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Screening, Brief Intervention and Referral to Treatment (SBIRT)
Here are the 11 DSM-5 criteria for substance use disorder filled in with the blank (___) replaced with "alcohol": 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused
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Screening, Brief Intervention and Referral to Treatment (SBIRT)
- 1. 1203 Preservation ParkWay, Suite 302 Oakland, CA 94612 | Tel: 510-268-1260 | schoolhealthcenters.org July 10, 2019 SCHOOL-BASED MENTAL HEALTH BEST PRACTICE SERIES: Screening, Brief Intervention & Referral to Treatment
- 2. The California School- BasedHealth Alliance is the statewide non-profit organization dedicated to improving the health & academic success of children & youth by advancing health services in schools. Learn more: schoolhealthcenters.org Putting Health Care in Schools
- 3. • Conference registration discount •Tools & resources • Technical assistance Sign up today: bit.ly/CSHAmembership Become a member, get exclusive benefits
- 4. California School-Based HealthConference May 14-15, 2020 | Sacramento
- 5. The views, opinions,and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS). DISCLAIMER
- 6. 6 Andrew Kurtz, MFT IntegratedSubstance Abuse Programs Department of Psychiatry & Biobehavioral Sciences David Geffen School of Medicine at UCLA Pacific Southwest Addiction Technology Transfer Center www.uclaisap.org www.psattc.org
- 7. We have ateam of dedicated and skilled trainers who deliver SBIRT training throughout the state of California: • Thomas E. Freese, PhD • Beth Rutkowski, MPH • James Peck, PsyD • Andrew Kurtz, MA, MFT • Albert Hasson, MSW • Grant Hovik, MA 7
- 8. 1. Increase knowledgeof screening and brief intervention concepts and techniques 2. Introduce and practice screening and identification skills 3. Review Motivational Interviewing Skills needed for Brief Interventions 4. Develop skills to deliver the F.L.O. Brief Intervention 8
- 9. In 2013, theUSPSTF recommended that clinicians screen adults age 18 years or older for alcohol misuse and provide those reporting risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Effective January 1, 2014, California provides Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care settings to all Medi-Cal beneficiaries, 18 years and older. Adolescent Medi-Cal beneficiaries ages 11-17 are to be assessed annually in primary care settings using the CRAFFT. ** Effective January 1, 2014, the law requires that Alternative Benefit Plans cover preventive services described in section 2713 of the Public Health Service Act as part of essential health benefits. Section 2713 includes, among others, alcohol screening and brief behavioral interventions. (Affordable Care Act Section 4106).** 9
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- 11. Substance abuse isa leading cause of illness and death. It can: • Lead to unintentional injuries and violence • Exacerbate medical conditions (e.g. diabetes, hypertension, sleep disorders) • Exacerbate neuropsychiatric disorders (e.g. depression, sleep disorders) • Induce injury/illness(e.g. stroke, dementia, cancers) • Result in infectious diseases and infections (e.g. HIV, Hepatitis C) • Affect the efficacy of prescribed medications • Be associated with abuse of prescription medications • Result in low birth weight, premature deliveries, and developmental disorders • Result in dependence, which may require multiple treatment services 16Conclusion: Substance abuse has a major impact on public health
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- 13. The Drug DangerZone: Most Illicit Drug Use Starts in Teenage Years SOURCE: NIDA. (2014). Drugs, Brains, and Behavior: The Science of Addiction. 18
- 14. 19 Continuing Brain Development Earlyin development, synapses are rapidly created and then pruned back. Children’s brains have twice as many synapses as the brains of adults. Shore, 1997
- 15. Information taken fromNIDA’s Science of Addiction http://www.drugabuse.gov/ScienceofAddiction/ SOURCE: Gagtay, et al., 2004. 20 Brain Development Ages 5-20 years MRI scans of healthy children and teens compressing 15 years of brain development (ages 5–20). Red indicates more gray matter, blue less gray matter. Neural connections are pruned back-to-front. The prefrontal cortex ("executive" functions), is last to mature.
