11/2/2016
Screening, Brief Intervention
and Referral to Treatment
(SBIRT)
in the community setting
Nancy Goldstein, DNP, APRN-BC
Acknowledgements
• This content is, in part, provided to
students in the MSN Entry into Nursing
Program at Johns Hopkins School of
Nursing, “Advancing and Sustaining SBIRT
Nursing Curricula.”
• The project is funded by Substance Abuse
and Mental Health Services Administration
(1 H79 TI025964-01) to Dr. Deborah S.
Finnell, PI.
Objectives
1. Identify potential health impact of substance
misuse and abuse (focus on Alcohol)
2. Describe universal substance use screening in the
practice setting
3. Understand application of screening tools in brief
intervention
4. Develop strategies for treatment plan
3
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What is SBIRT?
• Comprehensive, integrated, public health approach to
delivery of early intervention and treatment services
Screening: Universal screening for at-risk substance use
including alcohol, drugs and nonprescription use of
psychoactive medication.
Brief Intervention: Brief intervention aimed at reduction of
at-risk substance use using motivational interviewing
techniques
Referral to Treatment: Referrals for further assessment and
treatment for the person with a possible substance use
disorder.
(Substance Abuse and M ental Health Services Administration; SAM SHA, 2015; National Institute on Alcohol Abuse and Alcoholism; NIAAA, 2015)
4
Patient Comfort with
Screening Questions
80
70
60
50
40
30
20
10
0
Diet/Exercise
Smoking
Very Comfortable
Alcohol Use
Very Uncomfortable
(Nakashian, 2007)
5
Low Risk Alcohol Use
MEN over 65
years of age
and
(NIAAA, 2015)
6
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Pattern of Use:
Binge Alcohol Use
• 5 or more drinks
on one occasion
for men
• 4 or more drinks
on one occasion
for women of all
ages and men >
65 years
(NIAAA, 2015)
7
Blood Alcohol Concentration*
of 0.08
• Usually occurs with the
consumption of 4 or
more drinks in about 2
hours (3 or more with
women)
• Results in trouble
controlling speed and
difficulty processing
information and
reasoning
(CDC, 2015)
A BAC of 0.08 (0.08%) means there are 0.08 g
of alcohol for every dL of blood.
8
Screening, Brief Intervention,
Does It Work?
• “Alcohol Brief
interventions are feasible
and highly effective
components of an overall
public health approach to
reducing alcohol misuse.”
(Whitlock et al., 2004)
• “It [BI] can reduce how
much alcohol a person
drinks on an occasion by
25%.”
• For Drug Use there is less
evidence that SBI results
in a reduction in drug
use.
• Based on the severity of
the consequences (e.g.
opioid overdose deaths),
it is essential to offer an
intervention that has the
potential to reduce drug
related harm.
(CDC, 2015)
• Supported by SAMHSA
and CDC
9
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Global Burden of Disease
• Globally alcohol and drug use are
associated with increased risk for
adverse health consequences.
• Alcohol is one of the top three risk
factors for preventable deaths and
accounts for 5.4% of the global burden
of disease.
(United Nations; UN, 2014; World Health Organization; WHO, 2014)
10
Substance Use Past 30 Days
2014 Survey of 12 years & older
Alcohol Use
•
Illicit Drug Use
Current
•
Current All Ages  10.2%
– 18 to 25  22%
– All Ages  52.7%
– 26 or older  8.3%
– 18 to 25  59.6%
– 26 or older  56.5%
•
Marijuana Use
•
Heroin Use
•
Nonmedical Use of Psychoactive
Drugs
– 8.4%
•
Binge Alcohol Use
5 or more drinks on same occasion
on at least one day
– All Ages  23%
•
Heavy Alcohol Use
5 or more drinks on same occasion
5 or more days
– All ages  6.2%
– 0.3%
– 2.5%
(Center for Behavioral Health Statistics and Quality, 2015)
13
Harms Related to Substance Use
Injury/Trauma
Criminal Justice
Involvement
Mental Health
Consequences
(e.g., anxiety,
depression)
Social Problems
Increased
Absenteeism and
Accidents in the
Workplace
> 200 diseases/injuries
associated with or caused
by harmful use of alcohol
(US DHHS, 2013)
(WHO, 2014)
12
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Alcohol Use Among Women
2013
• 47.5 % of women aged 12 and older reported current drinking
• Women aged 18-25
– 56.9% reported current alcohol use
– 33.2 % reported binge drinking
• Women aged 25 or older
–
50.1% of reported current alcohol use
– 14.7% reported binge drinking
• Pregnant women
– 9.4% of pregnant women aged 15 to 44
reported alcohol use
– 2.3% reported binge drinking
– Lower alcohol use during the second & third trimesters
than during first trimester (5.0% and 4.4% vs. 19.0%)
13
(SAMSHA, 2015)
(SAMHSA, 2014)
Shifting the Paradigm
From detection
of substance
use disorders
To
identification
of health risk
14
Screening:
Primary & Secondary Prevention
• Used to identify persons among a
population who are apparently well
who may have a disease.
