1. Erich

2. Screening, Brief Intervention, and Referral to Treatment
CDR Kellie Cosby &
CDR Erich Kleinschmidt
Erich/ Kellie Introduce themselves.
Briefly discuss SAMHSA/CSAT and where SBIRT is housed there.

3. Recent CDC report – Jan. 2012
One in six Americans binge drinks four times per month
Average number of drinks during binge is 8
40,000 deaths per year (binge-specific)
$167.7 billion alcohol-related costs
Age group that binge drinks most often – 65+
Income group with most binge drinkers - $75K+
CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
Erich: Introduction
Notice populations with most severe problems – aged and middle-high income earners (doesn’t fit “typical” profile for alcohol abuser; these are good candidates for SBIRT); 65+ age group most episodes of binge drinking per month (5.5)
Age group with most binge drinkers – y/o; income group that binge drinks the most and the highest levels of etoh - $25K or less.

4. CDC Report continued – binge drinking responsible for:
Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS
85% of all alcohol-impaired driving episodes involved binge drinking (2010)
Accounted for 50% of all alcohol consumed by adults; 90% of youth
Most binge drinkers are not dependent
CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
Erich
States that most people who binge drink are not alcohol-dependent

5. Focus of SBIRT 4% 25% 71% Dependent Use Brief Intervention and
Referral to Treatment
Harmful or
Risky Use
Brief Intervention
Low Risk Use
or Abstention
Erich
Based on US population’s drinking usage; SBIRT mainly identifies those in 25% section “harmful or risky use” No
Intervention

6. What exactly is SBIRT?
SBIRT—Screening, Brief Intervention, and Referral to Treatment
Universal screening of patients within medical settings with use of validated screening tools
If screened positive – brief intervention (guided discussion) with medical provider occurs
If screening reveals dependence – referral to specialty substance abuse treatment provider
Kellie
Use of validated screening tools such as AUDIT, DAST, ASSIST; training and use of Motivational Interviewing – non-judgemental therapy based in “stages of change” model. Erich will talk more about the tools on a later slide.

7. SBIRT: Primary Care Context
Takes advantage of the “teachable moment”
Patients aren’t seeking treatment but screening opens door for awareness & education
Focus on addressing low/moderate risk usage as a preventative approach before addiction occurs
Kellie
CDC reports Americans, on average, visit their primary care provider at least once per year. Providers can link chronic health conditions and/or injuries that may be caused, or at least exacerbated, by excessive drinking or drug use. Medical “crisis” often provides the motivation to pts that they may need to move into action.
Example of dentist with tooth decay and/or doctor with pre-diabetic pts. 7

8. Ranked in top ten of prevention services
Discuss daily use of aspirin
Childhood immunization Series
Tobacco use screening and brief intervention
Colorectal cancer screening
Hypertension screening
Influenza immunization
Pneumococcal immunization
Problem drinking screening & brief intervention
Vision screening – adults
Cervical cancer screening
(Partnership for Prevention – Priorities for America’s Health:
Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)
Kellie
The National Commission on Prevention Priorities has ranked 25 clinical preventive services based on their relative health impact (number of deaths and diseases that would be prevented) and cost effectiveness.

9. SBIRT “Patient Flow” Brief Intervention Screen Brief Treatment
Cognitive behavioral treatment with multiple sessions available
Brief Intervention
Raises awareness of risks and motivates client toward concrete goals/actions
Screen
Identification of substance related problems
Erich
Referral to Tx
Referral of those with more serious abuse/dependency 9

10. Universal Prescreen (-) Negative (+) Positive Further screening with
Provide positive reinforcement
(+) Positive
Further screening with
ASSIST
AUDIT
CRAFFT
DAST
Low risk: Provide positive reinforcement
Moderate risk: Provide Brief Intervention
Erich
Use of “pre-screening” provides fast preliminary identification of pts who may have substance abuse problems (use of two or three questions typically). Very useful in time-stressed medical settings. Positive pre-screenings go on to “full” screens” such as listed above.
Moderate high-risk: Provide Brief Therapy
High risk:
Refer to treatment

