prepared for

Michigan Primary Care Association

Peer Assistance Services, Inc.

Dedicated to quality, accessible prevention and intervention services in workplaces and communities, focusing on substance abuse and related issues.

Incorporated in 1984

Programs

• Peer Health Assistance Programs (Dental, Pharmacy, Nursing, and other professions)

• Colorado TASC (Treatment Accountability for Safer Communities)

• Workplace Prevention Services (WPS)

• Prescription Drug Abuse Prevention Program

• SBIRT (Screening, Brief Intervention, and Referral to Treatment)

Acknowledgements

Objectives

• Discuss evidence that supports SBIRT• Identify core components of SBIRT• Describe lessons learned from SBIRT Colorado • Review solutions to commonly perceived barriers

Why SBIRT?

“The administration will continue to promote the integration of SBIRT in to mainstream health care, disseminate information

about SBIRT to a wide variety of health care settings, highlight model programs that are using SBIRT, and encourage training

opportunities for the allied health professions.”

-2012 National Drug Control Strategy

Support for SBIRT

• The Joint Commission• The American College of Surgeons Committee on Trauma• The U.S. Preventive Services Task Force• The American Congress of Obstetricians and Gynecology • The Emergency Nurses Association• The Office of National Drug Control Policy• The Centers for Medicare and Medicaid Services • The Center for Substance Abuse Treatment• Health Resources and Services Administration • National Institute on Alcohol Abuse and Alcoholism• National Institute on Drug Abuse

Prevention Priorities

Billing CodesPayer Code Description FeeCommercial CPT 99408

CPT 99409

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$33.41

$65.51

Medicare G0396

G0397

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$29.42

$57.69

Medicaid H0049

H0050

Alcohol and/or drug screening

Alcohol and/or drug service, brief intervention, per 15 minutes

$24.00

$48.00

SBIRT Colorado

History of SBIRT in Colorado

County Population Density 2000

Brief Therapy

2%

Referral to

Treatment

3%

Brief

Intervention

35%

Screening only

60%

0

2

4

6

8

10

12

14

16

Intake 6 mth follow-up

Alcohol

Marijuana

Illicit drugs

Screening, Brief Intervention and Referral to Treatment

The SBIRT Process

•Introducing SBIRT

•Brief Screen

•Screening

•Brief Intervention

•Referral to Treatment and Follow-Up

Introduction and Consent

Purpose of Screening

Brief Screen

1.How many drinks do you have per week?2.When was the last time you had 4/5 or more drinks in one day?3.In the past year, have you used or experimented with an illegal drug or prescription drug for nonmedical reasons?4.Do you currently smoke or use any form of tobacco products?

Moderate Drinking Guidelines

What is a standard drink?

Screening Instruments

Use for follow-up in those who test positive on the brief screen:

• ASSIST: Alcohol, Smoking, and Substance Involvement Screening Test

• AUDIT: Alcohol Use Disorders Identification Test

• DAST-10: Drug Screening Test (not including alcohol)

• CRAFFT: Adolescent drug and alcohol screening

Brief Intervention

What is Brief Intervention?

• A brief motivational conversation • Single 3-5 minute to multiple 15-30 minute sessions

have led to decreased use • Most effective with at-risk clients who are not

addicted • Educating clients about the health risks of their

substance use has led to behavior change • BIs are low cost, quick, client friendly, easy to do

Motivational Interviewing

William Miller and Steven Rollnick

Ambivalence as central construct

Persuasion elicits resistance

Alternative to direct persuasion and it works!

Source: William Miller (2002)

Examples of MI Strategies

Open-ended questions

Affirmation

Reflective listening

Summarizing

Goal is to elicit change talk!!!

Don’t Assume

• Patient ought to change• Patient wants to change• Patient’s health motivates him/her• Now is the right time for patient to change• Tough approach is best

Brief Intervention

Step 1: Raise the Subject

Step 2: Provide Feedback

Step 3: Enhance Motivation

Step 4: Negotiate and Advise

Step 1: Raise the Subject

Raise the subject of substance use

“Would you mind taking a few minutes to talk with me about your substance use?”

Step 2: Provide FeedbackDiscuss health risks of alcohol and other substances

“At this level of consumption, you are at increased risk for health and other consequences such as…”

Review drinking guidelines“The recommended guidelines for healthy women/men

are…

Pre-Contemplation

Contemplation

Maintenance

Action

Preparation

Step 3: Enhance Motivation

Step 4: Negotiate and AdviseElicit response: “What are some of your thoughts regarding

our discussion?

Negotiate a goal: “Why are you a 5 and not a 7?” and “What are some steps you could take?”

Assist in developing a plan: “What will be challenging for you to meet this goal? What is your plan for overcoming these challenges?”

Summarize: “What I heard you say is…”

Closing the Intervention

Show appreciation to your client

Affirm positive behaviors

Respect client’s decisions

Offer information

Arrange for follow up

Referral to Brief Therapy and Treatment

• If patient scores high on assessment

• What is brief therapy?

• Know your resources!

Sustainability

• Identify an internal champion

• Flexibility in how SBI can be implemented

• Best to combine with other health screening and education to enhance integrated care

• Involve the entire team

• Train nursing students and residents to establish SBI as a routine practice

References

• The National Center on Addiction and Substance Abuse at Columbia University. The Cost of Substance Abuse to America’s Health Care System. Report 2: Medicare Hospital Costs. May 1994. Available at http://www.casacolumbia.org/articlefiles/379-Cost%20of%20Substance%20Abuse%20Report%202.pdf.

• Mokdad A, Marks J, Stroup D, Gerberding J. Actual causes of death in the United States, 2000. JAMA 2004;291:1238--45.

• Substance Abuse and Mental Health Services Administration. (2006) Results from the 2005 National Survey on Drug Use and Health: National findings Rockville (MD): Office of Applied Studies.

• Maciosek, MV, Coffield, AB, Edwards, MS, et al. Priorities Among Effective Clinical Preventive Services. Results of a Systematic Review and Analysis. Am J Prev Med 2006; 31 (1) 52-61. Available at http://www.prevent.org/data/files/initiatives/prioritiesamongeffectiveclinicalpreventivesvcsresultsofreviewandanalysis.pdf .

• D’Onofrio G, Pantalon MV, Degutis LC, et al. The Yale Brief Negotiated Interview Manual. Yale University School of Medicine. 2005. Available at http://www.ihs.gov/nonmedicalprograms/nc4/documents/appendix_a_yale_bni_manual.pdf.

• William Miller, Rollnick Steven. Motivational Interviewing, Second Edition: Preparing People for Change. 2002.

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