Transcript Curriculum for Implementing Screening and

Implementing SBI Services
For Smokers & At-risk Drinkers
Sponsored by the University of University of Connecticut School of Medicine Office of
Continuing Education and the Department of Community Medicine and Health Care
Reducing Tobacco Use and Risky
Drinking in Underserved Populations
A project funded by Prescription for Health, a national program supported by
The Robert Wood Johnson Foundation
Wait a minute, what is SBI?
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Screening is method for identifying
someone at risk for a condition.
Brief Intervention is low-intensity, shortduration counseling for those who screen
positive (smokers and at-risk drinkers)
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Utilizes motivational interviewing style
Incorporates readiness to change model
Includes feedback and advice
Today’s Training Objectives
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Describe health issues associated with
smoking and at-risk drinking
Illustrate the components of effective
screening and brief intervention procedures
Practice brief intervention through role play.
Brainstorm implementation strategies.
Sample SBI Flow Diagram
Distribute Health & Lifestyle Screen (HLS) as
patient registers for appointment
Collect and score HLS:
Is patient eligible for a Brief Intervention?
YE
S
NO
Provide Brief Intervention
Record that patient received brief
intervention on HLS form. Place
copy in patient record.
Re-assess at next patient visit.
Record on HLS
Place copy in patient record
Health Problems Associated with
Smoking and At-risk Alcohol Use
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Smoking
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Cancer of the lung,
pancreas, bladder, cervix
Increased CO in
lungs/shortness of breath
Symptoms of asthma or
allergies worsened
Heart attack/stroke
Leukemia
Bronchitis, Emphysema
Increased risk of lung
cancer in spouse/children
Increased chance children
will be smokers
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At-risk Alcohol Use
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Interactions with medications
High blood pressure
Impotence
Depression
Aggressive/irrational behavior
Sleeplessness
Breast cancer
Stroke
Liver damage
Ulcers
Falls/accidents
Automobile accidents/arrests
Facts About Cigarette
Smoking in the US
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22% of adult Americans smoke
It is the chief avoidable cause of illness and death
Over 430,000 deaths each year
Known cause of cancer, heart, and lung disease
Annual smoking-attributable cost for medical care
is ≈$50 billion
More than 70% of the 50 million smokers have
made at least one prior quit attempt and about
46% try to quit each year
Tobacco Use and Oral Disease
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Tobacco use is a risk factor for oral cancer, oral
mucosal lesions, periodontal disease, gingival
recession and coronal and root caries.
Smoking accounts for 50% of all periodontal
disease and
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91% of oral cancers among males
59% of oral cancers among females
When combined with heavy alcohol use, smoking
synergistically increases the risk of oral cancer
Alcohol Use and Alcohol
Problems
Dependent
At Risk Drinkers
Low Risk Drinkers
Abstainers
National Drinking Guidelines
(U.S. Dept. of Agriculture Nutrition Guidelines)
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Men, no more than:
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2 drinks per day
14 drinks per week
A Standard Drink is:
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Women and persons >65 years
old, no more than:
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1 drink per day
7 drink per week
In as single occasion:
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No more than 3 drinks on one
occasion for women
No more than 4 drinks on one
occasion for men
One 12 ounce beer
One 5 glass of wine
1.5 ounces of liquor
Where is the Bulk of Harm?
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Persons with alcohol dependence
experience the most harm
There are many more individuals who are
at-risk users of alcohol
People tend to move back and forth from
low-risk to at-risk use
Most alcohol-related harm is caused by
people who are usually low-risk drinkers
Evaluating an SBI Program
Efficacy
Can it work?
Effectiveness
Does it work?
Availability
Is it reaching those who
need it?
Efficiency
Is it worth doing compared
to other uses of the same
source?
Let’s Start with the S in SBI Screening:
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Screening is method for identifying someone at
risk for developing a condition (alcohol
dependence / alcoholism).