- 16. Tips for Workingwith Adolescents Don’t pretend to know it all (you probably don’t) Be curious Develop discrepancy Connect to identified values Use open-ended questions 21
- 17. Substance Abuse Challenges: 30.5Million Americans Are Current* Users of Illicit Drugs SOURCE: SAMHSA, 2017 National Survey on Drug Use and Health (released in 2018). Alcohol 140.6 M → Slightly more than half (51.7 percent) of Americans aged 12 or older reported being current drinkers of alcohol in the 2017 survey, which was higher than the 2016 rate (50.7 percent). This translates to an estimated 140.6 million current drinkers in 2017.
- 18. What is SBIRT? SBIRTis a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For individuals with substance use disorders Individuals at risk of developing these disorders Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur 23
- 19. • Increase accessto care for persons with substance use disorders and those at risk of substance use disorders • Foster a continuum of care by integrating prevention, intervention, and treatment services • Improve linkages between health care services and alcohol/drug treatment services 24
- 20. Screening: Very briefset of questions that identifies risk of substance-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 25
- 21. • Brief interventionstrigger 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 • Cocaine/heroin users seen in primary care: 50% higher odds of abstinence at follow-up after receiving BI than those who didn’t get BI 26
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- 23. 28 Severe Problem Users Hazardous &Harmful Users Non-Users or Low Risk Users SBIRT SBIRT
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- 25. • Substance useis a global public health issue • Substance use is associated with significant morbidity and mortality • Early identification and intervention reduces substance-related health consequences 30
- 26. 1. Underweight 2. Unsafesex 3. High blood pressure 4. Tobacco consumption 5. Alcohol consumption 6. Unsafe water, sanitation, and hygiene 7. Iron deficiency 8. Indoor smoke from solid fuels 9. High cholesterol 10. Obesity 31
- 27. Study Results -conclusions Reference Trauma patients 48% fewer re-injury (18 months) 50% less likely to re-hospitalize Gentilello et al, 1999 Hospital ER screening Reduced DUI arrests 1 DUI arrest prevented for 9 screens Schermer et al, 2006 Physician offices 20% fewer motor vehicle crashes over 48 month follow-up Fleming et al, 2002 Meta-analysis Interventions reduced mortality Cuijpers et al, 2004 Meta-analysis Treatment reduced alcohol, drug use Positive social outcomes: substance-related work or academic impairment, physical symptoms (e.g., memory loss, injuries) or legal problems (e.g., driving under the influence) Burke et al, 2003 Meta-analysis Interventions can provide effective public health approach to reducing risky use. Whitlock et al, 2004
- 28. Study Cost SavingsAuthors Randomized trial of brief treatment in the UK Reductions in one-year healthcare costs $2.30 cost savings for each $1.00 spent in intervention (UKATT, 2005) Project TREAT (Trial for Early Alcohol Treatment) randomized clinical trial: Screening, brief counseling in 64 primary care clinics of nondependent alcohol misuse Reductions in future healthcare costs $4.30 cost savings for each $1.00 spent in intervention (48-month follow-up) (Fleming et al, 2003) Randomized control trial of SBI in a Level I trauma center Alcohol screening and counseling for trauma patients (>700 patients). Reductions in medical costs $3.81 cost savings for each $1.00 spent in intervention. Gentilello et al, 2005)
- 29. Screening & BriefIntervention for Illicit Drugs: Significant Reduction of Morbidity and Mortality* Study Results - conclusions Reference International randomized controlled trial in primary care • 60% of brief intervention group significantly reduced illicit substance use (3 months). • Most influential components of BI for participants: hearing screening score, the interview, and “hearing themselves speak” World Health Organization, 2008 6-sites nationally: trauma centers, ERs, primary care, hospitals • Rates of illicit drug use reduced 67% (6 months) • Improvements in general health, mental health and social measures • Feasibility of alcohol & drug screening demonstrated in variety of healthcare settings Madras et al., 2009 9 hospital ERs in Washington State • Significantly less use of illicit substances and alcohol, improved mental health, increased employment, and reduced homelessness. • Patients twice as likely to enter SU treatment Estee et al., 2010 12 sites in Colorado (ER, primary care, FQHCs, trauma) • Days using illicit drugs reduced by 47% (6 months) • Daily alcohol use reduced by 49% (6 months). SBIRT Colorado, 2012 * Screening for drug use is not currently reimbursable.
