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					                     SBIRT:
      Reducing Alcohol Related Morbidity
        and Mortality in Primary Care
         J. Paul Seale, MD, Principal Investigator
      Sylvia Shellenberger, PhD, Director of Training
      Denice Crowe Clark, MFT, Project Coordinator
              Department of Family Medicine
             Mercer University School of Medicine
The Southeastern Consortium for Substance Abuse Training
                          (SECSAT)
            Funded by Grant 1U79T1020278-01
            Substance Abuse and Mental Health
             Services Administration (SAMHSA)
                                                       1
SECSAT Key Personnel:
  Mercer Project Staff
     J. Paul Seale, MD, PI
   Denice Crowe Clark, MFT
        Project Coordinator

   Sylvia Shellenberger, PhD
        Director of Training

    J. Aaron Johnson, PhD
       Director of Evaluation

     Bonnie Cole, JD, MFT
    Standardized Patient Trainer

                                   2
  SECSAT Key Personnel:
         Site Coordinators
               David Miller, MD
        Wake Forest UBMC IM Residency
              Winston-Salem, NC

              David Parish, MD
Mercer University School of Medicine IM Residency
                    Macon, GA

              J. Paul Seale, MD
Mercer University School of Medicine FM Residency
                    Macon, GA

            Hunter Woodall, MD
          AnMed Health FM Residency
                Anderson, SC
                                                    3
          Module 1A Objectives

   Describe the importance of alcohol misuse
    as a health issue
   Examine the evidence base for alcohol
    screening brief intervention & referral to
    treatment (SBIRT)
   Outline the rationale for implementing
    SBIRT in primary health care
   Provide an overview of the steps in
    “SECSAT” Project
                                                 4
What is SBIRT?

     Screening

  Brief Intervention

Referral to Treatment

                        5
               What is SBIRT?

   SBIRT is a comprehensive, integrated,
    evidence-based approach to the delivery
    of early intervention and treatment
    services for individuals with substance use
    problems or risk.



                                        Burge et al, 2009


                                                     6
                What is SBIRT?
   Screening quickly assesses the severity of
    substance use and identifies the appropriate
    level of treatment.
   Brief Intervention focuses on increasing
    insight and awareness regarding substance use
    and motivation toward behavioral change.
   Referral to Treatment provides those
    identified as needing more extensive treatment
    with access to specialty care.

                                                     7
      Relationship Between
Alcohol Problems and Alcohol Use
      Problems         Alcohol Use

             Severe   Heavy

       Moderate        Moderate


       Few                Light


     None                     None

                                     8
               NIAAA (2009) Definition of
                   At-Risk Drinking
   Healthy Men ≤65
       More than 4 standard drinks in a day and/or
       More than 14 standard drinks in a week
   Healthy Women and Healthy Men >65
       More than 3 standard drinks in a day and/or
       More than 7 standard drinks in a week
                      A standard drink is 14 grams of pure alcohol

     http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf, NIAAA 2009

                                                                                                 9
What is a Standard Drink?
                                                   Beer:        12 oz   =   1
                                                                16 oz   =   1 1/3
                                                                22 oz   =   2
                                                                40 oz   =   3 1/3

                                                   Malt         12 oz   =   1 1/2
                                                   Liquor:      16 oz   =   2
                                                                22 oz   =   2 1/2
                                                                40 oz   =   4 1/2

                                                   Wine:        5 oz = 1
                                                                750 ml bottle = 5

                                                   Liquor:      1.5 oz shot = 1
                                                                Mixed drink = 1 or more
                                                                Pint = 8 1/2
                                                                Fifth = 17




                                                                        NIAAA, 2009
 http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf



                                                                                    10
Why is Management of Alcohol Misuse
Important to Primary Care Physicians?
     Prevalence
     Morbidity and mortality
     Barrier to treatment of chronic
      conditions
     Cost & time saving
     Potential for effective intervention


                                             11
Drinking Patterns in the U.S.

                       4%                      Dependent


                24%                                At Risk

           37%                                         Low Risk


      35%                                                   No Risk



http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009

                                                                                    12
                   Who Needs Attention?

                                         Nearly 3 in 10 exceed
 At Risk (19%)                           limits but most (24%)
                                           do not have alcohol
                                               dependence



                                           Functionally
                                           Dependent
                                           (3%)

                                                          Severely
                                 Abuse                    Dependent
                                 (5%)                     (1%)

