SBIRT: Best practices to address substance use in primary care and help patients change

CAROLYN SWENSON & KEVIN HUGHESPEER ASSISTANCE SERVICES, INC.WESTERN SLOPE COLORADO STATE INNOVATION MODEL (SIM) – COLLABORATIVE LEARNING SESSIONMARCH 8, 2019

Learning Objectives

Describe best practices for using evidence-based screening tools and clinical interviewing strategies to identify risky alcohol and other substance use in primary care.

Explore how a multidisciplinary primary care team can meet patients’ needs along the continuum of substance use.

Demonstrate using language to enhance patient motivation to engage in treatment when needed.

Screening, Brief Intervention and Referral to Treatment (SBIRT)

Screening – Use validated questionsBrief Intervention – A brief conversation to

enhance motivation to changeReferral to Treatment –Arrange services and

follow-up plan for patients with a more severe alcohol or drug use disorder

4%

25%

71%

Severe Alcohol Use Disorder

Alcohol Misuse

Low Risk Use or Abstention

Brief Intervention + Referral to Treatment

Brief Intervention + Monitoring and Support

Positive Reinforcement + Continued Screening

Focus of SBIRT

Alcohol use in the U.S. general populationadults age ≥ 21 years

Adapted from SAMHSA

Screening

Usual approach: Brief screening Further screening/assessment when indicated

Validated Screening Questions SBIRT in Colorado Brief Screen AUDIT-C Plus 2 AUDIT (alcohol) DAST (drugs) CUDIT-R (marijuana)

Brief Symptom Checklist

Brief Intervention

1. Raise the subject2. Provide feedback3. Enhance motivation4. Negotiate a plan

and advise

A Conversation with a Goal

Team Approach to SBIRT

Barriers to TreatmentFear of stigma is a common reason for

not seeking treatment

“Vital Sign” We ask everyone about alcohol

Substance use can affect our health in a lot of different ways. When we make a point to ask everyone about their use, it not only allows us to let them know the risks, but it can help to normalize conversations around substance

use in the future.Only about 15% of people who meet

criteria for a lifetime alcohol use disorder report receiving treatment

Reducing Stigma Through Elevated Language

1. Words Matter Avoid terms like “addict”

and “junkie” Instead use “suffering with

addiction“

2. Avoid Stigmatizing Language Perform language audits Dispel myths and misconceptions

3. Authenticity Be Open, Connecting, Passionate,

use Active Listening

4. Use Clinical Terminology DSM-5 and/or ICD-10

Substance Use Disorder Mild, Moderate, Severe

Avoid previous designations Abuse and Dependence

5. Stigma and Suicide Unintentionally harmful terms:

completed, commit, successful Preferred terms:

Died of suicide Suicide Death Suicide Attempt

Shutterstock

If we want addiction destigmatized, we need a language that is unified. www.recoveryanswers.org/addiction-ary/

What most helps people change alcohol or drug use?

Unconditional positive regard*

* Carl Rogers

Patient Scenario – Bill

72 year old male – Fell in his garage after driving home from a family gathering resulting in a shoulder fracture. Hospitalized after surgery for a blood clot in his leg. Discharged home with a month-long supply of opioids and anticoagulants. Being seen for a primary care post-hospitalization visit. Recently widowed.

Bill’s SBIRT Screening Results

3-4 drinks/day on average 5 or more drinks on one occasion: monthlyPHQ-9 score = 10Symptom checklist: score = 2Experienced craving: a strong need or urge to drink

alcoholTimes when ended up drinking more or longer than

intended

Other health conditions

HypertensionGERD InsomniaComplaints of chronic forgetfulness

Audience poll

What issues are most pressing about Bill’s health?What should we discuss with Bill based on his SBIRT

screening results?How could we tie alcohol and opioids to his current

concerns?What level of follow-up and ongoing monitoring is

appropriate?What services and treatments could we consider in the

future?