11. Effective Screening Program Typically Yields…
Approximately 25% of all patients will screen positive for some level of substance misuse or abuse
Of those, the approximately 70% will be “at-risk” drinkers
Most will be open to addressing their substance abuse problems (if discussed in a non-judgmental manner)
Kellie
Based on GPRA reporting by past three cohort of SBIRT grantees.
Based on our experiences from our SBIRT medical residency training grant program, many physicians don’t feel it’s their “job” to address substance abuse problems with their pts. Many uncomfortable with discussing such topics or take a “motivation by threats” approach which puts pts on defensive mode.
NIAAA guidelines – 3 drinks per day for women (7 total per week) & 4 drinks per day for men (14 total per wee

12. Brief Intervention Approach
Uses “Motivational Interviewing” techniques
Discuss healthy drinking levels for male/females (NIAAA standards)
Weigh pros/cons of cutting down or quitting
Use “scaling” to assess for readiness (i.e – on a 1 to 10 scale….)
Effects on quality of life and/or existing medical conditions
Plan to talk about it more than once (at future doctor visits)
Small, obtainable goals (let patient tell you want he/she can handle)
Erich

13. Identify Referral Resources
Short-term and long-term residential treatment centers
Community agencies for referrals
Erich
If patient is dependent/addicted; link to more intensive/specialty treatment providers; use of referral process
Hospital inpatient and outpatient centers
State treatment centers 13

14. Has been implemented in many settings
Thus far, SAMHSA has funded 21 states, 2 tribal organizations, and 12 colleges since 2003 (five year grants to states; 3 year to colleges)
Clinical sites include: trauma centers, EDs, inpatient units, community health centers, FQHCs, tribal health centers, elder services agencies, adolescent care clinics, college health centers, VA clinics, rural, urban, suburban
SBIRT training of resident physicians (17 grantees) since Sept ’08 (five year grants)
Kellie

15. Other Fed Collaborations
Dept of Labor – Youthbuild program – construction jobs training for at-risk young adults; pilot tested SBIRT in several sites in 2011; now plan to implement in all sites in US
Dept of Navy – assisted with physician training in SBIRT; planning on implementing within medical home and readiness clinic at Bethesda, MD (National Military Medical Center)
NIDA – integration of screenings within EHR systems
Kellie

16. Possible Federal Initiatives
Further expansion of SBIRT model into other health conditions related to behavioral change (ie – tobacco, depression, weight mgt, medication adherence, chronic illness mgt)
Further workforce development necessary to prepare medical providers to address behavioral related medical conditions
Kellie
Based on finding in the Primary Care Mental Health Behavioral Health integration white paper additional training is needed ( ??) Expand

17. Key Considerations for Starting SBI Program
Identify target population and location(s)
Develop a Screening protocol
Develop a Brief Intervention protocol
Identify staff to monitor and evaluate program (strong QI mgt essential)
Reimbursement strategy & considerations
Staff training needs and supervision
Program “champions” and buy-in from CEO/Admin staff
Erich 17 17

18. Additional Considerations
Who Will Do the Screening and Brief Intervention?
“SBIRT” counselors/health educator model
Social Workers
Registered Nurses
Psychologists
Physicians
Dedicated contracted personnel
Medical Assistants
Para-professionals
Kellie 18 18

19. Challenges & Lessons Learned
Buy-in issues from existing medical staff
Funding for additional staffing (or train existing staff)
Need for management to be supportive and influence implementation
Consistent training available for new staff
Kellie
Buy in issues: (time/work load, don’t want to deal with “addicts”, now that we’ve identified them, now what?, etc..)

20. Useful Resources
Numerous SBIRT grantee websites with training videos, screening protocols, insurance/billing information, toolkits, etc…
Addiction Technology Transfer Centers (ATTC) – SAMHSA funded trainings in SBIRT, MI, etc…
Other non-fed funded organizations offering training, resources, etc…
Kellie
If you would like additional information we can provide an extensive list of resources upon request.

21. Questions/Discussion
For additional information and resources. Contact:
Kellie
Our contact information is listed here. Reed Forman is the team leader of the SBIRT team and is available to discuss SBIRT resources along with Erich and myself.