                                                              13
Willenbring, 2010; NIAAA, 2009
                Who Needs Attention?
                                    These 24% account for more
 At Risk
                                 illness, death & social disruption
 (19%)
                                   than those with dependence




                                            Functionally
                                            Dependent
                                            (3%)

                                                            Severely
                                Abuse                       Dependent
                                (5%)                        (1%)

                                                                 14
Willenbring, 2010; NIAAA 2009
    Alcohol Misuse is Commonly
    Encountered by Primary Care
             Physicians
   7-20% of primary care patients
    exhibit patterns of alcohol misuse
   24-31% of patients in ERs
   22% of minor trauma patients
   50% of severely-injured trauma
    patients

                         Fiellin et al, 2000; D’Onofrio & Degutis, 2002
                                                                    15
Why Important: Morbidity & Mortality
   Alcohol is the third leading cause of preventable
    death in the US (CDC), (76,000 deaths, or 5% of
    all deaths in 2001)
   Alcohol is attributable to 4-8% of Disability-
    Adjusted Life Years (DALYs) in the US (WHO).
   Globally, alcohol causes morbidity and mortality
    at a higher rate than tobacco (WHO).

                  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004;
               http://www.who.int/substance_abuse/facts/alcohol/en/index.html, WHO, 2010;
          http://www.who.int/substance_abuse/publications/en/APDSSummary.pdf; WHO, 2002


                                                                                      16
Possibly Alcohol-Dependent Patients

                                                            Significant
   Highest risk/                                            morbidity,
   Dependent                        4%
                                                          mortality, and
                                                          economic cost




    http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009
                                                                                        17
       At-Risk Drinkers:
  Why Do They Need Attention?

                                                          At risk for short and
                                                           long term health
                                    24%                        problems &
At Risk drinking
                                                           may put others at
                                                                   risk




     http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009

                                                                                        18
Major Causes of Alcohol-related Morbidity &
                 Mortality

   Chronic liver disease               Stroke
    & cirrhosis                         Depression
   Cancer                              Injuries
   Heart disease                       Homicide, suicide
   Pancreatitis                        Family Violence
                                        Non-accidental/non-
                                         intentional poisoning
                                                                  Smith, 1999;
             http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004

                                                                             19
          Morbidity & Mortality
   Due to Chronic                        Due to Acute
    Alcohol Misuse                         Alcohol Misuse
       46% of total                           54% of total
        deaths                                  deaths
       35% of years of                        65% of years of
        life lost                               life lost
       Leading cause of                       Leading cause of
        liver disease                           MVAs in US




              http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004

                                                                            20
       Why Important: Morbidity
   Alcohol interacts
    with many
    medications
   Exacerbates
    numerous chronic
    medical conditions
    (HTN, DM, PUD,
    etc.)                                    Rehm et al, 2002; Stranges et al, 2004;
                       http://pubs.niaaa.nih.gov/publications/aa26.htm, NIAAA 2000;
           http://pubs.niaaa.nih.gov/publications/Medicine/medicine.htm, NIAAA 2007
                                                                                  21
     Alcohol Misuse
Complicates Treatment of
Chronic Medical Conditions




                             22
                       Economic Cost:
                     $185 Billion Annually
                     $200
                     $180
                     $160
                     $140
  Cost in Billions




                     $120
                     $100
                      $80
                      $60
                      $40
                      $20
                       $0
                            Alcohol    Drug   Cancer   Coronary
                            Abuse     Abuse             heart
Mokdad et al, 2000; Harwood, 2000                      disease


                                                                  23
    Increasing Patient Recognition of
        Alcohol as a Health Issue

   Expectation that health care providers
    will give sound advice about alcohol
       Potential benefits for cardiovascular
        conditions
       Potential breast cancer risk among
        women


                 http://www.niaaa.nih.gov/FAQs/General-English/default.htm#heart; NIAAA 2007;
        http://pubs.niaaa.nih.gov/publications/brochurewomen/women.htm#drinking; NIAAA 2008
                                                                                           24
               Patients’ Sense of
            Screening’s Importance
     %
80
70
60
50                                                                  Diet/Exercise
40                                                                  Smoking
30                                                                  Drinking
20
10
 0
     Very                                          Very
     Important                                 Unimportant

            http://www.cdc.gov/InjuryResponse/alcohol-screening/resources.html, 2009   25
 Patients’ Comfort with Screening
 %
80
70
60
50                                                                        Diet/Exercise

40                                                                        Smoking
30                                                                        Drinking
20
10
 0
     Very                                             Very
     Comfortable                                  Uncomfortable

                                                                                       26
            http://www.cdc.gov/InjuryResponse/alcohol-screening/resources.html, 2009
                  Why SBIRT?
   At-risk drinking is common
   At-risk drinking increases risk for trauma and
    other health problems
   At-risk drinking exacerbates chronic health
    problems
   At-risk drinking often goes undetected
   Patients are more open to change than you
    might expect
   You can make a difference!
                                      Adapted from Burge et al, 2009

                                                                 27
    What is the Evidence Base for
               SBIRT?

   Does SBIRT really change patients’
    drinking behavior?