– It is not diagnostic
• Includes early identification of those
– With a substance use disorder (SUD)
– Those at risk for alcohol associated
disease and/or injury
15
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Screening for
Substance Use
What Does “At-Risk” Mean?
17
Universal Screening
• Used to detect at-risk alcohol and drug use at
an early stage—before the development of
adverse consequences.
• Screening tools typically examine quantity,
pattern, duration, and frequency of alcohol
and drug use.
• Provide opportunity to intervene and educate
about at-risk alcohol and other drug use.
18
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Screening in Practice Setting
At check-in, patient
completes a health and
wellness screen including
substance use screening
questions
Patient escorted to
examine room.
Clinician reviews
screen
Patient in
need of
treatment
Yes
Referral to
Treatment
made at
that time
No
No
Positive
screen
Reinforce
positive
health
behavior
Yes
Patient
encounter
documented
in EMR
Patient
encounter
documented
in EMR
Patient asked to
complete screening
tool
Clinician reviews results
of screening and delivers
brief intervention
Clinician follow up
scheduled
Clinician follow up
scheduled
19
Standard Drink
Equivalent to 14 grams pure alcohol
20
Alcohol Screening Flow
A Positive Alcohol Screen
= At-Risk
Alcohol Use Above Recommended Daily Limits
(in a day 5 for men or 4 for women of all ages & anyone 65+)
> Recommended limits = at-risk
NO
YES
Patient is at low risk.
Patient is at risk. Screen for
maladaptive pattern of use and
clinically significant alcohol
impairment using AUDIT (US).
21
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Single Question Alcohol
Screen
Do you sometimes drink beer, wine, or other
alcoholic beverages?
If yes 
• How many times in the past year have you had five
(men) or four (women of all ages and men over age
65) drinks or more in a day?
Positive score = one or more times  move on to full
screen
(Smith et al., 2009)
22
Alcohol Use Disorders
Identification Test
AUDIT 1-3 (US)
• Short, easy-to-administer screen using the
first three questions of the AUDIT (US)
• Developed to measure weekly alcohol
consumption and occasions of excessive
alcohol use.
(Babor et al., 2006)
23
AUDIT 1-3 (US)
Questions
1.How often do you have
a drink containing
alcohol?
2.How many drinks
containing alcohol do
you have on a typical
day when you are
drinking?
3.How often do you have X
(5 for men; 4 for women
& men over age 65) or
more drinks on one
occasion?
0
1
2
3
4
5
6
Never
Less than
monthly
Monthly
Weekly
2-3
times a
week
4-6
times
a
week
Daily
1 drink
2 drinks
3 drinks
4 drinks
5-6
drinks
7-9
drinks
10 or
more
drinks
Never
Less than
monthly
Monthly
Weekly
2-3
times a
week
4-5
times
a
week
Daily
24
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Scoring and Interpretation
Scoring: All three items are scored 0 to 6. Then, add all the scores to obtain
the total score.
Interpreting the AUDIT 1-3 (US):
• A score of 7 or more for men over age 65 and women of all
ages is positive.
• A score of 8 or more for men under age 65 is positive.
25
Alcohol Use Disorders
Identification Test
AUDIT (US)
• Ten questions, self-administered or through
an interview;
• Questions address recent alcohol use,
alcohol dependence symptoms, and alcoholrelated problems.
• Developed by World Health Organization
(WHO).
(Babor et al., 2001)
26
AUDIT (US)
Strengths
• Public domain—test and manual are free.
• Validated in multiple settings, including primary care.
• Brief, flexible.
• Focuses on recent alcohol use.
• Consistent with ICD-10 and Diagnostic and Statistical
Manual 5th Edition definitions of alcohol disorders.
Limitations
• Does not screen for drug use, only alcohol.
27
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AUDIT (US)
Questions
1.How often do you have
a drink containing
alcohol?
2.How many drinks
containing alcohol do
you have on a typical
day when you are
drinking?
3.How often do you have
X (5 for men; 4 for
women & men over age
65) or more drinks on
one occasion?