- 30. Screening & BriefIntervention for Illicit Drugs: Significant Reduction in Healthcare Costs Study Cost Savings Authors 9 hospital ERs in Washington State Medicaid costs reduced $366 per person per month. Estee et al., 2010 * Screening for drug use is not currently reimbursable.
- 31. Brief interventions aremost successful when clinicians relate patients’ risky substance use to improvement in their overall health and well-being 36
- 32.
- 33. 4M people (1%)receiving treatment* 23M people (8%) have problems needing treatment, but not receiving it* ≈ 60-80M people (≈19-25%) using at risky levels US Population: 316,148,990 US Census Bureau, Population Division July 2013 estimate *NSUDH, 2012 results 38
- 34. In treatment (4Million) • Diagnosable problem with substance use • Referred to treatment by:* *Los Angeles County Data Self/Family 37% Criminal Justice 25% Other SUD Program 8% County Assessment Center 19% Healthcare 3% Other 8% Healthcare 3% 39
- 35. In need oftreatment (23 Million) • Reported problems associated with use • Not in treatment currently • 1.7% Made an effort to get treatment • 3.7% Felt they needed treatment, but made no effort to get it. • 94.6% Did not feel that they needed treatment Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are unaware of the problem or do not feel they need help. 40SOURCE: SAMHSA, NSDUH, 2012 results.
- 36. Using at riskylevels (60-80 Million) • Do not meet diagnostic criteria • Level of use indicates risk of developing a problem. • Some examples… Drinks 3-4 glasses of wine a few times per week Pregnant woman occasionally has a shot of vodka to relieve stress Adolescent smokes marijuana with his friends on weekends Occasionally takes one or two extra Vicodin to help with pain These people may need services, but will never enter the treatment system 41
- 37. As long asspecialty care programs (SUD treatment programs) are the only places that address substance use: • Most individuals with severe substance-related problems will not receive treatment • Virtually all individuals with moderately risky use will not receive professional attention that might otherwise have prevented escalation to more severe health consequences 42
- 38. Screening to Identify PatientsAt Risk for Substance Use Problems 45
- 39. Men: Nomore than 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 Beer Wine Fortified Wine Liquor 12 oz 5 oz 3.5 oz 1.5 oz
- 40. 12 fl ozof regular beer = 8-9 fl oz of malt liquor (i.e. Olde English; shown in a 12-oz glass but usually purchased in 40 oz btls) = 5 fl oz of table wine = 3-4 oz of fortified wine (i.e. sherry, port, Thunderbird; 3.5 oz shown) = 2-3 oz of cordial, liqueur, or aperitif (2.5 oz shown) = 1.5 oz of brandy (a single jigger or shot) = 1.5 fl oz shot of 80-proof spirits ("hard liquor") about 5% alcohol about 7% alcohol about 12% alcohol about 17% alcohol 24-35% alcohol about 40% alcohol about 40% alcohol
- 42. Screen Target Population # Item Assessment Setting (most common) Type ASSIST (WHO) -Adults -Validatedin many cultures and languages 8 Hazardous, harmful, or dependent drug use (including injection drug use) Primary Care Interview AUDIT (WHO) -Adults and adolescents -Validated in many cultures and languages 10 Identifies alcohol problem use and dependence. Can be used as a pre-screen to identify patients in need of full screen/brief intervention -Different settings -AUDIT C- Primary Care (3 questions) Self-admin, Interview, or compu- terized DAST- 10 Adults 10 To identify drug use problems in past year Different settings Self-admin/ Interview CRAFFT Adolescents 6 To identify alcohol and drug abuse, risky behavior, & consequences of use Different settings Self-admin TWEAK Pregnant women 5 -Risky drinking during pregnancy. Based on CAGE. -Asks about number of drinks one can tolerate, alcohol dependence, related problems Primary Care, Women’s organizations, etc. Self-admin, Interview, or compu- terized