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Early detection of the condition with the hope of
improving the prognosis
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Will also detect individuals who already have the
condition (alcoholics / alcohol-dependent persons)
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Secondary Prevention
At-risk drinker ►low-risk or moderate drinker
Tertiary Prevention
Referral to more intensive program
Alcoholic drinker ►abstinence
Most effective when targeted at high-risk populations
What’s in the Screening Survey?
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Health and Lifestyle Screen
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Includes other “lifestyle” questions
Exercise, diet, tobacco, alcohol and stress
questions
Four questions about tobacco use (3-6)
Three questions about alcohol use (7-9)
How Are At-risk Patients Identified?
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Your decision about the best method for gathering
the Health and Lifestyle Screening information
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Hand out to patient as part of the usual check-in
process in the waiting area
Include questions as part of the vital signs process
Give questionnaire to patient when waiting in exam
room
Score screening assessment
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You decide who scores and how information is
transferred to Brief Interventionist
How are Tobacco Users Identified on
the Health and Lifestyle Screen?
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If patient checks “yes” to questions 3 or 4, s/he
is eligible for a tobacco Brief Intervention (BI)
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Check the box marked “T” (tobacco user) and give
information to staff member who will conduct the
Brief Intervention
After BI is delivered, check box marked “TBI”
(Tobacco Brief Intervention received)
Separate form and store white copy in patient
record, yellow copy will go to UConn.
How are At-risk drinkers Identified
on the Health and Lifestyle Screen?
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If patient is a female or is over 65 years old
(male or female) and scores 7 or higher on
questions 7-9, s/he is eligible for a drinking (BI)
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Check the box marked “D – F&>65”
(at-risk drinker who is over 65 or is a female)
If patient is a male and scores 8 or higher on
questions 7-9, he is eligible for a drinking (BI)
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Check the box marked “D – M”
(at-risk drinker who is a male)
How are At-risk drinkers Identified
on the Health and Lifestyle Screen?
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If patient is under 21 and scores a 1 or higher on
questions 7-9, s/he should receive a drinking BI
Give screening information to staff member who
will conduct the drinking Brief Intervention
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After BI is delivered, check box marked “DBI”
(Drinking Brief Intervention received)
Separate form and store white copy in patient
record, yellow copy will go to UConn
What if a Patient is an At-risk
Drinker and a Tobacco User?
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Patient is eligible to receive both BI’s
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If time, deliver both
If pressed for time, choose the one of most concern
to the patient
After delivering one or both BI(s) check box
marked “DBI”, “SBI” or both, depending on
intervention received
Separate form and store white copy in patient
record, yellow copy will go to UConn
What are the Ingredients of
Successful Brief Interventions?
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Evidence-based
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Incorporates the Stages of Change Model
Based on a motivational interviewing or
counseling style
Tobacco BI based on AHRQ guidelines
Drinking BI based on NIAAA guidelines
Stages of Change Model for Interventionists
PRECONTEMPLATION
CONTEMPLATION
RELAPSE
MAINTENANCE
PREPARATION
ACTION
Incorporating Readiness to
Change in Brief Interventions
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Pre-contemplation
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Contemplation
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Negotiate a plan
Action
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Motivate and increase confidence in ability to change
Preparation
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Increase awareness of need to change
Reaffirm commitment and follow-up
Maintenance
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Encourage active problem-solving
The Nature of Motivation
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Motivation is a key to change
Motivation fluctuates
Motivation is interactive
Motivation can be modified
The clinician’s style influences patient
motivation
Motivational Style
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Express empathy
Develop discrepancy
Avoid argument
Roll with resistance
Support self-efficacy
Five Motivational Interviewing
Strategies (#1)
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Ask open-ended questions
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Tell me about your cigarette use on a
typical day (open-ended) vs. how many
do you smoke on a typical day (closed)
What are your thoughts about setting a
quit date (open-ended) vs. would you like
to set a quit date (closed)
Five Motivational Interviewing
Strategies (#2)
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Listen reflectively
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Patient: I’m worried that alcohol is
pickling my brain – I’ve heard that too
much kills brain cells…but I don’t think
I’m an alcoholic.