                                         28
          Brief Intervention Works!

   SBIRT meta-analyses & reviews:
       More than 34 randomized controlled trials
       Focused primarily on at risk and problem
        drinkers
       Result in 10-30% reduction in alcohol
        consumption at 12 months


              Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005; Kaner et al, 2007


                                                                                             29
        Net Percentage Reduction in
          Mean Drinks Per Week
             (USPSTF review)
   9 high quality studies reviewed
       3 single intervention studies resulted in
        reductions in weekly alcohol consumption
        ranging from 6-19%
       6 multi-contact intervention studies resulted
        in reductions in weekly alcohol consumption
        ranging from 7-34%
             http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomissum.htm, Whitlock et al, 2004

                                                                                           30
US Preventive Services Task Force: SBIRT
 Recommended for All Adult PC Patients
       Class B recommendation (flu shots,
        cholesterol screening, SBIRT)
       “…good evidence that screening in
        primary care can accurately identify patients
        whose levels of alcohol consumption…place
        them at risk for increased morbidity and
        mortality”
       “…good evidence that brief behavioral
        counseling interventions…produce small to
        moderate reductions in alcohol
        consumption”
                       http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm; USPSTF, 2004
                                                                                31
       SBIRT & Joint Commission
             Accreditation
   Currently being considered by the Joint
    Commission as a requirement for hospital
    accreditation
   Performance measures in development in
    2009 for tobacco and alcohol use
   Pilot testing in hospitals began in 2010
                                       The Joint Commission, November 2009
                    http://www.jointcommission.org/PerformanceMeasurement

                                                                       32
  Nursing Involvement Significantly
Increases Clinician Intervention Rates
   Vital Signs Study: clinicians were 12x more
    likely to intervene if nurses screened for
    at-risk drinking as part of vital signs
   Healthy Habits Study: clinicians were 3x
    more likely to intervene with at-risk
    drinkers if given alcohol assessment
    results by the nurse
                               Seale et al, 2005; Seale et al, 2010

                                                                 33
        Number Needed to Treat
Cessation advice for smoking                                                  20


Nicotine replacement therapy                             10


    Alcohol-related harm                             8


  Hazardous alcohol use                              8


  Tricyclics for depression                     6


                                 0          5          10       15         20         25

         http://www.phepa.net/units/phepa/html/en/dir361/doc9736.html, Gaul et al, 2005
         What Does This Mean for Your
                  Patients?
Calculate based on the numbers of adult
  patients you see per week…
For example, if
   You see on average 40 patients per week
   If 20% of these patients are at risk (8 patients)
   With brief intervention, 1 patient weekly is likely
    to lower his/her risk


     http://www.phepa.net/units/phepa/html/en/dir361/doc9736.html, Gaul et al, 2005
           Other Benefits of SBIRT

   Fewer hospitalizations
   Fewer ER visits
   Benefit vs. Cost (48 months f/u)
       Medical Benefit-Cost Ratio           4.3:1
       Societal Benefit-Cost Ratio           39:1



                             Fleming et al, 2002; Mundt, 2006; Kraemer, 2007

                                                                          36
        SBIRT is Underutilized in
             Primary Care

   Less than half of self-reported problem
    drinkers are asked by their PC physicians
    about their alcohol consumption or
    advised to quit drinking or cut back.
   Most PC physicians prefer not to counsel
    nondependent problem drinkers
    themselves.
                           D’Amico et al, 2005; Spandorfer et al, 1999

                                                                    37
        SBIRT Can Be Effectively
      Implemented in Primary Care

   Effective models exist for implementing
    screening and brief intervention in
    residency training.
   Trained clinicians typically intervene with
    more than 70% of patients.

