FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

SBIRT in Primary Care Settings

Dr. Ginetta Salvalaggio MSc MD CCFP FCFP

Assistant Professor, University of Alberta Department of Family Medicine

Research Director, Inner City Health and Wellness Program, Edmonton, AB

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Faculty/Presenter Disclosure Faculty: Ginetta Salvalaggio

Relationship with commercial Interest

◦ None

Grant support

◦ Royal Alexandra Hospital Foundation (research lead)

◦ Alberta Innovates Health Solutions (principal investigator)

◦ Coalition Linking Action and Science for Prevention (co-investigator)

Affiliations

◦ Member of the BETTER coalition for chronic disease prevention and screening in primary care

◦ Member of the Alberta Research Network of the AHS Addiction and Mental Health Strategic Clinical Network

◦ Provincial SBIR champion as nominated by the ACFP, in partnership with the CFPC and the Canadian Centre on Substance Abuse

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Disclosure of Commercial Support

This session has not received financial support

This session has not received in-kind support

Potential for Conflicts of Interest:

◦ Dr. Salvalaggio has received research funding from Alberta Innovates—

Health Solutions to develop, implement, and evaluate SBIRT knowledge

translation resources

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Mitigating Potential Bias

Session content is derived from a comprehensive review of

the relevant literature

Recommendations are based on best available evidence

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Objectives

Learn how to screen for problematic alcohol and drug use in

various clinical settings

Learn how to discuss problematic use in a patient-centered

fashion and negotiate common goals using Brief Intervention

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

What is SBIRT?

Screening, Brief Intervention, and Referral to Treatment A public health measure that uses brief screening tools to identify those at risk

of developing alcohol or substance use disorders, accompanied by brief

counseling derived from motivational interviewing, and if needed, referral to

more intensive treatment

A three-step strategy that can be as brief as a few questions and some

feedback, or it can involve a more structured approach

A well validated approach to decrease overall alcohol consumption and

increase addiction treatment uptake and retention

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

SBIRT: Where?

Primary care office: solo, group or multidisciplinary practices

Emergency Department

Hospital Based Clinics

Jail medical departments

Community based clinics, drop-ins

Nursing stations

Prenatal care settings

Primary care settings provide an excellent opportunity for

screening and intervention

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

SBIRT: When?

Incorporated into preventive care

◦ Periodic health exam

◦ Pregnancy

◦ EMR reminder systems

Opportunistic screening

◦ Conditions where substances may play a role

◦ Poor response to treatment

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Canadian resources for SBIRT

www.sbir-diba.ca

Canada’s Low-Risk Alcohol Drinking Guidelines

A Clinical Guide: Alcohol Screening, Brief Intervention and Referral

http://knowledgex.camh.net/primary_care/toolkits/addictio

n_toolkit/pages/default.aspx

Practical tools for using SBIRT in the clinical setting

www.knowmo.ca

Knowledge mobilization website about addictions and mental health in

Alberta

Home page> Toward Patient Centered Addiction Care

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Where do I start? Screening….

"How many times in the past year have you had X or more

drinks in a day?" (where X is 5 for men and 4 for women)

“How many times in the past year have you used an illegal

drug or used a prescription medication for nonmedical

reasons?”

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Screening: one step further

AUDIT

CAGE

TICS

TACE / TWEAK in pregnancy

CRAFFT in adolescence

If the screen is positive: further questions

◦ Quantity: regular use, weekly amounts, maximum amount consumed in the past

month

◦ Consequences: medical, financial, social, legal

◦ Evidence of withdrawal, tolerance, use despite harm

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Now what? Brief Intervention

Negative screen: • Acknowledge healthy decisions

• Feedback on health effects of low risk drinking and drug use abstinence

Positive screen: FRAMES • Feedback: Give feedback on the risks

and negative consequences of alcohol and substance use. Seek the client's reaction and listen

• Responsibility: Emphasize that the individual is responsible for making his or her own decision about his/her alcohol or drug use

• Advice: Give straightforward advice on modifying alcohol and drug use

• Menu of options: Give menus of options to choose from, fostering the client’s involvement in decision-making

• Empathy: Be empathic, respectful, and non-judgmental

• Self-efficacy: Express optimism that the individual can modify his or her alcohol or substance use if they choose

Miller WR, Sanchez VC. Motivating young adults for treatment and lifestyle change. In G. Howard (ed.), Issues in Alcohol Use and Misuse in Young Adults. Notre Dame, IN: University of Notre Dame Press;1999.

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Assessing Readiness to Change

Readiness to change scale

Confidence to change scale

Prochaska & DiClemente. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice 1982:19,276-88

“On a scale from 0 to 10, where 0 is not at all ready and 10 is very ready, how ready are you to ______ your marijuana use right now?”

“Wow, so you are_______% ready, great”

0 1 2 3 4 5 6 7 8 9 10

Not at all Very

Ready Ready

15

“On a scale from 0 to 10, where 0 is not at all confident and 10 is very confident, how confident are you right now that you can meet your goal of ________ ?”

“What might take you from a ___to a____in your confidence?”

0 1 2 3 4 5 6 7 8 9 10

Not at all Very

Confident Confident

16

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Matching Brief Intervention to the Stage

of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse

Raise doubt- increase the patient’s perception of

the risks and problems with current behavior

Tip the balance- evoke reasons to change, risks of

not changing; strengthen the patient’s self efficacy

to change

Help the patient to determine the best course of

action to take in seeking change

Help the patient to take steps toward change

Help the patient to identify and use strategies

to prevent relapse

Support the patient through renewal

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Brief Intervention In Action

http://www.youtube.com/watch?v=1KNEKZu7PUY

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Referral to Treatment Outpatient treatment:

• Multidisciplinary team members

• Community addiction agencies

• 12 Step meetings

• Addiction Medicine consultation

• Pharmacotherapy

Intensive or Inpatient treatment:

• Day programs

• Inpatient programs

Web based resources

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

Engaging Your Patients

Asking permission

Thanking patient for disclosure

Consistent and comprehensive assessment

Partnership in care

Harm reduction basic principles

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

SBIRT Implementation

Barriers

◦ Time

◦ Complexity

◦ Remuneration

◦ Documentation

◦ Resources

◦ Follow-up

Facilitators

◦ Multidisciplinary team

◦ Understand your billing

codes

◦ EMR-embedded tools

FUNDAMENTALS COURSE

CSAM 2014 – OTTAWA

SBIRT: lots more questions……

Non-alcoholic substances

Non-primary care settings

Implementation strategies

Thank you!