Provider: You don’t think that you’re that
bad off, but you wonder if maybe you’re
overdoing it and damaging yourself in the
process…
Five Motivational Interviewing
Strategies (#3)
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Affirm
I think it’s great you want to do
something positive for yourself
 That must have been very difficult
for you
 That’s a good suggestion
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Five Motivational Interviewing
Strategies (#4)
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Summarize
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Periodically summarize what has occurred
during the BI
Reinforce what has been said and prepare
the patient to move on
Link the patient’s positive and negative
feelings about substance use which can
then promote the perception of
discrepancy
Five Motivational Interviewing
Strategies (#5)
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Elicit self-motivational statements
Self-motivational Statements
Counter-motivational Statements
Sometimes when I’ve been drinking
I just can’t think or concentrate.
When I’m drunk, I’m more relaxed
and happy.
If I really put my mind to something, I have so much going on right now I
I can do it.
can’t think about quitting.
I feel terrible about how my
smoking upsets my family.
I’m not the one with the problem.
How is the Tobacco BI
Conducted?
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Conduct the BI in a confidential area:
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Provide feedback to the patient about tobacco use
Determine the patient’s willingness to set a quit
date
Discuss Nicotine Replacement Therapy (NRT), if
applicable
Distribute educational materials/referral
information
AHRQ Guidelines for Tobacco
Cessation Brief Interventions
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5 A’s
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ASK (screen every patient)
ADVISE (to quit in a clear, personalized manner by
tying smoking to current health or family-related
problems)
ASSESS (willingness to make a quit attempt)
ASSIST (in making a quit attempt, encourage the
use of NRT, provide educational materials –
contacts)
ARRANGE (for follow-up contacts to prevent
relapse)
AHRQ Guidelines for Tobacco
Cessation Brief Interventions
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5 R’s
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Relevance (encourage patient to indicate why quitting
is personally relevant)
Risks (ask patient to identify risks of continued use)
Rewards (ask patient to identify benefits of stopping
use)
Roadblocks (ask patient to identify barriers to
quitting)
Repetition (repeat every time unmotivated patient
visits the office)
Brief Intervention Guide for
Smokers
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Three interventions based on patient’s
readiness to change
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Feedback Report for educating patient about
risks associated with smoking
AHRQ patient booklet for those willing to
make a quit attempt
Other patient handouts
Provide or prescribe NRT if appropriate
Pharmacotherapies
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First-line pharmacotherapies (FDA-approved)
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Bupropion SR (Zyban)
Nicotine Gum (Nicorette)
Nicotine Patch (Nicoderm CQ)
Nicotine Inhaler (Nicotrol)
Nicotine Nasal Spray (Nicotrol NS)
Second-line pharmacotherapies (Not FDAapproved)
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Clonidine
Nortriptyline
NRT Warnings
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Pregnant or nursing
Heart disease, irregular heart beat, recent heart
attack
High blood pressure not controlled by medication
Taking prescription drugs for depression or asthma
or taking insulin for diabetes
Stomach ulcer
Allergic to adhesive tape (patch)
How is the Drinking BI
Conducted?
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Conduct the BI in a confidential area:
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Provide feedback to the patient about at-risk
drinking
Determine the patient’s willingness to set a date to
cut back on drinking
Distribute educational materials/referral
information
NIAAA Guidelines for At-risk
Drinking Brief Interventions
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FRAMES
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Feedback of personal risk
Responsibility of the patient
Advice to change
Menu of ways to reduce drinking
Empathetic counseling style
Self-efficacy or optimism of the patient
Brief Intervention Guide for At-risk
Drinkers
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Three interventions based on patient’s
readiness to change
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Feedback Report for educating patient about
risks associated with smoking
NIAAA patient booklet for those willing to
make a quit attempt
Other patient handouts
How is a Combined BI
Conducted?
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If time permits, conduct both BI’s starting
with the substance that is of most concern to
the patient
If time is scarce, conduct the BI for the
substance of most concern to the patient.
At all opportunities tie the two behaviors
together.