                               Seale et al, 2005; Adams et al, 1998


                                                                 38
     Key to Implementation:
Systems Approach Targeting Both
 The Clinicians & Office System
   Train clinicians & clinic staff in SBIRT
   Create office system that will support SBIRT
       Screening & prompting system
       Assessment instruments
       Intervention materials
       Reminder system for re-assessment &
        reinforcement

                                                   39
        5 Basic Components of This
          Project’s SBIRT System
   Prescreening of all patients using single
    question screen
   Screening of all prescreen-positive patients
    using the Alcohol Use Disorders Identification
    Test (AUDIT)
   Clinician Interventions for all screen-positive
    patients
   Referral for patients desiring more help
   Follow-up (re-assessment & reinforcement) at
    future visits
                                                  40
          Summary of Module 1A
   Alcohol misuse is a major cause of
    morbidity & mortality in the US
   SBIRT is effective in decreasing at risk
    drinking & its related consequences
   Clinician training & systems intervention
    are effective in implementing primary care
    SBIRT protocols
   Training Modules 1B & 1C will equip this
    clinic to effectively perform SBIRT—stay
    tuned!
                                             41
       Module 1B

      The Procedures of
Screening, Brief Intervention &
    Referral to Treatment




                                  42
         Objectives for Module 1B
   Describe the procedures of SBIRT
   Practice using and scoring the Healthy
    Habits Prescreen and the Healthy Lifestyles
    Screen (AUDIT)
   Review the steps of the intervention for
    at- risk drinkers
   Review added steps for those possibly
    dependent
   Practice conducting interventions
                                             43
        5 Basic Components of This
          Project’s SBIRT System

   Prescreening (single question screen)
   Screening (Alcohol Use Disorders Identification
    Test or AUDIT)
   Clinician Interventions for all screen-positive
    patients
   Referral as appropriate for patients with higher
    levels of risk or possibly dependent
   Follow-up assessment/reinforcement at future
    visits

                                                   44
      STEP 1:
Prescreen is routinely
performed every 6-12
       months


 Tool: Single alcohol
 screening question
  (SASQ - NIAAA)

                         45
                Single Question:

   “How many times in the past 12 months
    have you had X or more drinks in a day?”
       X = 5 for men
       X = 4 for women
   Positive screen = one or more times in the
    past year


                                               46
Standard Drink Sizes
                                                 Beer:        12 oz   =   1
                                                              16 oz   =   1 1/3
                                                              22 oz   =   2
                                                              40 oz   =   3 1/3

                                                 Malt         12 oz   =   1 1/2
                                                 Liquor:      16 oz   =   2
                                                              22 oz   =   2 1/2
                                                              40 oz   =   4 1/2

                                                 Wine:        5 oz = 1
                                                              750 ml bottle = 5

                                                 Liquor:      1.5 oz shot = 1
                                                              Mixed drink = 1 or more
                                                              Pint = 8 1/2
                                                              Fifth = 17




                                                                      NIAAA, 2009
http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf

                                                                                  47
        Process When Prescreen is
                 Positive

   Patient is given the Healthy Lifestyles
    Screen (AUDIT)
   Patient completes the AUDIT and gives it
    to his/her clinician
   Physician performs intervention



                                               48
Expected Results of Prescreen

    Prescreen         80-85%
                      negative




15-20% will receive
     full screen



                                 49
Step 2: Screening




                    50
                                       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                                                         0           1             2              3                  4
1. How often do you have a drink containing alcohol?            Never      Monthly     2-4 times a    2-3 times a         4 or more
                                                                           or less       month           week              times a
                                                                                                                            week
2.   How many drinks containing alcohol do you have on
                                                                1 or 2      3 or 4        5 or 6         7 to 9       10 or more
     a typical day you are drinking?
3.   How often do you have four or more drinks on one                     Less than                                    Daily or
                                                                Never                    Monthly        Weekly
     occasion?                                                            monthly                                    almost daily
4.   How often during the last year have you found that                   Less than                                    Daily or
                                                                Never                    Monthly        Weekly
     you were not able to stop drinking once you had                      monthly                                    almost daily
     started?
5.   How often during the past year have you failed to do                 Less than                                    Daily or
                                                                Never                    Monthly        Weekly
     what was expected of you because of drinking?                        monthly                                    almost daily
6.   How often during the past year have you needed a                     Less than                                    Daily or
     drink first thing in the morning to get yourself going     Never     monthly        Monthly        Weekly       almost daily
     after a heavy drinking session?
7.   How often during the past year have you had a                        Less than                                    Daily or
                                                                Never                    Monthly        Weekly
     feeling of guilt or remorse after drinking?                          monthly                                    almost daily
8.   How often during the past year have you been unable
                                                                          Less than                                    Daily or
     to remember what happened the night before because         Never                    Monthly        Weekly
                                                                          monthly                                    almost daily
     of your drinking?
9.   Have you or someone else been injured because of                                   Yes, but                      Yes, during
     your drinking?                                               No                    not in the                   the past year
                                                                                        past year
10. Has a relative, friend, doctor, or other health care          No                    Yes, but
                                                                                                                      Yes, during
    worker been concerned about your drinking and                                       not in the
                                                                                                                     the past year
    suggested you cut down?                                                             past year




