Transcript Overview of the SBIRT Process

Overview of the SBIRT Process
David P. Miller, MD, MS, FACP
Associate Professor
Internal Medicine and Public Health Sciences
5 Basic Components of an SBIRT System
 Prescreening (1-2 question screen)
 Screening (AUDIT / DAST; CRAFFT)
 Clinician Intervention for all screen-positive
clients
 Referral as appropriate for clients with higher
levels of risk or possibly dependent
 Follow-up assessment/reinforcement at future
visits
2
STEP 1:
Prescreen is routinely performed every 6-12
months
Tools: Single alcohol screening question (SASQ - NIAAA)
single drug screening question (NIDA)
3
Prescreening
Questions
“Single Alcohol Screening Question” (NIAAA)
1. Do you sometimes drink beer, wine, or liquor?
2. How many times in the past year have you had more
than (3 or 4) drinks in a day?
“Single-Item Drug Use” (NIDA)
1. How many times in the past year have you used an
illegal drug or used a prescription medication for
nonmedical reasons?
4
STEP 2: Administer screening IF
prescreen is positive
Tools: AUDIT (for alcohol)
DAST-10 (for drugs)
5
AUDIT (for + alcohol prescreen)
Healthy Lifestyles Screen (AUDIT)
PATIENT: Because alcohol use can affect your health and can interfere with certain medications and
treatments, it is important that we ask some more questions about your use of alcohol. If we find that you
are drinking more than you or we feel is good for you, we have some services right here that can help you
take better care of yourself. Your answers will remain confidential so please be honest.
Place an X in one box that best describes your answer to each question.
QUESTIONS
1. How often do you have a drink containing alcohol?
2.
3.
4.
5.
6.
7.
8.
9.
How many drinks containing alcohol do you have on
a typical day you are drinking?
How often do you have four or more drinks on one
occasion?
How often during the last year have you found that
you were not able to stop drinking once you had
started?
How often during the past year have you failed to do
what was expected of you because of drinking?
How often during the past year have you needed a
drink first thing in the morning to get yourself going
after a heavy drinking session?
How often during the past year have you had a
feeling of guilt or remorse after drinking?
How often during the past year have you been unable
to remember what happened the night before because
of your drinking?
Have you or someone else been injured because of
your drinking?
10. Has a relative, friend, doctor, or other health care
worker been concerned about your drinking and
suggested you cut down?
6
0
Never
1
Monthly
or less
2
2-4 times a
month
3
2-3 times a
week
4
4 or more
times a
week
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
Daily or
almost daily
Monthly
Weekly
Daily or
almost daily
Never
Never
Never
Never
Less than
monthly
Less than
monthly
Less than
monthly
Less than
monthly
Daily or
almost daily
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
No
Yes, but
not in the
past year
Yes, but
not in the
past year
Yes, during
the past year
Yes, during
the past year
Adapted from World Health
Organization
 3 quantity & frequency
questions (1-3)
 3 questions probing signs
of dependency (4-6)
 4 questions about
alcohol-related problems
(7-10)
 Score Range: 0 - 40
DRUG USE QUESTIONNAIRE (DAST -10)
These questions refer to the past 12 months only:
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Have you had medical problems as a result of your drug use (e.g., memory loss,
hepatitis,
convulsions, bleeding, etc.)?
4. Have you had “blackouts” or “flashbacks” as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parent) 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. Are you always able to stop using drugs when you want to?
Circle
Response
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
Yes
DAST-10 score (add circled responses in left column)
www.sbirtonline.org
Southeastern Consortium for
Substance Abuse Training
© 2013
DAST-10
Advantages
 Short, self-administered




8
www.sbirtonline.org
Disadvantages
Is not drug-specific
Validation data is
limited
Does not distinguish
between active and
inactive illicit drug use
Focuses on dependence
Southeastern Consortium for
Substance Abuse Training
© 2012
Risk Zones
AUDIT Score:
≥ 14
1-13
High
Risk
At Risk
Low/No Risk
DAST Score:
3-10
1-2
(No drug use)
Sensitivity & specificity in the discrimination of drug use disorders
with psych populations are optimized with a score of ≥3 (Maisto et al., 2000)
9
www.sbirtonline.org
Southeastern Consortium for
Substance Abuse Training
© 2012
Prescreening/Screening for
Adolescents: CRAFFT
During the past 12 months, did you:
 Drink any alcohol (more than a few sips)?
 Smoke any marijuana or hashish?
 Use anything else to get high?
10
Prescreening/Screening for
Adolescents: CRAFFT
11
Ask everyone
Risk Zones
CRAFFT
12
>2
High
Risk
0 or 1
(use alcohol or drugs)
At Risk
0
Low/No Risk
www.sbirtonline.org
Southeastern Consortium for
Substance Abuse Training
© 2012
STEP 3: Administer Brief Intevention
13
Components of a Brief Intervention
 Ask permission
 Provide feedback
 Enhance motivation
 Provide advice
 Discuss next steps
 Close on good terms
14
Intervention Guide
Zone I: At Risk
AUDIT 1-13 (≥ 1 binge); DAST 1-2
Ask Permission
Provide Feedback
Enhance Motivation
& Elicit Change Talk
15
Zone II: High Risk, Possibly Dependent
AUDIT ≥ 14; DAST 3-10
“I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”
Refer to pyramid & provide patient’s AUDIT/DAST score & risk level(s). [As your physician] “Drinking/using at this level
can be harmful to your health and possibly responsible for the health problem for which you came in today. What do
you make of that?”
“What are the good things/not so good things about your alcohol/drug use?” (Decisional balance)
“On a scale of 0-10, how important is it that you cut back or quit your alcohol/drug use?”
If >0, “Why that number and not a lower one?” [Use rulers to also ask about confidence, readiness]
“Have you ever considered cutting back or quitting?” If so, “Why?” If not, “What would have to happen for you to
consider cutting back/quitting?”
Provide Advice
Refer to chart on front of card in providing advice to quit or cut
down as per NIH guidelines (or offer advice to quit or cut back
drug use).
Discuss Next Steps
“If you were to make a change, what would be your first step?”
Close on Good
Terms
Summarize, emphasize patient strengths, highlight change
talk and decisions made. Arrange for follow-up as appropriate.
Zone II Additional Steps:
Ask: “If you go a day or 2 without drinking/using do
you ever get sick, shaky, have
tremors/seizures/cramps, or see/hear things that are
not there?”
Offer menu of options for more help:
► Medication (naltrexone, acamprosate,
disulfiram, methadone, Suboxone)
► Referral
•Counseling/Brief treatment
•Support group (e.g., AA, NA, Celebrate
Recovery)
•Treatment or substance abuse program
www.sbirtonline.org
Funded by:
Rev. Mar 2012
Intervention card adapted from Oregon Health & Sciences University
SBIRT Primary Care Residency Initiative
STEP 4: Refer to Treatment
(if indicated)
16
Local Treatment Resources
 Detox
 Inpatient
 Outpatient
 Faith-based
 Long-term residential
17
STEP 5: Follow-up
Reassess
Reinforce
18
19