1. SBIRT and Public Health Practice: The Peer In-Reach Team Model …bridging the gap between clinical medicine and public health Edward Bernstein MD Judith Bernstein RNC, PhD Dept. of Emergency Medicine Project Assert and the BNI-ART Institute NIAAA Youth Alcohol Prevention Center NIAAA Youth Alcohol Prevention Center

2. BNI-ART Education Faculty Lisa Allee MSW, Boston Medical CenterLisa Allee MSW, Boston Medical Center Kate Brown, Youth Alcohol Prevention Center, BU School of Public HealthKate Brown, Youth Alcohol Prevention Center, BU School of Public Health James Feldman MD, Dept. of Emergency Medicine, BU School of MedicineJames Feldman MD, Dept. of Emergency Medicine, BU School of Medicine William Fernandez MD, Dept. of EM, BU School of MedicineWilliam Fernandez MD, Dept. of EM, BU School of Medicine Andrea Hall LISW, Boston Medical Center/ BEST TeamAndrea Hall LISW, Boston Medical Center/ BEST Team Patricia Mitchell RN, Dept. of EM, BU School of MedicinePatricia Mitchell RN, Dept. of EM, BU School of Medicine Melanie Rambaud, Youth Alcohol Prevention Center, BU School of Public HealthMelanie Rambaud, Youth Alcohol Prevention Center, BU School of Public Health Brenda Rodriquez MBA, BNI-ART Institute, BU School of Public HealthBrenda Rodriquez MBA, BNI-ART Institute, BU School of Public Health Benjamin Shelton MD, Chief Resident, EM Residency Program, Boston Medical CenterBenjamin Shelton MD, Chief Resident, EM Residency Program, Boston Medical Center Luann Sweeney RN, Boston Medical CenterLuann Sweeney RN, Boston Medical Center Ludy Young, Licensed LADC II, Project ASSERT, BMCLudy Young, Licensed LADC II, Project ASSERT, BMC

3. SBIRT Workshop rationale and evidence for SBIRT Project ASSERT collaborative model NIAAA screening guidelines motivational interviewing principles brief negotiation interview & referral skills practice SBIRT with case studies

4. Contending Frameworks, Strategies & Policies Is addiction a moral failing/crimeIs addiction a moral failing/crime –best controlled by punishment (jail or drug court mandate) Is addiction a medical problemIs addiction a medical problem –best treated by acute and chronic disease management Is addiction a public health problem requires access toIs addiction a public health problem requires access to –universal screening –brief intervention –specialized treatment –comprehensive supports for individuals, families and communities (i.e. jobs, mental health services and housing) –safeguards for human rights

5. Why do SBIRT? SBIRT--Treatment Works! NESARC study 2001-02 35.9% of U.S. adults with alcohol dependence that began more than one year ago were in full recovery (18% abstainers, 17% low risk drinkers)35.9% of U.S. adults with alcohol dependence that began more than one year ago were in full recovery (18% abstainers, 17% low risk drinkers) an additional 27% were in partial remissionan additional 27% were in partial remission 12% were asymptomatic high risk drinkers12% were asymptomatic high risk drinkers only 25% with alcohol dependence who began treatment more than one year ago were still dependent (treatment failures)only 25% with alcohol dependence who began treatment more than one year ago were still dependent (treatment failures)

6. Substance abuse resembles other chronic recurrent illnesses: a time for a paradigm shift <30% of patients with asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes, and 50% experience recurrence<30% of patients with asthma, HTN, diabetes adhere to prescribed diet and/or behavioral changes, and 50% experience recurrence challenges of adherence and recurrence with a substance abuse diagnosis are not different from those found in other chronic diseaseschallenges of adherence and recurrence with a substance abuse diagnosis are not different from those found in other chronic diseases substance abuse should be insured, monitored, treated and evaluated like other chronic diseasessubstance abuse should be insured, monitored, treated and evaluated like other chronic diseases McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.