                                                                                                                                      51
Instrument: Healthy Lifestyles Screen
              (AUDIT)
   Adapted from World Health Organization
   Validated in numerous studies worldwide
   Fits US guidelines for at risk drinking
   Content
       3 quantity & frequency questions (1-3)
       3 questions probing signs of dependency (4-6)
       4 questions about alcohol-related problems (7-10)



                                                            52
          Screening Procedures

1.   Patient completes form
2.   Patient gives form to clinician
3.   Clinician notes items marked
4.   Clinician calculates the score
5.   Clinician obtains & documents recent
     alcohol & drug use


                                            53
         AUDIT Screen – Scoring

   Note numbers in top shaded row
   Enter checked number for each question
   Enter total score of 10 questions
   Ask the 3 questions under Provider Use
    Only (frequency, quantity, drugs)



                                             54
         View Video One

       Nursing staff Asking
    Healthy Habits Prescreen
& Giving Healthy Lifestyles Screen
             (AUDIT)


                                 55
   Clinicians: Practice Scoring
    Healthy Lifestyles Screen
             (AUDIT)


Nursing staff: Practice Giving Healthy
          Habits Prescreen
       & Administering AUDIT

                                         56
                      STEP 3: Intervention
   Clinician identifies level of intervention based on Healthy Lifestyles
    Screen (AUDIT) score
   Clinician conducts the intervention using the intervention card as a
    guide

                 Your AUDIT score:                        Standard Drink Sizes                            Lower Risk Drink Limits

           16+         Major consequences/       12 oz        8-9 oz       5 oz       1.5 oz/                      Per         Per
                       Possibly dependent         Beer         Malt        Wine       1 shot                       Day        Week
           15                                                 Liquor                  Liquor        Healthy
                                                                                                                    4           14
                                                                                                     Men
                                                          =            =          =                 Healthy
                      At-risk drinking                                                                              3               7
                                                                                                    Women

                                                                                                    All ages        3               7
                                                                                                      >65
            1
                                                 ~5%          ~7 %         ~12%       ~40%
                                                                                                    No drinking if: driving, pregnant
            0         Zero (no risk)             The percent of “pure” alcohol expressed here            or possibly dependent
                                                    as alcohol/volume varies by beverage.


                    Not at all   0       1   2        3        4       5     6         7        8     9       10 Extremely
                            cm



                                                                                                                                        57
                  Intervention Guide

                        Zone I: At Risk                                               Zone II: Possibly Dependent
                     AUDIT 1-15 (≥ 1 binge)                                                    AUDIT ≥ 16

 Ask Permission        “I appreciate you answering our health questionnaire. Could we take a minute to discuss your results?”


     Provide           Refer to bar graph & provide patient’s AUDIT score. [As your physician] “Drinking at this level can be harmful to your
    Feedback           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 use?” (Decisional balance)
     Enhance           “On a scale of 0-10, how important is it that you cut back or quit your alcohol use?”
   Motivation &         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
Elicit Change Talk     cutting back?”

     Provide           Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines. If ZONE II: “If you go a day or
     Advice            2 without drinking, do you ever get sick, shaky, have tremors/seizures/ or see/hear things that are not there?”

