2. Integrating Care through the Use of Screening and Brief Intervention in HIV Settings TRAINER’S NAME TRAINING DATE TRAINING LOCATION

3. Pacific AIDS Education and Training Center  Charles R. Drew University of Medicine and Science  University of California, Los Angeles Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs 2

4. Test Your Knowledge 3

5. 1. What is the maximum number of standard drinks that are within the low-risk drinking range for a healthy, non-pregnant 35 year-old woman? A. No more than 1 drink per occasion B. No more than 2 drinks per occasion C. No more than 3 drinks per occasion D. No more than 4 drinks per occasion 4

6. 2. Please identify what the 5-letters in the AUDIT acronym stand for: A. Alcohol Use Disease Inventory Test B. Alcohol Use Disorders Identification Test C. Alcohol Use Disorders Inventory Test D. Alcohol Use Disease Inventory Training 5

7. 3. Because of the linkage between substance use and HIV, screening and brief intervention protocols have been adopted throughout the United States. A. True B. False 6

8. 4. Brief interventions often include: A. Feedback about the patient’s drug and/or alcohol use B. Advice on how to cut down on one’s alcohol and/or drug use C. Motivational techniques D. A and B only E. All of the above 7

9. Briefly tell us: What is your name? Where do you work and what you do there? Who is your favorite musician or performer? What is one reason you decided to attend this training session? 8

10. This brief training course will teach you how to: Administer substance use screening Deliver a brief intervention Employ a motivational approach Make referrals to specialized treatment, if needed 9

11. Take some time to think about the most difficult change that you had to make in your life. How much time did it take you to move from considering that change to actually taking action? 10

12. Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that 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: Procedures to help patients access specialized care. 11

13. Substance abuse SBI may reduce alcohol and drug use significantly Morbidity and mortality SBI reduces accidents, injuries, trauma, emergency department visits, depression, drug-related infections and infectious diseases 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 DUIs, and improve neonatal outcomes 12

14. Increases clinicians’ awareness of substance use issues. Offers clinicians more systematic approach to addressing substance use (less of a “judgment call”). 13

15. Brief interventions are successful when clinicians relate patients’ risky substance use to improvement in patients’ overall health and wellbeing. 14

16. College students Primary care patients Mental health patients Patients in infectious disease clinics People with alcohol- or drug-related legal offenses (e.g., DUI) 15

17. Rationale for Conducting SBIRT in an HIV Care Setting 16

18. HIV is now considered a manageable, chronic illness HIV patients are living longer and facing multiple health issues in addition to their HIV disease Homelessness Disease progression Mental illness Substance abuse Engagement, retention, and adherence among HIV patients continues to present challenges to HIV care providers SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012). 17

19. Poorer adherence to treatment and medication regimens Higher hospitalization rates for medical complications Greater likelihood of treatment drop-out or being lost to follow-up Greater risk for opportunistic (re-) infection Greater risk of psychosocial problems Greater risk of suicide or accidental death SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012). 18

20. SBIRT in primary care settings is effective in changing behavior and preventing adverse outcomes attributable to alcohol and other drugs. People living with HIV are more likely than the general population to experience substance abuse problems. SBI protocols have not been readily implemented in HIV care settings. SOURCE: Fischer, L. (2012). Addiction Science & Clinical Practice, 7(Suppl 1): A73. 19

21. SOURCE: Center for Community Collaboration, UMBC Psychology Department. (2012). 20

22. Implemented in San Francisco General Hospital’s Positive Health Program (PHP) in 2010-11: Most common substances reported were: tobacco (68%), alcohol (64%), cannabis (58%), cocaine (39%), amphetamines (37%), nonmedical sedative use (32%), and nonmedical opioid use (26%). SBI for unhealthy substance use is acceptable to patients in HIV primary care settings Significant decreases observed with amphetamines and sedatives; significant increase in number of patients with HIV viral suppression. SOURCE: Dawson Rose et al. (2012). IAC Poster. 21