0
1
2
3
4
5
6
Never
Less than
monthly
Monthly
Weekly
2-3
times a
week
4-6
times
a
week
Daily
1 drink
2 drinks
3 drinks
4 drinks
5-6
drinks
7-9
drinks
10 or
more
drinks
Never
Less than
monthly
Monthly
Weekly
2-3
times a
week
4-5
times
a
week
Daily
28
0
1
2
3
4
4. How often during the last year have you
found that you were not able to stop
drinking once you had started?
5. How often during the last year have you
failed to do what was expected of you
because of drinking?
6. How often during the last year have you
needed a first drink in the morning to get
yourself going after a heavy drinking
session?
7. How often during the last year have you
had a feeling of guilt or remorse after
drinking?
8. How often during the last year have you
been unable to remember what happened
the night before because you had been
drinking?
9. Have you or someone else been injured
because of your drinking?
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
No
Yes, but
not in
the past
year
Yes,
during
the past
year
10.Has a relative or friend or a doctor or other
health worker been concerned about your
drinking or suggested that you cut down?
No
Yes, but
not in
the past
year
Yes,
during
the past
year
Questions
5
6
29
Scoring and Interpretation
Scoring: Items 1, 2, and 3 are scored 0 to 6. Items 4 to 8 are scored 0 to 4. Items 9 and 10 are
scored 0 (No), 2 (yes, but not in the last year), and 4 (yes, during the last year). Then, add all the
item scores to obtain the total score.
Interpreting the AUDIT (US):
•
A score of 0-7 suggests abstinence or drinking below the low-risk
guidelines. These patients should receive information that defines
risky drinking levels and when any alcohol consumption is
unhealthy.
•
A score of 8-15 suggests drinking in excess of screening guidelines,
which merits a brief intervention.
•
A score of 16-19 suggest not only drinking above guidelines but also
the experience of alcohol-related harm, which merits a brief
intervention and follow-up.
•
A score of 20 or more suggests but does not diagnose alcohol
disorder, which may require a referral to specialized treatment.
30
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Drug Use Screening Flow
A Positive Drug Prescreen
= At-Risk
Positive Drug Prescreen?
NO
YES
Patient is at low risk.
Patient is at risk. Screen for
maladaptive pattern of use
and clinically significant drug
impairment using DAST.
31
Single Drug Question Screen
• How many times in the past year have you
used an illegal drug or used a prescription
medication for nonmedical reasons, for
instance because of the experience or
feeling it caused?
• Positive screen =1 or more times. (If
response is, “None,” screening is complete).
(Smith et al., 2009)
32
Drug Abuse Screening Test
(DAST 10)
• Designed to provide a brief instrument for
clinical screening of drug use.
• Can be used for adults and older youth to
determine extent of drug use.
(Skinner, 1982)
33
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DAST 10
Strengths
• Sensitive screening tool for at-risk drug use.
Weaknesses
• Does not include alcohol use.
• Focuses on drug use disorder.
• Does not distinguish between active and
inactive use.
• Does not include quantity, frequency, pattern,
duration or type of drug used.
34
DAST 10
These questions refer to the past 12 months only. Please circle your response.
1. Have you used drugs other than those required for medical reasons?
Yes
No
2. Do you abuse more than one drug at a time?
Yes
No
3. Are you always able to stop using drugs when you want to?
Yes
No
4. Have you ever had blackouts or flashbacks as a result of drug use?
Yes
No
5. Do you ever feel bad or guilty about your drug use?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
6. Does your spouse (or parents) ever complain about your involvement
with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you
stopped taking drugs?
10. Have you had medical problems as a result of your drug use (e.g.
memory loss, hepatitis, convulsions, bleeding)?
Total:
Scoring: For all items except #3, each “Yes” = 1; “No = 0.; Item # 3 “No” = 1. Add all items to obtain total score.
35
Interpretation
DAST-10 Score
Degree of Problems
Related to Drug Abuse
Suggested Action
0
No problems reported
None at this time
1–2
Low level
3–5
Moderate level
Monitor, re‐assess at a
later date
Further investigation
6–8
Substantial level
Intensive assessment
9–10
Severe level
Intensive assessment
36
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Screening < 21 years
During the past 12 months did you
1. Drink any alcohol (more than a few sips)? (Do not
count sips of alcohol taken during family or
religious events.)
2. Smoke any marijuana or hashish?
3. Use anything else to get high? (“anything else”
includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or
“huff”)
Scoring: No response to all, ask “Car” question on CRAFFT; Any
Yes response, ask all 6 CRAFFT questions.
37
CRAFFT
1. Have you ever ridden in a CAR driven by someone
(including yourself) who was “high” or had been
using alcohol or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel
better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by
yourself, or ALONE?