    Discuss            “If you were to make a change, what would be your first step?”            Offer menu of options for more help:
   Next Steps                                                                                    ► Medication (naltrexone, acamprosate,
                                                                                                   disulfiram)
                                                                                                 ► Referral
                       Summarize, emphasize patient strengths, highlight change talk and           •Counseling/Brief treatment
   Close on            decisions made. Arrange for follow-up as appropriate.                       •Support group (e.g., AA, NA, Celebrate
  Good Terms                                                                                        Recovery)
                                                                                                   •Treatment or substance abuse program




                                                                                                                                                        58
    Stratified Intervention Protocols:
         Zone I: At Risk Drinker
   At risk drinker with limited or no
    consequences (AUDIT score 1-15 &
    positive prescreen)
   Brief intervention
       Ask permission
       Provide feedback
       Enhance motivation
       Provide advice
       Discuss next steps
       Close on good terms
                                         59
    Stratified Intervention Protocols:
      Zone II: Possibly Dependent
   Patient with major consequences/possibly
    dependent (AUDIT score ≥ 16 or polysubstance
    abuse)
   Brief intervention
       Ask permission
       Provide feedback
       Enhance motivation
       Provide advice encouraging abstinence
       Evaluate & address possible withdrawal risk
       Discuss next steps including information about getting
        help
       Close on good terms                                  60
  How to Use the
Intervention Guide




                     61
      Step 1: Ask for Permission

   “I appreciate your answering our health
    questionnaire. Could we take a minute to
    discuss your results?”




                                           62
      Step 2: Provide Feedback from
       Prescreen and AUDIT Screen
                                Refer to bar graph & provide
                                 patient’s AUDIT score
 Your
AUDIT
Score:
 16+      Major
          consequences/         [As your physician] “Drinking
                                 at this level can be harmful
 15
          Possibly
          dependent

          At-risk drinking
                                 to your health and possibly
                                 responsible for the health
  1
                                 problem for which you came
  0       Zero (no risk)
                                 in today.”
                                “What do you make of that?”
                                                            63
        Step 3: Enhance Motivation:
             Decisional Balance
   Ask, “What are some of the good/not-so-good
    things about your alcohol use?”
   Summarize both sides of their thinking
       On the one hand… and on the other hand…




                                                  64
    Step 3: Enhance Motivation: Rulers
   “On a scale of 0 to 10, how important is it for
    you to cut back or quit your alcohol use?”
    [Clarify whether discussing quitting or cutting
    back.]
   If > 0, ask “Why that number and not a lower
    one?” [Also ask about confidence, readiness]
   Explore asking “Have you ever considered
    cutting back (or quitting)? If so, “Why?” If not,
    “What would have to happen for you to consider
    cutting back (or quitting)?”
                                              10
                      0
                                                        65
      Step 3: Enhance Motivation:
    Summarize, Highlight Change Talk

                                             10
                          0



   Summarize information from decisional
    balance and rulers highlighting change
    talk in particular

                                              66
                              Step 4: Provide Advice

                                         Use Chart on Front of Card for
 Lower Risk Drink Limits
                                           Low-Risk Drinking
            Per Day         Per
                                          (NIAAA Guidelines)
                           Week
                                             Healthy men ≤ 65 years old
Healthy         4            14
 Men                                              No more than 4 per day or 14 per week
Healthy
Women
                3             7
                                             Healthy women of all ages
All ages        3             7                   No more than 3 per day or 7 per week
  >65

No drinking if driving, pregnant or
                                             All healthy individuals >65 years of
       possibly dependent
                                              age
                                                  No more than 3 per day or 7 per week

                                                                                           67
        Inform All Patients of the
            Risks of Drinking:
   When driving—this causes the largest
    proportion of alcohol-related death and
    disability
   When pregnant or considering pregnancy-
    alcohol is the most frequent cause of
    preventable birth defects
   When contraindicated by a medical
    condition or medication
   If a history of failed attempts to cut back
                                              68
     Step 5: Discuss Next Steps

   “If you were to make a change, what
    would be your first step?”




                                          69
Step 6: Close on Good Terms

   Summarize
   Emphasize patient strengths
   Highlight change talk
   List decisions made regarding
    next steps
   Arrange for followup as
    appropriate

                                    70
   View Video Two

Clinician Intervention for
      At-risk Drinker



                             71
Practice Intervention
    with Patient
with At-Risk Drinking




                        72
         Dealing with Time Pressure
   Do your brief intervention over multiple
    visits
   At the first visit, use 1 minute to cover the
    first three steps
       Ask permission to discuss alcohol use
       Provide feedback on patient’s risk level
       Offer advice to reduce drinking at least to low
        risk levels
     Invite the patient to discuss alcohol use
      at a future visit
   Investing a few minutes now may avoid a
    greater problem later
                                                          73
  Zone II: Added Steps for Those
   Patients with Possible Alcohol
Dependence & Polysubstance Abuse
               AUDIT score of ≥ 16
                indicates possible
                dependence on alcohol
               Advice is to stop
               Assess withdrawal risk
               Discuss other resources
                available if patient is
                interested
                                          74
 Intervention Steps for Possibly
Dependent Patients (AUDIT ≥ 16)
   Brief intervention
       Ask permission
       Provide feedback
       Enhance motivation
       Provide advice encouraging abstinence
       Assess & address possible withdrawal risk
       With permission, offer menu of other helps
       Discuss Next Steps
       Close on Good Terms