23. Of 2,500 patients screened: 31% (n=775) received a BI for risky alcohol, tobacco, or drug use 23% (n=575) were referred for therapy or specialized treatment Recommendations for standardizing SBIRT in HIV settings include: Apply a systematic screening approach Train providers to conduct BI Establish a referral network Integrate SBIRT with adherence and retention efforts SOURCE: Fischer, L. (2012). Addiction Science & Clinical Practice, 7(Suppl 1): A73. 22

24. Can SBIRT work in your setting? 3 minutes End 23

25. Screening to Identify Patients At-Risk for Substance Use Problems 24

26. Screening Assessment What’s going on in these pictures? 25

27. Self-report Interview Self-administered questionnaires Biological markers Breathalyzer testing Blood alcohol levels Saliva or urine testing Serum drug testing 26

28. Brief (10 or fewer questions) Flexible Easy to administer, easy for patient Addresses alcohol and other drugs Indicates need for further assessment or intervention Has good “sensitivity” and “specificity” 27

29. Provide historical picture Inexpensive Non-invasive Highly sensitive for detecting potential problems or dependence 28

30. Self-reports are more accurate when people are: Alcohol- or drug-free when interviewed Told that their information is confidential Asked clearly worded, objective questions Provided memory aides (calendars, response cards) 29

31. 30

32. What is a Standard Drink? 31

33. Men: No more that 4 drinks on any day and 14 drinks per week Women: No more than 3 drinks on any day and 7 drinks per week Men and Women >65: No more than 3 drinks on any day and 7 drinks per week NIAAA, 2011 Drinking Guidelines 285 ml 100 ml 60 ml 30 ml Beer Wine Fortified Wine Liquor 12 oz 5 oz 3.5 oz 1.5 oz 32

34. Pre-screening is a very quick approach to identifying people who need to do a longer screen and brief intervention. Self-report, 1-4 questions Biological, blood alcohol level test 33

35. NIAAA 1-item for alcohol use “How many times in the past year have you had X or more drinks in a day?” 5 for men 4 for women Identifies unhealthy alcohol use Positive screen > 1 or more (provide BI) SOURCE: Smith, P.C. et al. (2009). Primary care validation of a single-question alcohol screening test. Journal of General Internal Medicine, 24(7), 787-780. 34

36. NIDA 1-item for drug use "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Identifies overall drug use Positive screen = 1 or more SOURCE: Smith, P.C. et al. (2010). A single question screening test for drug use in primary care. Archives of Internal Medicine, 170, 1155-160. 35

37. Alcohol: Women = 0 – 2 Men = 0 – 4 Alcohol: Women = 4+ Men = 5+ Other Drugs: Any Yes Other Drugs: All Nos Administer the AUDIT Administer the DAST Alcohol Screen Complete Other Drug Screen Complete Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT Complete Pre-Screen 36

38. 10-question alcohol use screening instrument Original target groups included: Medical patients Accident victims DWI offenders Mental health clients Designed for primary health care workers 37

39. Hazardous Alcohol Use Question 1: Frequency of Drinking Question 2: Typical quantity Question 3: Frequency of heavy drinking 38

40. Dependence Symptoms Question 4: Impaired control over drinking Question 5: Failure to meet expectations because of drinking Question 6: Morning drinking 39

41. Harmful Consequences of Alcohol Use Question 7: Guilt after drinking Question 8: Blackouts Question 9: Alcohol-related injuries Question 10: Others’ concerns about drinking 40

42. ScoreLevelAction 0-7LowEncouragement 8-19Low/ModerateBI 16-19ModerateBI/RT 20+HighBT/RT 41

43. I am going to ask you some personal questions about alcohol (and other drugs) that I ask all my patients. Your responses will be confidential. These questions help me to provide the best possible care. You do not have to answer them if you are uncomfortable. 42

44. Feedback? Reactions? 43

45. Administer the AUDIT Administer the DAST Alcohol Screen Complete Other Drug Screen Complete Low/No Risk: Alcohol = 0 – 7 Other drugs = 0 At Risk: Alcohol = 8 – 15 Other drugs = 1 – 2 Mod/High Risk: Alcohol = 16 – 19 Other drugs = 3 – 5 High/Severe Risk: Alcohol = 20 – 40 Other drugs = 6 – 10 Reinforce behavior; Monitor Brief Intervention Goal: Lower Risk; Reduce use to acceptable levels BI/Referral to tx/BT Goal: Encourage pt. to accept a referral to tx, or engage in BT Referral to tx. Goal: Encourage pt. to accept referral to tx, or engage in BT 44

