention for that level of use (‘no treatment’, ‘brief intervention’ or ‘referral to specialist assessment and treatment’ respectively).

Standard introduction

Question 1

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Scoring the ASSIST

Stages of Change

u Reestablish self-efficacy and commitment Prochaska & DiClemente: Stages of Readiness to Change Stage Description Counseling Objectives Pre-contemplation Not considering change u Identify patient’s goals u Provide information u Bolster self-efficacy Contemplation Ambivalent about change u Develop discrepancy between goal & behavior u Elicit self-motivational statements Determination Cognitively committed to u Strengthen commitment to change change u Plan strategies for change Action Involved in change u Identify and manage new barriers u Recognize relapse or impending relapse Maintenance Behavior change is stable u Assure stability of change u Foster personal development Relapse Undesired behaviors occur u Identify relapse u Reestablish self-efficacy and commitment u Develop new behavioral strategies Termination Change is very stable u Assure stability of change

Risk areas Violence Suicide Deliberate self harm Accidental overdose Injecting/sharing paraphernalia Physical health Vulnerability to abuse/exploitation Accidental injury Self neglect Social isolation Breakdown in relationships Sexual health Criminal behaviour Poor contact with services Medication compliance Child protection

Reaching a diagnosis – ICD-10 harmful use A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Reaching a diagnosis – ICD-10 dependent use A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

Reaching a diagnosis – ICD-10 dependent use A strong desire or sense of compulsion to take the substance; Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use; A physiological withdrawal state when substance use has ceased or have been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms; Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill non tolerant users); Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects; Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm.

When to refer on….factors that might determine this Complexity of presentation Competency/capabilities of assessor/services Clients choice

Post sessional work Check out the IPL platform in mylearning – key resources will be available including examples of screening & assessment tools