                                                     75
        Withdrawal Assessment:

   “Some people have the following after
    a day or two without drinking. Have
    you ever had these symptoms?”
       Felt sick or shaky
       Tremors
       Nausea
       Heart racing
       Seizures
       Seen or heard things that were not there
                                                   76
         Two Options for Addressing
           Potential Withdrawal
   Arrange withdrawal treatment immediately
       Transfer to detox unit or treatment center
       Outpatient detox where appropriate
   Tell patient what to do if these symptoms
    occur
       Present to ED/Detox Center
       Call on-call physician
   Document what you do in the patient’s
    chart
                                                     77
Red Zone Offers Information on
Getting Help                        Offer menu of options for more help:
                                    ► Medication (naltrexone, acamprosate,
                                      disulfiram, suboxone, methadone)
                                    ► Referral
                                      •Support group (e.g., AA, NA, Celebrate
                                        Recovery)
                                      •In-house counseling (Brief treatment)
                                      •Treatment or substance abuse program


   Menu of options
       Medication: (naltrexone, acamprosate, or
        disulfiram)
       Referral
          Self-help/support group (e.g., Alcoholics
           Anonymous, Celebrate Recovery, etc.)
          In-house counseling (brief treatment)

          Treatment or substance abuse program



                                                                                78
         Referral to Treatment

   Local treatment referral sources
       Detox
       Inpatient
       Outpatient
       Faith-based
       Long-term residential



                                       79
            Get Help: Procedures
   Ask permission to tell the patient about
    resources that have helped other patients
   If the patient is interested, attempt to
    make contact with referral sources while
    patient is still in your office, if possible
   Ambivalence is common—encourage
    treatment providers or AA contacts to call
    the patient, if patient agrees
   Get patient’s “best phone number(s)”

                                                   80
    Tips to Enhance Intervention
   Resist the urge to fix the patient at
    this visit—behavior change starts with
    “seed planting”
   Focus on building rapport
   Avoid labeling (don’t say
    “alcoholic”)
   Encourage self efficacy based on
    past successes
     “Look at successes you have had
    in the past”                             81
       View Video Three

Clinician Intervention for Patients with
          Major Consequences
         & Possible Dependence




                                           82
      Cultural Competence & SBIRT
         DON’Ts                                DO’s

   Label                         Consider cultural
   Judge                          context of drinking
   Assume alcohol is             Work collaboratively
    viewed the same in            Show empathy
    the patient’s culture as      Build trust
    in yours                      Elicit patient concerns
   Stereotype                     about drinking
   Use stigmatized
    language

                                                         83
Practice Intervention
 with Patient Who is
Possibly Dependent




                        84
               Follow-up Procedures
                 (Clinician tasks)*
   Assess 7-day alcohol use & last binge
   Determine patient’s view of his/her use
   Repeat decisional balance
   Repeat rulers (importance, confidence)
   Explore and reflect
   Discuss readiness to make a change
   Discuss next steps, change plan where
    appropriate
   Consider menu of options for help
       *Follow-up procedures will be covered in-depth in a future training
                                                                             85
       Module 1C

Establishing Office Systems




                              86
        Objective for This Module
   Introduce Implementation Committee &
    their areas of responsibility
   Clarify any questions regarding procedures
   Give information on locating SBIRT
    materials
   Summarize documentation & coding
   Suggest channels & procedures for
    feedback
                                            87
     SBIRT Committee Members
   Faculty—Drs. Seale, Boltri & McLaurin
   Residents—Drs. Ansari & Chhabria
   Screening & Nursing--Denise Gary, RN
   Brief Int. & Brief Tx--Denice Clark, MFT
   Referrals—Tim Prather
   Medical Records--Keisha Hill
   Administration—Leslie Scarbary, RN
   Suboxone—Seale, McLaurin, Davis-Smith
   Evaluation—Dr. Johnson
                                               88
     Where to Find SBIRT Materials:
       All materials can be found in black
    notebooks in the MD stands outside clinic
                      rooms
   Healthy Habits Prescreen Information
    (salmon sheet)*
   Healthy Lifestyles Screens (AUDITs)*
   Intervention Cards
   Brochures
   Referral resource sheets
*These items are also kept behind the nurses’ desk with check-in materials
                                                                             89
            Nursing Procedures &
               Documentation
   When patients are put in the rooms,
    nurses will check for completed salmon
    sheets
       If sheet is blank, they will ask the tobacco &
        alcohol questions , fill in answers and give out
        blue & pink sheets for positive answers to
        tobacco or alcohol questions
       If AUDIT is given, mark checkbox on
        physician’s office note for the day
                                                       90
           Physician Documentation
           Guidelines—DOCUMENT!