46. Start by asking two simple questions: Do you have a dentist? Do you have any mouth/oral pain or discomfort that interferes with your eating or speaking? SOURCE: Dr. Fariba Younai, UCLA School of Dentistry (personal communication, May 24, 2013. 45

47. Brief Interventions for Patients At-Risk for Substance Use Problems 46

48. “Brief…interventions are short, face-to- face conversations regarding drinking, motivation to change, and options for change which are provided during a window of opportunity or potentially teachable moment occasioned by a medical event.” SOURCE: Dr. Craig Field, University of Texas. 47

49. Behavior change Awareness of problem Motivation Presenting problem Screening results 48

50. Brief interventions trigger change. A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min. Research is less extensive for illicit drugs, but promising. A randomized study with cocaine and heroin users found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls. SOURCE: Bernstein et al. (2005). Drug and Alcohol Dependence, 77, 49-59. 49

51. What you do depends on where the patient is in the process of changing. The first step is to be able to identify where the patient is coming from. 50

52. Stages of Change: Primary Tasks 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate change strategies 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills for maintaining recovery 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences and determine what to do next 51

53. Stages of Change: Intervention Matching Guide Offer factual information Explore the meaning of events that brought the person to treatment Explore results of previous efforts Explore pros and cons of targeted behaviors Explore the person’s sense of self- efficacy Explore expectations regarding what the change will entail Summarize self-motivational statements Continue exploration of pros and cons Offer a menu of options for change Help identify pros and cons of various change options Identify and lower barriers to change Help person enlist social support Encourage person to publicly announce plans to change Support a realistic view of change through small steps Help identify high-risk situations and develop coping strategies Assist in finding new reinforcers of positive change Help access family and social support Help identify and try alternative behaviors (drug-free sources of pleasure) Maintain supportive contact Help develop escape plan Work to set new short and long term goals Frame recurrence as a learning opportunity Explore possible behavioral, psychological, and social antecedents Help to develop alternative coping strategies Explain Stages of Change & encourage person to stay in the process Maintain supportive contact 1. Pre- contemplation 2. Contemplation 3. Determination 4. Action 5. Maintenance 6. Recurrence 52

54. 53

55. All change contains an element of ambivalence. We “want to change and don’t want to change” Patients’ ambivalence about change is the “heart” of the brief intervention. 54

56. Young man is treated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video? SOURCE: The BNI-ART Institute, Boston University School of Public Health. Interactive Cases: SBIRT in Action. Accessed on September 26, 2011 at http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/ (INSERT “BAD SBIRT” VIDEO) 55

57. Listen to both what the patient says and to what the person means Show empathy and don’t judge what patient says You do not have to agree Be aware of intonation Reflect what patient says with statement not a question, e.g., “You couldn’t get up for work in the morning.” 56

58. Repeating – Repeating what was just said. Rephrasing/Paraphrasing – Restatement of what the person said. Listener infers meaning of what was said. Can be thought of as continuing the thought. Reflecting Feeling – Listener reflects not just the words, but the feeling or emotion underneath what the person is saying. 57

59. Challenging “What do you think you are doing?” Warning “You will damage your liver if you don’t stop drinking.” Finger-wagging “If you want to be a good student, you must stop drinking on school nights.” 58

60. Benefits of change Costs of using drugs Benefits of using drugs Costs of change 59

61. Avoid questions that lead to a yes/no response. 60

62. What change are you wanting to make? What makes you want to change? What are the good things about making this change? Not-so-good things? 61

63. Change talk consists of self-motivational statements that suggest: Recognition of a problem Concern about staying the same Intention to change Optimism about change 62

64. Same scenario, but different doctor. What does this doctor do that is different? Does it work? (INSERT “GOOD SBIRT” VIDEO) SOURCE: The BNI-ART Institute, Boston University School of Public Health. Interactive Cases: SBIRT in Action. Accessed on September 26, 2011 at http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/ 63

