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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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