7. THE TREATMENT GAP Past Year Need for & Receipt of Tx for Illicit Drug/ Alcohol Abuse among Persons Aged 12+: 2002-3

8. WHY DO SBIRT: SCREENING WIDENS THE NET ABSTAINERS & MILD DRINKERS (71%) AT-RISK DRINKERS (20%) ABUSE/ DEPENDENCE (8.5%) Primary Prevention Brief Intervention Specialized Treatment

9. Intersection of Opportunity & Need An Emergency Department Perspective Intersection of Opportunity & Need An Emergency Department Perspective 7.6 /111 million ED visits are alcohol attributable (McDonald, 2004)7.6 /111 million ED visits are alcohol attributable (McDonald, 2004) 31% of urban ED pts > 2 CAGE positive (Bernstein, 1996)31% of urban ED pts > 2 CAGE positive (Bernstein, 1996) 26% of ED patients high risk/dependent drinkers (Academic ED SBIRT Collaborative, 2005)26% of ED patients high risk/dependent drinkers (Academic ED SBIRT Collaborative, 2005)

10. WHY DO SBIRT? …because brief intervention works! Chafetz et al, 1961Chafetz et al, 1961 –(n=200) –65% of those receiving brief intervention in the MGH ED showed up for treatment vs 5% of controls –40% in the intervention group vs 0% in the control group kept 5 appointments Establishing treatment relations with alcoholics. J Nerv Ment Dis 1962; 134: 390-410.

11. Brief Intervention in the Trauma Center 1153 (46%) of 2524 screened positive1153 (46%) of 2524 screened positive 762 were randomized to control or intervention status762 were randomized to control or intervention status at 6 months, decreases in both groups (NS)at 6 months, decreases in both groups (NS) at 12 monthsat 12 months –↓ 21.9 drinks per week (intervention) vs 6.7 (control) at 3 yearsat 3 years –47% greater reduction in serious repeat injuries in the intervention group vs controls (state dataset) Gentilello, Rivara et al. Ann Surg 1999; 230: 473-483

12. Meta-analyses of Motivational Interviewing small but real effect sizessmall but real effect sizes –Dunn et al, 2001 –Hettema et al, 2005 (.30 at 1 yr) –Vasilaki et al, 2006 (aggregate.18,.60 at 3 mo)

13. So if brief intervention works and saves money… Why don’t health professionals routinely screen, practice brief intervention, and refer, when indicated, to the substance abuse treatment system?

15. Project ASSERT: Bringing down the barriers A Model for Brief Intervention in the ED 1993 SAMHSA –CSAT Critical Populations Demonstration Grant Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based intervention to increase access to primary care, preventive services and the substance abuse treatment system. Ann Emerg Med 1997;30:181-189.

16. Established with funding from CSAT in 1993 to empower patients to reduce substance abuse and other harmful health and social behaviors, and facilitate ED patient access to primary care, preventive services and substance abuse treatment.

18. Peer educators provide consultation to nurses and physicians

19. …providing empathy and support

20. …offering resources

21. From CSAT Demonstration Grant to Boston Medical Center ED Budget Line Item… RESULTS FROM PROJECT ASSERT 17,495 patients received screening and BNI from 2001-200517,495 patients received screening and BNI from 2001-2005 16,114 total referrals made to SA treatment, AA/NA, social service, behavioral health and primary care.16,114 total referrals made to SA treatment, AA/NA, social service, behavioral health and primary care. 5,607 patients sent to detox often by taxi5,607 patients sent to detox often by taxi 1608 beds detox unavailable—case management1608 beds detox unavailable—case management 1708 SA outpatient1708 SA outpatient 1,656 appointments made for primary care1,656 appointments made for primary care

22. Brief Intervention in the Clinical Setting Reduces Cocaine and Heroin Use Bernstein et al. Drug & Alcohol Dependence, 2004;77:49-59 23,669 patients screened23,669 patients screened 1175 enrollees (follow-up rate 82%)1175 enrollees (follow-up rate 82%) among 778 with positive hair at baselineamong 778 with positive hair at baseline –intervention group more likely to be abstinent at 30 days than the control group cocaine alone (22.3% vs 16.9%)cocaine alone (22.3% vs 16.9%) heroin alone (40.2% vs 30.6%)heroin alone (40.2% vs 30.6%) both drugs (17.4% v s 12.8%), with adjusted OR of 1.51-1.57both drugs (17.4% v s 12.8%), with adjusted OR of 1.51-1.57 –cocaine levels in hair reduced 29% for intervention group vs 4% control group29% for intervention group vs 4% control group