- 43. • All currentscreening instruments are based on DSM-IV diagnostic criteria • What happens in DSM-5? 58
- 44. • Substance UseDisorder • Re-conceptualized to single, one-dimensional condition, i.e. no more “substance abuse” or “substance dependence” • Craving / strong desire to use (new criterion) • Legal problems removed as criterion • 11 criteria, as follows: 59
- 45. 60 1. ______ isoften taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control _____ use. 3. A great deal of time is spent in activities necessary to obtain __________ , or recover from its effects. 4. Craving, or a strong desire or urge to use _____________ 5. Recurrent ______ use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued ______ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
- 46. 7. Important social,occupational, or recreational activities are given up or reduced because of ______ use. 8. Recurrent ______ use in situations in which it is physically hazardous. 9. ______ use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 2. A markedly diminished effect with continued use of the same amount of ______ 11. Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). 2. ______ is taken to relieve or avoid withdrawal symptoms. 61
- 47. • Criteria 1-4assess impulse control • Criteria 5-7 assess social impairment • Criteria 8-9 assess level of risk associated with use • Criteria 10-11 assess tolerance/withdrawal • Severity Rating: • 2-3 criteria: Mild • 4-5 criteria: Moderate • 6 or more criteria: Severe 62
- 48. The DSM-5 revisionsare intended to: (1) Strengthen the reliability of substance use diagnoses by increasing the number of required symptoms (2) Clarify the definition of "dependence," which is often misinterpreted as implying addiction and has at its core compulsive drug-seeking behaviors. In contrast, features of physical dependence, such as tolerance and withdrawal, can be normal responses to prescribed medications that affect the CNS and that need to be differentiated from addiction Stetka & Correll. A Guide to DSM-V. Medscape Psychiatry, 2013 63
- 49. Added: Cannabis Withdrawal Caffeine Withdrawal TobaccoUse Disorder Removed: Polysubstance Dependence Moved: Gambling Disorder (from Impulse Control Disorders to Substance-Related/Addictive Disorders) Not Added: Hypersexual Disorders (Section III-further research) 64
- 50. • BAC/Drug Screen •Pre-Screens • AUDIT • AUDIT-C • DAST • CRAFFT • ASSIST 83
- 51. • Car, Relax,Alone, Forget, Family, Trouble • The CRAFFT is a behavioral health screening tool for use with adolescents and young adults under the age of 21 and is recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents • Consists of 6 questions developed to screen adolescents for high risk alcohol and other drug use disorders simultaneously • Short and effective • Designed to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted 84 http://www.ceasar-boston.org/CRAFFT/
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- 54. 88 Knight JR, SherrittL, Shrier LA, et al. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 156(6), 607-14.