4. Do you ever FORGET things you did while using
alcohol or drugs?
5. Do your FAMILY or FRIENDS ever tell you that you
should cut down on your drinking or drug use?
6. Have you ever gotten into TROUBLE while you
were using alcohol or drugs?
(Knight et al., 2002)
38
CRAFFT Scoring
• Each “yes” response scores 1 point.
• A total score of 2 or higher is a
positive screen, indicating a need for
additional assessment.
39
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Duration of Use
• Screening and assessment tools screen
for current alcohol and drug use.
• As with smoking, determining lifetime
use is important in order to identify
– The risk of health consequences associated
with long term use
– Those who are in recovery and may benefit
from ongoing support
40
Therapeutic Interactions
Important to
Conducting Screening
Hi, I'm __________, it is nice to meet you. If it's okay
with you, I'd like to ask you a few questions that will
help us give you better health care.
These are questions that we ask all patients as part
of our standard care.
The questions relate to your experience with alcohol
and other drugs.
Is it okay with you to get started on these questions?
42
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11/2/2016
Summary
• Universal screening for at-risk alcohol and drug
use should be normalized as important factors
in wellness and good health.
• Screening, using an established measure is the
first step of the SBIRT process and determines
the severity and risk level of the patient’s
alcohol and/or drug use.
• The result of a screen allows the provider to
determine if a brief intervention or referral to
treatment is a necessary next step for the
patient.
43
Brief Intervention
(BI)
Brief Intervention (BI)
• Goal: raise awareness of substance-related
consequences and motivate person
toward behavior change
• Most effective among persons who do not
have diagnosable disorder or at highest
risk
• Systematic reviews- 56 unique primary
healthcare-based randomized controlled
trials found consistent evidence for
effectiveness of brief alcohol interventions
in reducing hazardous and harmful
drinking when delivered in primary care
settings
(O’Donnell et al., 2014; Whitlock et al., 2004)
48
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Positive role of nurses delivering
alcohol interventions
• Systematic review and meta-regression
analysis, 25 RCTs measuring effect of alcohol
SBI on alcohol consumption.
• Different providers (counsellors, general
practitioners, nurses, peers, others
[psychologists, social worker, research nurse])
compared on alcohol-related outcomes
following intervention.
• Interventions delivered by nurses had the
most effect in reducing quantity (d= - .23,
95% CI (- 0.33 to - 0.13)) but not frequency of
alcohol consumption.
(Platt et al., 2016)
49
Brief Negotiated Interview (BNI)
4. Negotiate a plan
3. Enhance motivation
2. Provide feedback
1. Raise the subject
(D'Onofrio, et al, 1998)
50
Negotiating a Change Plan
Development is a process of shared
decision making and negotiation
involving:
1. Setting goals
2. Considering change options
3. Arriving at a plan
4. Eliciting commitment
51
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Change Plan Work Sheet
• The most important
reasons I want to make
this change are:
• Other people could help
me with change in these
ways:
– Person
• My main goals for
making this change are:
• I plan to do these things
in order to accomplish
my goals:
– Specific action
– When
– Possible ways to help
• There are some possible
obstacles to change and
how to handle them:
– Possible obstacles to
change
– How to respond
• I will know my plan is
working when I see these
results:
52
Summary
• The four steps of the Brief Negotiated
Interview are intended to lead the person
toward positive behavior change and
healthy choices.
• Using motivational interviewing including
the OARS to guide the conversation helps
foster collaboration and evoke change
while being respectful of the person’s
autonomy while conveying compassion.
54
Referral to Treatment
17
11/2/2016
Considerations for
Treatment/Management
Diabetic Person
SUD Person
• Lifestyle
• Lifestyle
• Education &
Counseling
• Psycho-education &
Counseling
• Mutual Support
Groups
• Mutual Support
Groups
• Medications
• Medications
• Social determinants
of health
• Social determinants
of health
56
Comprehensive Care
“…patient
centered,
comprehensive
care from a
primary care
clinician may be
an important
treatment
component for
substance use
disorders”
(Kim, et al., 2007)
• Coordination of referrals and
services.
• Communication among different
providers.
• Medication-assisted treatment
management.
• Facilitate sustained health behavior
change.
• Ongoing follow-up:
– Routine screening
– Promotion of healthy lifestyle
– Management of co-occurring conditions
57
Mutual Support / Self-Help
Programs
• The most recommended program of
recovery by both lay persons and
professionals.
• There is a mutual benefit in sharing
one’s experience, strength, and hope
with another person who is trying to
quit substance use.