23. THE IMPACT OF ED Provider SBIRT ON PATIENTS’ ALCOHOL USE THE IMPACT OF ED Provider SBIRT ON PATIENTS’ ALCOHOL USE Funded in part by NIAAA R21 AA015123 and 14 RO3s AA 01511-14 with collaborative funding from SAMHSA

24. 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

25. Patient Response to SBIRT at 3 month F/U Summary At 3 months, controlling for baseline drinking levels, patients receiving the intervention reportedAt 3 months, controlling for baseline drinking levels, patients receiving the intervention reported –3.25 fewer ‘typical number of drinks per week’ than controls (B= -3.25 SE= 1.16, p <.05) –almost ¾ of a drink less for ‘maximum number of drinks per occasion’ than controls (B= -.72 SE=.32, p <.05). Benefits of brief intervention were confined to those with at-risk drinking rather than dependent drinking patterns, as measured by the CAGE.Benefits of brief intervention were confined to those with at-risk drinking rather than dependent drinking patterns, as measured by the CAGE.

26. SBIRT The Toolbox

27. SBIRT: Why Screen? THE PROBLEM DRINKER (National Gallery)

28. Screening Questions   Do you smoke? Do you drink? Do you use drugs?   On average, how many days per week do you drink alcohol ( beer, wine, liquor )?   On a typical day when you drink, how many drinks do you have?   NIAAA Guidelines (risky drinking):>14 drinks/week for men and >7 drinks per week for women   What is the maximum number of drinks you had on any given occasion during the last month?   NIAAA Guidelines: >4 for men & >3 for women

29. Remember that a “standard drink” consists of:

30. THE ED BRIEF NEGOTIATION INTERVIEW A toolkit for enhancing motivation for change in the clinical setting-- developed with Stephen Rollnick,1994

31. Effective communication about alcohol and drugs…. ….approaching the drinking driver to facilitate behavior change from The Emergency Physician and the Problem Drinker D’Onofrio, Bernstein & Bernstein, 1996

32. NEGOTIATING BEHAVIOR CHANGE Principles of Good Practice Respect the autonomy of clients and their choicesRespect the autonomy of clients and their choices Set an agenda for change togetherSet an agenda for change together Offer information in a neutral, non-personal mannerOffer information in a neutral, non-personal manner Make clear from the start that the client is the active decision makerMake clear from the start that the client is the active decision maker

33. OTHER PRINCIPLES OF MOTIVATIONAL INTERVIEWING Ask open-ended questions.Ask open-ended questions. Practice reflective listening to encourage patients to talk about their drinking and the barriers to change.Practice reflective listening to encourage patients to talk about their drinking and the barriers to change. Accept resistance as a normal response.Accept resistance as a normal response. Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.

34. NEGOTIATING BEHAVIOR CHANGE Principles of Good Practice “Motivational interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change.” Stephen Rollnick, PhD Addiction 2001; 96:1769-70.

35. THE BRIEF NEGOTIATION INTERVIEW establish rapport & ask permission to raise subject provide feedback enhance motivation explore pros and cons assess readiness to change and sources of resilience explore discrepancies between actual state & goals develop action plan, using strengths/resources referral to primary care and tx if indicated 1 2 3 4 5 6 7 8 9 10 UNSURE (4 - 7) NOT READY (1 - 3) READY (8 - 10)

36. INTERVENTION ALGORITHM 1. Raise subject 1. Raise subject 2. Provide feedback Review screen Make connection For alcohol… Show NIAAA guidelines & norms Hello, I am _____. Would you mind taking a few minutes to talk with me about your use of [X]? > Before we start, could you tell me a little about yourself and your goals (or what’s important to you?) From what I understand you are using [insert screening data]… We know that drinking above certain levels and/or use of illicit drugs can cause problems, such as [insert medical info]… I am concerned about your use of [X]. What connection (if any) do you see between your use of [X] and this ED visit? If pt sees connection: reiterate what pt has said. If pt does not see connection, suggest one, using medical info (but don’t confront). These are what we consider the upper limits of low risk drinking for your age and sex. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines.

