Transcript SBIRT and Public Health Practice: The Peer In-Reach Team Model

SBIRT and Public Health Practice:
The Peer In-Reach Team Model
…bridging the gap between clinical
medicine and public health
Edward Bernstein MD
Judith Bernstein RNC, PhD
Dept. of Emergency Medicine
Project Assert and the BNI-ART Institute
NIAAA Youth Alcohol Prevention Center
BNI-ART Education Faculty
• Lisa Allee MSW, Boston Medical Center
• Kate Brown, Youth Alcohol Prevention Center, BU School of
Public Health
• James Feldman MD, Dept. of Emergency Medicine, BU School
of Medicine
• William Fernandez MD, Dept. of EM, BU School of Medicine
• Andrea Hall LISW, Boston Medical Center/ BEST Team
• Patricia Mitchell RN, Dept. of EM, BU School of Medicine
• Melanie Rambaud, Youth Alcohol Prevention Center, BU School
of Public Health
• Brenda Rodriquez MBA, BNI-ART Institute, BU School of
Public Health
• Benjamin Shelton MD, Chief Resident, EM Residency
Program, Boston Medical Center
• Luann Sweeney RN, Boston Medical Center
• Ludy Young, Licensed LADC II, Project ASSERT, BMC
SBIRT Workshop
• rationale and evidence for SBIRT
• Project ASSERT collaborative model
• NIAAA screening guidelines
• motivational interviewing principles
• brief negotiation interview & referral skills
• practice SBIRT with case studies
Contending Frameworks, Strategies & Policies
• Is addiction a moral failing/crime
– best controlled by punishment (jail or drug court mandate)
• Is addiction a medical problem
– best treated by acute and chronic disease management
• Is addiction a public health problem requires access to
– universal screening
– brief intervention
– specialized treatment
– comprehensive supports for individuals, families and
communities (i.e. jobs, mental health services and housing)
– safeguards for human rights
Why do SBIRT?
SBIRT--Treatment Works!
NESARC study 2001-02
• 35.9% of U.S. adults with alcohol dependence that
began more than one year ago were in full recovery
(18% abstainers, 17% low risk drinkers)
• an additional 27% were in partial remission
• 12% were asymptomatic high risk drinkers
• only 25% with alcohol dependence who began
treatment more than one year ago were still
dependent (treatment failures)
Substance abuse resembles other chronic recurrent
illnesses: a time for a paradigm shift
• <30% of patients with asthma, HTN, diabetes adhere to
prescribed diet and/or behavioral changes, and 50%
experience recurrence
• challenges of adherence and recurrence with a substance
abuse diagnosis are not different from those found in other
chronic diseases
• substance abuse should be insured, monitored, treated and
evaluated like other chronic diseases
McClellan AT, Lewis DC, et al. JAMA 2000; 284:1689-1695.
THE TREATMENT GAP
Past Year Need for & Receipt of Tx for Illicit Drug/
Alcohol Abuse among Persons Aged 12+: 2002-3
WHY DO SBIRT:
SCREENING WIDENS THE NET
ABSTAINERS &
MILD DRINKERS
(71%)
AT-RISK
DRINKERS
(20%)
ABUSE/
DEPENDENCE
(8.5%)
Specialized Treatment
Brief Intervention
Primary Prevention
Intersection of Opportunity & Need
An Emergency Department Perspective
• 7.6 /111 million ED visits are alcohol attributable
(McDonald, 2004)
• 31% of urban ED pts > 2 CAGE positive
(Bernstein, 1996)
• 26% of ED patients high risk/dependent drinkers
(Academic ED SBIRT Collaborative, 2005)
WHY DO SBIRT?
…because brief intervention works!
• Chafetz et al, 1961
– (n=200)
– 65% of those receiving brief intervention in the
MGH ED showed up for treatment vs 5% of
controls
– 40% in the intervention group vs 0% in the control
group kept 5 appointments
Establishing treatment relations with alcoholics.
J Nerv Ment Dis 1962; 134: 390-410.
Brief Intervention in the Trauma Center
• 1153 (46%) of 2524 screened positive
• 762 were randomized to control or intervention status
• at 6 months, decreases in both groups (NS)
• at 12 months
– ↓ 21.9 drinks per week (intervention) vs 6.7 (control)
• at 3 years
– 47% greater reduction in serious repeat injuries in
the intervention group vs controls (state dataset)
Gentilello, Rivara et al. Ann Surg 1999; 230: 473-483
Meta-analyses of Motivational
Interviewing
• small but real effect sizes
– Dunn et al, 2001
– Hettema et al, 2005 (.30 at 1 yr)
– Vasilaki et al, 2006 (aggregate .18, .60 at 3 mo)
So if brief intervention works and
saves money…
Why don’t health professionals routinely
screen, practice brief intervention, and
refer, when indicated, to the substance
abuse treatment system?