   Problem: Clinicians frequently fail to
    document alcohol-related diagnoses and
    interventions
   Results:
       Failure to reinforce interventions at future
        visits
       Other providers lack important clinical
        information when caring for these patients
       Potential medicolegal risk
                                                       91
        Documentation System: Goals
   Designed to
       Remind provider to follow up on alcohol
        consumption
       Alert other providers to at risk or problem
        drinking
       Protect patients from stigma or discrimination
       Respect current privacy legislation




                                                     92
Clinician Documentation Procedures
            in This Clinic
   Salmon sheet—initial and date if complete
       If not filled out, recycle it (don’t sign it!)
   Healthy Lifestyles Screen (AUDIT)—score AUDIT
    and complete “Provider Use Only” area
       Choose the appropriate Zone
       Use check boxes within Zone to document what you
        did
       On your progress note
            Record AUDIT score in “lab results” area
            Use check box to document intervention—”advised to stop
             drinking or cut back”
                                                                       93
Diagnosis Wording & Coding Options
            (Clinicians)
    Options:
        V65.42 Counseling on substance use &
         abuse
        Alcohol use (no ICD code)
        305.0 Alcohol abuse*, excessive drinking
         (episodic)
        303.9 Alcohol dependence*, alcoholism
        V69.9 Lifestyle problem
        V79.1 Special screening for mental disorders
         (alcoholism)
        At risk drinking (no ICD code)—probably should
         not be used until ICD code is approved, as this
         could be miscoded or misinterpreted as alcohol
         abuse
                *See DSM-IV diagnostic criteria in Support Materials
                                                                       94
Billing Options for Patients Receiving
        15-30 minutes of SBIRT
    2010 Medicare [& Medicaid*] Billing Codes
         G0396 Alcohol/Drug Screening 15-30 minutes ($30)
         G0397 Alcohol/Drug Service >30 minutes ($60)

    For Patients with Commercial Insurance: CPT
     Codes
         99408      15-30 minutes                            ($30)
         99409      > 30 minutes                             ($60)

     Note: Faculty may use your usual E&M code and add -25 modifier

     *Medicaid codes valid in NC, not yet “turned on” in Georgia

                                                                      95
          Other Billing Options
   Since most interventions involve greater
    time spent or greater complexity, document
    and code for your work
       If time and complexity criteria are met, non-
        residents may code 99214 or 99215
   In your private practice, have/train a non-
    MD to do SBIRT
       Advantage: less rushed, often will use 15
        minutes or more
       Can then use CPT or G codes and generate
        $30-$60 per BI

                                                        96
      Options for Protecting Privacy
            & Confidentiality
   Nationally, there is no consensus or clear
    guideline about whether Regulation 42CFR Part 2,
    which requires special confidentiality measures for
    mental health and substance abuse treatment,
    applies to SBIRT activities

   Each individual practice should make its own
    decision regarding how to manage SBIRT patient
    records

                                                     97
      Options for Protecting Privacy
            & Confidentiality
   Most primary care clinicians do not use special
    confidentiality measures for mental health
    diagnoses made in the context of routine primary
    care office practice
   Some clinicians use more general terms describing
    behavior (“alcohol use”), not diagnoses
   Some place AUDITs in chart areas separate from
    office notes , others file them with progress notes
   A few practices place AUDITs in protected areas
    requiring special release of information
                                                     98
    Privacy Protections at This Clinic

   AUDITs are filed with progress note for
    the day

   No Special Precautions for SBIRT
    Documentation

   HIPAA precautions are considered
    adequate privacy protection
                                              99
Questions re SBIRT Procedures?

   Good luck!

   Call us with any questions

   Where to call for help:
       Dr Seale’s pager #1248
       Denice Clark’s extension 3-5731

                                          100

				
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