37. 3. Enhance motivation Explore Pros and Cons Use reflective listening Use reflective listening Readiness to change Reinforce positives Develop discrepancy between ideal and present self Ask pros and cons. Help me to understand what you enjoy about [X]? > Now tell me what you enjoy less about [X] or regret about your use. > On the one hand you said… > On the other hand you said…. > So tell me, where does this leave you? [show readiness ruler] On a scale from 1-10, how ready are you to change any aspect of your use of [X]? Ask: Why did you choose that number and not a lower one like a 1 or a 2? Other reasons for change? How does this fit with where you see yourself in the future?

38. 4. Negotiate & advise Negotiate goal Benefits of change Reinforce resilience / resourcesSummarize Provide handouts Suggest PC f/u Thank patient What’s the next step? What do you think you can do to stay healthy and safe? If you make these changes what do you think might happen? What have you succeeded in changing in the past? How? Could you use these methods to help you with the challenges of changing? This is what I’ve heard you say…Here’s an agreement I would like you to fill out, reinforcing your new goals. This is really an agreement between you and yourself. Provide agreement and information sheet Suggest Primary Care f/u to discuss/support carrying out plan Thank patient for his/her time

39. Applying the algorithm… Getting to ‘yes’ with a high risk drinker Provider: Clara Safi, NP www.ed.bmc.org/sbirt

40. Connecting drinking & Reason for Visit This is the patient’s chance to name the problem.This is the patient’s chance to name the problem. If there is resistance or lack of awareness of a connection, the provider can help the patient see the connection.If there is resistance or lack of awareness of a connection, the provider can help the patient see the connection. Listen carefully for the patient’s own concerns to make the link.Listen carefully for the patient’s own concerns to make the link. Use open ended questions to explore:Use open ended questions to explore: –What would make this a problem for you? –How might you prevent that from happening? –Have you ever done anything you wished you hadn’t while drinking? Give feedback empathetically, with no shame or blame.Give feedback empathetically, with no shame or blame.

41. 1 2 3 4 5 6 7 8 9 10 ASSESSING READINESS TO CHANGE On a scale of 1-10, ten meaning ‘most ready’ and one ‘least ready’, please mark on the ruler where you are now on your readiness to change your use of alcohol and/ or drugs? You marked five, which indicates you are fifty percent ready to make a change, so tell me, why didn’t you mark a lower number like a one or two?

42. The pros and cons in action…. Provider: Ludy Young, Health Promotion Advocate at National Alcohol Screening Day www.ed.bmc.org/sbirt

43. Exploring the Pros and Cons exploring the pros and cons can help you understand where the patient is coming from and obstacles to changeexploring the pros and cons can help you understand where the patient is coming from and obstacles to change pros and cons strategypros and cons strategy –ask, “What do you like about your use of [X]?” –acknowledge that you have heard what they say –elicit statements about consequences by asking “What do you like less or regret about your use?”“What do you like less or regret about your use?” –repeat and affirm statements that lead to change –summarize briefly: on the one hand you said.., and on the other you said…. –ask, “Where does that leave you?” On a scale of 1-10, how ready are you to make some changes?

44. Provider advice and negotiation with the dependent drinker…. Provider: Gail D’Onofrio, MD www.ed.bmc.org/sbirt

45. THE ROLE OF PROVIDER ADVICE meet people where they are atmeet people where they are at timing is important—the patient should feel heard and respected before the physician weighs intiming is important—the patient should feel heard and respected before the physician weighs in conversational style matters—advice should be brief, and non-judgmentalconversational style matters—advice should be brief, and non-judgmental advice should be based on fact and weave in medical eventsadvice should be based on fact and weave in medical events

46. IN NEGOTIATING A PLAN, EXPLORE…. previous strengths, resources and successesprevious 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?” or or –“Have you made other kinds of changes successfully in the past?” –“How did you accomplish these things?”

47. Developing and Using a Referral Network Provider expectations: setting realistic goals for change in a chronic diseaseProvider expectations: setting realistic goals for change in a chronic disease http://findtreatment.samhsa.govhttp://findtreatment.samhsa.govhttp://findtreatment.samhsa.gov www.ed.bmc.org/sbirtwww.ed.bmc.org/sbirt