65. 64

66. Avoid Warnings! F L O W Feedback Listen & Understand Warn Options Explored (that’s it) 65

67. Feedback Setting the stage Tell screening results Listen & understand Explore pros & cons Explain importance Assess readiness to change Options explored Discuss change options Follow up 66

68. F L O Feedback Listen & Understand Options Explored 67

69. The Feedback Sandwich Ask Permission Give Feedback Ask for Response 68

70. What you need to cover: 1. Range of scores and context 2. Screening results 3. Substance use norms in population 4. Interpretation of results (e.g., risk level) 5. Patient feedback about results 69

71. What do you say? 1. Range of score and context - Scores on the AUDIT range from 0-40. Most people who are social drinkers score less than 8. 2. Results - Your score was 18 on the alcohol screen. 3. Norms - A score of 18 means that your drinking is higher than 75% of the U.S. adult population. 4. Interpretation of results - 18 puts you in the moderate- to-high risk range. At this level, your use is putting you at risk for a variety of health issues. 5. Patient reaction/feedback - What do you make of this? 70

72. 71

73. The 1 st Task: Feedback Handling Resistance Look, I don’t have a drug problem. My dad was an alcoholic; I’m not like him. I can quit using anytime I want to. I just like the taste. Everybody drinks in college. What would you say? 72

74. Neuropathy SUD HIV Con- fusion Medical Issues Anxiety SUD 73

75. To avoid this… LET GO!!! The 1 st Task: Feedback 74

76. The 1 st Task: Feedback Easy Ways to Let Go I’m not going to push you to change anything you don’t want to change. I’d just like to give you some information. What you do is up to you. 75

77. The 1 st Task: Feedback Finding a Hook Ask the patient about their concerns Provide non-judgmental feedback/information Watch for signs of discomfort with status quo or interest or ability to change Always ask this question: “What role, if any, do you think alcohol played in your (getting injured)? Let the patient decide. Just asking the question is helpful. 76

78. Activity: Role Play Let’s practice F : Role Play Giving Feedback Using Completed Screening Tools Focus the conversation Get the ball rolling Gauge where the patient is Hear their side of the story 77

79. 78

80. F L O Feedback Listen & Understand Options Explored 79

81. Ambivalence is Normal 80

82. Tools for Change Talk Pros and Cons Importance/Readiness Ruler 81

83. 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….” 82

84. Listen for the Change Talk Maybe drinking did play a role in what happened. If I wasn’t drinking this would never have happened. Using is not really much fun anymore. I can’t afford to be in this mess again. The last thing I want to do is hurt someone else. I know I can quit because I’ve stopped before. Summarize, so they hear it twice! 83

85. 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 84

86. Activity: Role Play Let’s practice L : Role Play Listen & Understand Using Completed Screening Tool Pros and Cons Importance/Confidence/Readiness Scales Develop Discrepancy Dig for Change 85

87. O Options Explored F L Feedback Listen & Understand 86

88. What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next? 87

89. Offer a Menu of Options Manage drinking/use (cut down to low-risk limits) Eliminate your drinking/drug use (quit) Never drink and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment) 88

90. During MENUS you can also explore previous strengths, resources, and successes Have you stopped drinking/using drugs before? What personal strengths allowed you to do it? Who helped you and what did you do? Have you made other kinds of changes successfully in the past? How did you accomplish these things? 89

91. Giving Advice Without Telling Someone What to Do Provide Clear Information (Advise or Feedback ) What happens to some people is that… My recommendation would be that… Elicit their reaction What do you think? What are your thoughts? 90

92. The Advice Sandwich Ask Permission Give Advice Ask for Response 91

93. Closing the Conversation (“SEW”) S ummarize patients views (especially the pro) E ncourage them to share their views W hat agreement was reached (repeat it) 92

94. Activity: Role Play Let’s practice O : Role Play Options Explored Ask about next steps, offer menu of options Offer advice if relevant Summarize patient’s views Repeat what patient agrees to do 93

95. Feedback Range Listen and Understand Pros and Cons Importance/Confidence/Readiness Scales Summary Options Explored Menu of Options 94