Project ASSERT: Bringing down the barriers
A Model for
Brief Intervention in the ED
1993 SAMHSA –CSAT
Critical Populations Demonstration Grant
Bernstein E, Bernstein J, Levenson S: Project ASSERT: An ED-based
intervention to increase access to primary care, preventive services and the
substance abuse treatment system. Ann Emerg Med 1997;30:181-189.
tablished with funding from CSAT in 1993 to empower patients to reduce substanc
use and other harmful health and social behaviors, and facilitate ED patient access
mary care, preventive services and substance abuse treatment.
Project ASSERT Linkage Strategy
General
Medical
Setting
Screening for
Health and
Safety
Needs
Community
Health Promotion
Advocates
Empowerment
through Brief
Negotiated Interview
(Bernstein & Rollnick)
Active
Referral Network
for
Community
Resources
Peer educators provide consultation to
nurses and physicians
…providing empathy and support
…offering resources
From CSAT Demonstration Grant to
Boston Medical Center ED Budget Line Item…
RESULTS FROM PROJECT ASSERT
• 17,495 patients received screening and BNI from 2001-2005
• 16,114 total referrals made to SA treatment, AA/NA, social
service, behavioral health and primary care.
• 5,607 patients sent to detox often by taxi
• 1608 beds detox unavailable—case management
• 1708 SA outpatient
• 1,656 appointments made for primary care
Brief Intervention in the Clinical Setting Reduces
Cocaine and Heroin Use
Bernstein et al. Drug & Alcohol Dependence, 2004;77:49-59
• 23,669 patients screened
• 1175 enrollees (follow-up rate 82%)
• among 778 with positive hair at baseline
– intervention group more likely to be abstinent at 30 days
than the control group
• cocaine alone (22.3% vs 16.9%)
• heroin alone (40.2% vs 30.6%)
• both drugs (17.4% v s 12.8%), with adjusted OR of
1.51-1.57
– cocaine levels in hair reduced
• 29% for intervention group vs 4% control group
THE IMPACT OF ED Provider SBIRT
ON PATIENTS’ ALCOHOL USE
Funded in part by NIAAA R21 AA015123
and 14 RO3s AA 01511-14
with collaborative funding from SAMHSA
Academic Emergency Medicine SBIRT Collaborative
New England Med.
Boston Medical
Univ. of Michigan.
Rhode Island Hospital
Yale Univ.
Denver Health Medical
Cooper Health
Univ. of Southern California
Univ. of Virginia
Charles Drew Univ.
Univ. of California
Univ. of New Mexico
Howard Univ.
Emory University
Patient Response to SBIRT at 3 month F/U
Summary
• At 3 months, controlling for baseline drinking levels,
patients receiving the intervention reported
– 3.25 fewer ‘typical number of drinks per week’ than
controls (B= -3.25 SE= 1.16, p < .05)
– almost ¾ of a drink less for ‘maximum number of
drinks per occasion’ than controls (B= -.72 SE=
.32, p < .05).
• Benefits of brief intervention were confined to those
with at-risk drinking rather than dependent drinking
patterns, as measured by the CAGE.
SBIRT
The Toolbox
SBIRT: Why Screen?
THE PROBLEM DRINKER (National Gallery)
Screening Questions
 Do you smoke? Do you drink? Do you use drugs?
 On average, how many days per week do you drink
alcohol ( beer, wine, liquor )?
 On a typical day when you drink, how many drinks do
you have?
NIAAA Guidelines (risky drinking):>14 drinks/week
for men and >7 drinks per week for women
 What is the maximum number of drinks you had on
any given occasion during the last month?
NIAAA Guidelines: >4 for men & >3 for women
Remember that a “standard drink”
consists of:
THE ED BRIEF NEGOTIATION
INTERVIEW
A toolkit for enhancing motivation for change
in the clinical setting-developed with Stephen Rollnick,1994
Effective communication about alcohol
and drugs….
….approaching the drinking driver
to facilitate behavior change
from The Emergency Physician and the Problem Drinker
D’Onofrio, Bernstein & Bernstein, 1996
NEGOTIATING BEHAVIOR CHANGE
Principles of Good Practice
• Respect the autonomy of clients and their choices
• Set an agenda for change together
• Offer information in a neutral, non-personal manner
• Make clear from the start that the client is the active
decision maker
OTHER PRINCIPLES OF
MOTIVATIONAL INTERVIEWING
• Ask open-ended questions.
• Practice reflective listening to encourage patients to
talk about their drinking and the barriers to change.
• Accept resistance as a normal response.
• Avoid confrontation, labeling, stereotyping and forcing
patients to accept a label or diagnosis.
NEGOTIATING BEHAVIOR CHANGE
Principles of Good Practice
“Motivational interviewing was developed from the
rather simple notion that the way clients are spoken
to about changing addictive behavior affects their
willingness to talk freely about why and how they
might change.”
Stephen Rollnick, PhD
Addiction 2001; 96:1769-70.