Key Patient Questions

What things concern you the most about your health at this time?

What are your top priorities for our visit today?

What next steps do we agree on today?

Shared Decision Making

Identify priorities from the patient’s perspective.Explore awareness, goals and readiness for change

with the patient.Establish ongoing communication among providers.Primary care and behavioral health providers may

meet together with the patient.

Conversation-1 with Bill

Ongoing Care & Monitoring

Assessment of patient engagement Self-management status update Symptom monitoring Identify patient strengths Increase knowledge and access to

support resources Coordination among providers Referral and feedback pathways

Sample Referral Work Flow

PCMP identifies a BHP need

RN or identified referral specialist at the clinic fills out a referral form

with the reason for the referral INCLUDING what was

communicated to the patient and if medication management or

consultation is being requested. *SUD ROI is obtained from patient

for referral to BHP

Referral Form given to Point

Person at PCMP to fax to Point Person at BHP

Form is faxed to BHP

at: FAX #

BHP Point Person sets up an appointment

with the patient; notifies PCMP that the patient has an appointment. *SUD

ROI is obtained from patient through BHP.

Afterappointment,

BHP Point Person will fax form to PCMP (Did patient show up?)

Send fax to: FAX #

Documentation to be shared: - BHP Initial assessment and medical summary from PCMP- Medication changes (goes both ways), Consider possible medication interactions. Pharmacy consult?- 30 days (update)- 90 days, 120 days, etc. (update)- Discharge summary

BHP Point Person will be

given this information to fax to PCMP

Evidence-Based Practices: Alcohol and Drug Use Disorders1.Cognitive Behavioral Therapy2.Motivational Enhancement Therapy3.12-Step Facilitation and Peer driven support4.Family Behavior Therapy5.Contingency Management6.Community Reinforcement Approach7.Medication Assisted Treatment (alcohol and opioid use

disorders)

Spectrum of SUD Treatment Intensities

Primary Care-Based TreatmentOutpatient Treatment Intensive Outpatient TreatmentOpioid Treatment ProgramsResidential/Inpatient Treatment Level IResidential/Inpatient Treatment Level II

Conversation-2 with Bill

Hi, I’m Jordan!

I enjoy partying, but my drinking and smoking weed have been

getting in the way of keeping my job.

Hi, I’m Donna!

I'm dealing with a lot these days, and I use alcohol to cope with

stress.

One Degree:Practice conversations with virtual humans about

alcohol or marijuana use

Conversation goals:

• Bring up concerns about substance use without upsetting Jordan

• Brainstorm ways to balance partying with life goals

Conversation goals:

• Bring up concerns about substance use without upsetting Donna

• Brainstorm healthier ways to cope with stress

Available online and as a mobile app (Apple and Android) at www.shifttheinfluence.org

No-cost Online SBIRT Training & Practice

Information - Clinical Tools - TA

Screening tools SBIRT pocket cards (mobile and

print) Reimbursement Adolescent SBIRT Marijuana clinical guidance Patient education materials: Exam

room posters, bilingual fact cards, alcohol wallet cards

www.sbirtcolorado.org

• Substance use disorder treatment

• Online interactive training simulations

• Parity for mental health and substance use treatment

• Safe opioid prescribing

• And more…!

Links to Additional Helpful Tools Implementing Care for AOD Use in Medical Settings

https://www.thenationalcouncil.org/wp-content/uploads/2018/03/021518_NCBH_ASPTReport-FINAL.pdf

Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults - US Preventive Services Task Force Recommendation Statement https://jamanetwork.com/journals/jama/fullarticle/2714537

SAMHSA Information on Medication Assisted Treatment (MAT) https://www.samhsa.gov/medication-assisted-treatment

AAFP Addressing Alcohol Use Practice Manual https://www.aafp.org/dam/AAFP/documents/patient_care/alcohol/alcohol-manual.pdf

Thank you!