96. At follow-up visit: Inquire about use Review goals and progress Reinforce and motivate Review tips for progress 95

97. Enhancing Motivation for Change Inservice Training Based Treatment Improvement Protocol (TIP) 35 Published by the Center for Substance Abuse Treatment www.samhsa.gov SOURCE: SAMHSA/CSAT. Treatment Improvement Protocol (TIP) Series: Enhancing motivation for change in substance abuse treatment. 35. Rockville (MD): U.S. DHHS. 96

98. Referral to Treatment for Patients At-Risk for Substance Dependence 97

99. Approximately 5% of patients screened will require referral to substance use evaluation and treatment. A patient may be appropriate for referral when: Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use. These high risk patients will receive a brief intervention followed by referral. 98

100. Describe treatment options to patients based on available services Develop relationships between health centers, who do screening, and local treatment centers Facilitate hand-off by: Calling to make appointment for patient/student Providing directions and clinic hours to patient/student Coordinating transportation when needed 99

101. Try screening and giving feedback only. After several practices with F add in L & O. 100

102. 101

103. Identify champions within primary care, HIV, and substance abuse settings Promote SBI as a standard of care for all patients Have an openness to new modalities, such as brief intervention and brief treatment Expand scope of focus to include high-risk alcohol and drug use, not only dependence SOURCE: J. Esquibel (2012), Colorado SBIRT, www.improvinghealthcolorado.org. 102

104. What did you learn? 103

105. 1. What is the maximum number of standard drinks that are within the low-risk drinking range for a healthy, non-pregnant 35 year-old woman? A. No more than 1 drink per occasion B. No more than 2 drinks per occasion C. No more than 3 drinks per occasion D. No more than 4 drinks per occasion 104

106. 2. Please identify what the 5-letters in the AUDIT acronym stand for: A. Alcohol Use Disease Inventory Test B. Alcohol Use Disorders Identification Test C. Alcohol Use Disorders Inventory Test D. Alcohol Use Disease Inventory Training 105

107. 3. Because of the linkage between substance use and HIV, screening and brief intervention protocols have been adopted throughout the United States. A. True B. False 106

108. 4. Brief interventions often include: A. Feedback about the patient’s drug and/or alcohol use B. Advice on how to cut down on one’s alcohol and/or drug use C. Motivational techniques D. A and B only E. All of the above 107

109. Alcohol and drug problems are common, identifiable, and treatable conditions in a variety of medical settings. Screening helps HIV providers to understand and address the consequences of untreated substance use disorders. Screening and brief intervention strategies can be used to maximize a “teachable moment” with your HIV patients. 108

110. Foundations of SBIRT Self-Paced, Online Course (www.attcelearn.org) SBIRT Implementation Guide for HIV Care Service Programs (www.centerforcommunitycollaboration.org ) NIAAA SBIRT Pocket Guide (http://pubs.niaaa.nih.gov/publications/Practitio ner/PocketGuide/pocket.pdf) SAMHSA SBIRT White Paper (http://www.samhsa.gov/prevention/sbirt/) 109

111. SAMHSA-HRSA Center for Integrated Health Solutions – SBIRT Page (http://www.integration.samhsa.gov/clinical- practice/sbirt) Alcohol SBI Guide for Public Health Professionals (http://www.apha.org/NR/rdonlyres/B03B4514- CCBA-47B9-82B0-5FEB4D2DC983/0/ SBImanualfinal4_16.pdf) National SBIRT ATTC (http://www.attcnetwork.org/regcenters/index_n fa_sbirt.asp) 110

112. Thank You! For more information: Tom Freese: tfreese@mednet.ucla.edutfreese@mednet.ucla.edu Beth Rutkowski: brutkowski@mednet.ucla.edubrutkowski@mednet.ucla.edu Maya Talisa Gil-Cantu: maya@HIVtrainingCDU.orgmaya@HIVtrainingCDU.org Pacific Southwest ATTC: www.psattc.orgwww.psattc.org PAETC Training calendar: www.HIVtrainingCDU.orgwww.HIVtrainingCDU.org