- 55. Score of 0:No Evidence of risk Score of 1 or more: Positive screen; indicates need for further assessment 89
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- 60. Young man istreated in the ER after a car accident. He had been drinking heavily before the accident. How does the doctor address drinking in this video? 95
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- 62. What is Motivational Interviewing? Itis: A style of talking with people constructively about reducing their health risks and changing their behavior. 97
- 63. What is Motivational Interviewing? Itis designed to: Enhance the client’s own motivation to change using strategies that are empathic and non- confrontational. 98
- 64. MI - TheSpirit: Style Nonjudgmental and collaborative Based on patient and clinician partnership Gently persuasive More supportive than argumentative Listens rather than tells Communicates respect and acceptance for patients 99
- 65. MI - TheSpirit: Patient Responsibility for change is left with the patient Change arises from within rather than being imposed from without Emphasis on patient’s personal choice for deciding future behavior Focus on eliciting the patient’s own concerns 100
- 66. All change containsan element of ambivalence. We “want to change and don’t want to change” Patients’ ambivalence about change is the “meat” of the brief intervention. 101
- 67. How does MIdiffer from traditional or typical medical counseling? AMBIVALENCE is the key issue to be resolved for change to occur. People are more likely to change when they hear their own discussion of their ambivalence. This discussion is called “change talk” in MI. Getting patients to engage in “change talk” is a critical element of the MI process. *Glovsky and Rose, 2008 102
- 68. 103 Avoid questions thatinspire a yes/no answer. The good things about ______ The not- so-good things about ____ The good things about changing The not-so- good things about changing
- 69. • Use reflectivelistening and empathy • Avoid confrontation • Explore ambivalence • Elicit “change talk” 104
- 70. • Open-ended questioning •Affirming • Reflective listening • Summarizing Building Motivation OARS (the micro-skills) 105
- 71. Open and Closed QuestionsQuiz 1. Don’t you think your drinking is part of the problem? 2. Tell me about when you were able to quit smoking? 3. How is it going with managing your pain meds? 4. Do you know you might die if you don’t stop using? 5. What do you want to do about your drinking? C O O C O 6. Can you tell me about what you know about your heart condition? C
- 72. • Listen toboth what the patient says and to what the patient means • Demonstrate empathy without judging what patient says • You do not have to agree • Be aware of intonation • Reflect what patient says with statement, not with a question, e.g., “You couldn’t get up for work in the morning.” 107 We are listening to understand, NOT to diagnose and fix a problem, which is how most healthcare interactions are oriented, as demonstrated here
- 73. • Repeating –Repeating what was just said. • Rephrasing – Substituting a few words that may slightly change the emphasis. • Paraphrasing – Major 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. 108
- 74. 109 1. Simple Reflection(repeat) 2. Amplified Reflection (amplify/exaggerate the consumer’s point) 3. Double-Sided Reflection (captures both sides of the ambivalence)
- 75. 110 • Challenging “What doyou 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.”
- 76. 111 Change talk consistsof self-motivational statements that suggest: • Recognition of a problem • Concern about staying the same • Intention to change • Optimism about change
- 77. Moving Toward “ChangeTalk”: the DARN Steps 112 Desire Ability Reason Need Commitment
- 78. What if…? Whatif the patient doesn’t say ANY change talk? “Actions speak louder than words.” Do the patient’s actions express any change talk? (Can you address any discrepancy between their words and their actions?) Pt: “This program is worthless. I don’t want anything to do with it.” “On the one hand, you don’t really want to be here and you don’t think it will help you at all. On the other hand, you’re still sitting here with me. I’m wondering how that adds up.” Pt: ? 113
- 79. What If, Continued No, I mean it: What if the patient gives you NO change talk? AT ALL? Try reflecting the resistance. Can you get even MORE resistant than the patient? Patient: “My PO wants me working and going to counseling and TASC. You guys want me going to all these meetings, making curfew, giving you all my money. My wife is always on my case. I’m gonna have to get loaded just to deal with you all!” Staff: “It would be impossible to deal with all these people sober. In fact, nobody could do it!” Patient: “Well ok, maybe not impossible…” 114
- 80. What If, Continued Consider the possibility that you are not talking about the right issue… 115
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- 84. Which of thesetechniques you use with any given patient 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 119
- 85. Stages of Change: PrimaryTasks 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 120
- 86. 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 121
- 87. Same scenario, butdifferent doctor. What does this doctor do that is different? Does it work? 122
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- 90. Avoid Warnings! 125 F LO W Feedback Listen&Understand Warn OptionsExplored (that’s it)
- 91. 126 Feedback Setting the stage Tellscreening results Listen & understand Explore pros & cons Explain importance Assess readiness to change Options explored Discuss change options Follow up
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- 93. The Feedback Sandwich 128 AskPermission Give Feedback Ask for Response
- 94. 129 What you needto cover: 1. Range of scores and context 2. Screening results 3. Interpretation of results (e.g., risk level) 4. Patient feedback about results
- 95. 130 What do yousay? 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. 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 4. Patient reaction/feedback - What do you make of this?