54
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Mutual Support Programs
• Alcoholics Anonymous®: http://www.aa.org
– Information for professionals
– How to find A.A. Meetings
• Al-Anon www.al-anon.org
• Narcotics Anonymous: http://www.na.org
– Find a meeting
• Secular http://www.sossobriety.org/
– Find a meeting
55
Treatment and Maintenance
Phases
Goals
Detoxification
Safe reduction from substance use
addressing the immediate
withdrawal symptoms.
Initial Recovery
Sustained motivation to tolerate
distressful symptoms of longer
abstinence from substances.
Relapse
Prevention /
Maintenance
Maintaining new behaviors and
ways of managing internal and
external stresses.
56
Levels of Care
Level
Treatment Setting
1. Outpatient treatment
Outpatient care
Methadone maintenance
2. Intensive outpatient or
partial hospitalization
3. Medically monitored
intensive inpatient
treatment
4. Medically managed
intensive inpatient
treatment
Intensive outpatient program
Medical sub-acute hospital
Chemical dependency program
Psychiatric hospital
Medical acute-care hospital
Emergency room / department
(American Society of Addiction Medicine, 2013)
57
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Outpatient Detoxification
Where Offered
Advantages
Disadvantages
• Emergency
• Less expensive than • Available access
Departments
inpatient treatment.
to substances
• Patient’s life is not as
of abuse.
• Intensive
disrupted as during
• Less ability than
Outpatient
inpatient treatment.
inpatient to
Programs
• Patient does not have
quickly adjust
• Methadone
abrupt transition
detoxification
Maintenance/
from protected
regimen.
Buprenorphine
inpatient setting to
Clinics
the home/work
• Office-Based
settings.
Clinics
58
Inpatient Detoxification
Where Offered
Acute care
hospitals
Psychiatric
hospitals
Medically
managed
residential
treatment
centers
Advantages
Disadvantages
• Provides protected
• Expense
setting where access • Variability in care
to substances of
depending on
abuse is restricted.
number of
• Intensive level of
appropriately
care that can
credentialed
provide close
personnel,
observation for
implementation of
serious withdrawal
evidence-based
symptoms and
protocols.
ability to rapidly
adjust treatment
protocol.
59
Identify Referral Resources
• Inpatient treatment / Hospitals
• Outpatient Specialty Treatment Programs
• Community agencies
• Office-based treatment providers
• State treatment centers
• Internal resources within health care system
60
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Reasons for Not Receiving
Treatment
10.4%
Did not know where to go for
treatment
11.1%
Might cause
neighbors/community to have
negative opinion
11.6%
Might have a negative effect on
job
30.8%
41.2%
No health insurance and could
not afford cost
Not ready to stop using
65
(Han et al., 2015)
Using a “Warm Handoff”
• “The manner in which a referral to further
treatment is provided can have tremendous
impact on whether the client will actually receive
services with the referred provider.”
http://www.integration.samhsa.gov/clinical-practice/sbirt/referral-to-treatment
• A warm handoff achieved 80%-90% enrollment, as
opposed to 10% enrollment via less intensive referral
methods.
(Cummings, O’Donnell, & Cummings, 2009)
• For sample warm handoff scripts and additional
supportive evidence:
http://www.ibhp.org/index.php?section=pages&cid=122
66
Navigating Barriers
• Use your MI skills and attempt to use neutral language to
normalize the conversation.
• Provide information on health coverage for those with little or
no insurance.
• Provide all high risk patients list of referrals with contact
information. Include local support groups, Veterans
Assistance Programs, Community Service Boards, Clinic-Based
Social Worker, Employee Assistance Programs, Student
Services and Crisis Hotlines.
• For more treatment info:
http://findtreatment.samhsa.gov/TreatmentLocator/faces/qui
ckSearch.jspx
63
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Summary
• Mutual support / self-help groups are beneficial
for many.
• The appropriate level of treatment needs to be
matched to the clinical needs of the individual.
• Motivational strategies and patient education
can be provided to remove real and perceived
barriers to an individual’s acceptance of
treatment referral.
• Warm handoffs increase the likelihood that a
patient will seek additional levels of
treatment/support.
64
Resources & Educational
Materials
• Substance Abuse and Mental Health
Services Administration (SAMHSA)
www.samhsa.gov
• National Institute on Drug Abuse (NIDA)
www.drugabuse.gov
• National Institute on Alcohol Abuse and
Alcoholism (NIAAA) www.niaaa.nih.gov
• International Nurses Society on
Addictions (IntNSA) www.intnsa.org
69
References
•
•
•
•
•
•
•
•
•
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Nancy Goldstein, [email protected]
• Thank you!
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