THE BRIEF NEGOTIATION INTERVIEW
• establish rapport & ask permission to raise subject
• provide feedback
• enhance motivation
• explore pros and cons
• assess readiness to change and sources of resilience
• explore discrepancies between actual state & goals
• develop action plan, using strengths/resources
• referral to primary care and tx if indicated
NOT READY
(1 - 3)
1
2
READY
(8 - 10)
UNSURE
(4 - 7)
3
4
5
6
7
8
9
10
INTERVENTION ALGORITHM
1. Raise subject
2. Provide feedback
Review screen
Hello, I am _____. Would you mind taking a few
minutes to talk with me about your use of [X]?
<<PAUSE and LISTEN>>
Before we start, could you tell me a little about
yourself and your goals (or what’s important to
you?)
From what I understand you are using [insert
screening data]… We know that drinking above
certain levels and/or use of illicit drugs can
cause problems, such as [insert medical info]…
I am concerned about your use of [X].
Make connection
What connection (if any) do you see between
your use of [X] and this ED visit?
If pt sees connection: reiterate what pt has said.
If pt does not see connection, suggest one,
using medical info (but don’t confront).
For alcohol…
Show NIAAA
guidelines & norms
These are what we consider the upper limits of
low risk drinking for your age and sex. By low
risk we mean that you would be less likely to
experience illness or injury if you stayed within
these guidelines.
3. Enhance motivation
Explore Pros and Cons
Use reflective listening
Readiness to change
Reinforce positives
Develop discrepancy
between ideal and
present self
Ask pros and cons. Help me to understand
what you enjoy about [X]?
<<PAUSE AND LISTEN>>
Now tell me what you enjoy less about [X]
or regret about your use.
<<PAUSE AND LISTEN>>
On the one hand you said…
<<RESTATE PROS>>
On the other hand you said….
<<RESTATE CONS>>
So tell me, where does this leave you?
[show readiness ruler]
On a scale from 1-10, how ready are you
to change any aspect of your use of
[X]?
Ask: Why did you choose that number
and not a lower one like a 1 or a 2?
Other reasons for change? How does
this fit with where you see yourself in
the future?
4. Negotiate & advise
What’s the next step?
Negotiate goal
What do you think you can do to stay
healthy and safe?
Benefits of change
If you make these changes what do you
think might happen?
Reinforce resilience /
resources
What have you succeeded in changing in
the past? How? Could you use these
methods to help you with the challenges
of changing?
Summarize
This is what I’ve heard you say…Here’s an
agreement I would like you to fill out,
reinforcing your new goals. This is
really an agreement between you and
yourself.
Provide handouts
Suggest PC f/u
Thank patient
Provide agreement and information sheet
Suggest Primary Care f/u to
discuss/support carrying out plan
Thank patient for his/her time
Applying the algorithm…
Getting to ‘yes’ with
a high risk drinker
Provider: Clara Safi, NP
www.ed.bmc.org/sbirt
Connecting drinking & Reason for Visit
• This is the patient’s chance to name the problem.
• If there is resistance or lack of awareness of a connection, the
provider can help the patient see the connection.
• Listen carefully for the patient’s own concerns to make the link.
• Use open ended questions to explore:
– What would make this a problem for you?
– How might you prevent that from happening?
– Have you ever done anything you wished you hadn’t while
drinking?
• Give feedback empathetically, with no shame or blame.
ASSESSING READINESS TO CHANGE
On a scale of 1-10, ten meaning ‘most ready’ and
one ‘least ready’, please mark on the ruler where
you are now on your readiness to change your use
of alcohol and/ or drugs?
You marked five, which indicates you are fifty percent
ready to make a change, so tell me, why didn’t you
mark a lower number like a one or two?
1
2
3
4
5
6
7
8
9
10
The pros and cons in action….
Provider: Ludy Young, Health Promotion Advocate
at National Alcohol Screening Day
www.ed.bmc.org/sbirt
Exploring the Pros and Cons
• exploring the pros and cons can help you understand
where the patient is coming from and obstacles to change
• pros and cons strategy
– ask, “What do you like about your use of [X]?”
– acknowledge that you have heard what they say
– elicit statements about consequences by asking
• “What do you like less or regret about your use?”
– repeat and affirm statements that lead to change
– summarize briefly: on the one hand you said.., and on
the other you said….
– ask, “Where does that leave you?” On a scale of 1-10,
how ready are you to make some changes?
Provider advice and negotiation with
the dependent drinker….
Provider: Gail D’Onofrio, MD
www.ed.bmc.org/sbirt
THE ROLE OF PROVIDER ADVICE
• meet people where they are at
• timing is important—the patient should feel heard
and respected before the physician weighs in
• conversational style matters—advice should be
brief, and non-judgmental
• advice should be based on fact and weave in
medical events
IN NEGOTIATING A PLAN, EXPLORE….
• previous strengths, resources and successes
– “Have you stopped drinking/using drugs before?”
– “What personal strengths allowed you to do it?”
– “Who helped you and what did you do?”
or
– “Have you made other kinds of changes
successfully in the past?”
– “How did you accomplish these things?”
Developing and Using a Referral Network
• Provider expectations: setting realistic goals
for change in a chronic disease
• http://findtreatment.samhsa.gov
• www.ed.bmc.org/sbirt