- 96. The 1st 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? 131
- 97. The 1st 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. 132
- 98. The 1st 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. 133
- 99. Activity: Role-Play Using AUDITresults from Chris, 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 134
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- 101. 136 Tools for ChangeTalk • Pros and Cons • Importance/Readiness Ruler
- 102. 137Avoid questions thatcall for a yes/no answer. The good things about ______ The not- so-good things about ____ The not-so- good things about changing The good things about changing
- 103. 138 Listen for theChange 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!
- 104. 139 Strategies for Weighingthe Pros and Cons • What do you like about drinking? What does it do for you? • What are the not-so-good aspects of drinking? • What else are you aware of about your drinking? Summarize Both Pros and Cons “On the one hand you said.., and on the other you said….”
- 105. 140 Importance/Confidence/Readiness On a scaleof 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
- 106. The Payoff forAsking the Questions… These questions will lead to a working treatment plan Stage of change Benefits of use Consequences of use Willingness to work on these issues 141
- 107. Activity: Role Play Let’spractice L: Role-play Listen & Understand using completed screening tool • Pros and Cons • Importance/Confidence/Readiness Scales • Develop Discrepancy • Dig for Change 142
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- 109. What now? • Whatdo 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? 144
- 110. Offer a Menuof 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) 145
- 111. During MENUS youcan 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? 146
- 112. Giving Advice WithoutTelling Someone What to Do • Provide Clear Information (Advice 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? 147
- 113. The Advice Sandwich 148 AskPermission Provide Suggestion Ask for Response
- 114. Closing the Conversation(“SEW”) 149 • Summarize patient’s views (especially the pro) • Encourage them to share their views • What agreement was reached (repeat it)
- 115. Activity: Role Play Let’spractice 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 150
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- 117. 152 Feedback • Range Listen andUnderstand • Pros and Cons • Importance/Confidence/Readiness Scales • Summary Options Explored • Menu of Options
- 118. At follow-up visit: •Inquire about use • Review goals and progress • Reinforce and motivate • Review tips for progress 153See reference list
- 119. Challenges to SBIRTEfficacy The brief intervention is too brief Motivation for change is lacking Effective linkage is difficult Saitz, 2015 Patient, provider, and system characteristics hinder transition to services and outcomes Patient knowledge, expectations and SUD treatment preference can act as barriers Cucciare, et al, 2015 167
- 120. Considerations to addressbarriers The “RT” needs additional empirical evidence and rigorous trial Effective RT needs to be incorporated specifically – not as an afterthought Identify barriers AND facilitators Repeated contact is key Integrated case management consistent with readiness to change is essential 168SOURCE: Glass, 2015
- 121. Closing the Conversation(“SEW”) 173 • Summarize patient’s views (especially the pro) • Encourage them to share their views • What agreement was reached (repeat it)
- 122. Activity: Role Play Let’spractice 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 174
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- 124. 176 Feedback • Range Listen andUnderstand • Pros and Cons • Importance/Confidence/Readiness Scales • Summary Options Explored • Menu of Options
- 125. At follow-up visit: •Inquire about use • Review goals and progress • Reinforce and motivate • Review tips for progress 177See reference list
- 126. Challenges to SBIRTEfficacy The brief intervention is too brief Motivation for change is lacking Effective linkage is difficult Saitz, 2015 Patient, provider, and system characteristics hinder transition to services and outcomes Patient knowledge, expectations and SUD treatment preference can act as barriers Cucciare, et al, 2015 191
- 127. Considerations to addressbarriers The “RT” needs additional empirical evidence and rigorous trial Effective RT needs to be incorporated specifically – not as an afterthought Identify barriers AND facilitators Repeated contact is key Integrated case management consistent with readiness to change is essential 192SOURCE: Glass, 2015
- 128. schoolhealthcenters.org [email protected] schoolhealthcenters sbh4ca sbh4ca STAY CONNECTED 1203 PreservationPark Way, Suite 302 Oakland, CA 94612 | Tel: 510-268-1260 | schoolhealthcenters.org Molly Baldridge [email protected] Peter Le [email protected] Tracy Mendez [email protected]