“At Risk” d - SGIM Library/SGIM/Meetings/Annual... · No Risk At Risk 4% Dependent 37% 24% Low...
Transcript of “At Risk” d - SGIM Library/SGIM/Meetings/Annual... · No Risk At Risk 4% Dependent 37% 24% Low...
SGIM WORKSHOP April 25, 2014
An Effective Method for Identifying and Helping Hazardous Drinkers in the Primary Care Setting:
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Kristy Barnes Le, MD David P. Miller, MD, MS, FAACP
Magdelena Greene, MD
Session Outline
Segment 1 (Kristy) Introductions
Epidemiology of “At Risk” drinking, and the evidence base for SBIRT
Segment 2 (Dave) Incorporating SBIRT into clinical practice: a systems approach
How to conduct an effective brief intervention (BI) with at-risk drinkers Video skills demonstration
Segment 3 (Kristy) Hands-on practice: BI with at-risk drinker
Segment 4 (Maggie) Time pressures
Added steps of a brief intervention with possibly-dependent drinkers Hands-on practice: BI with possibly-dependent drinker
Segment 5 (Kristy) Session Evaluation
Question and Comments
1
Funded by: www.sbirtonline.org
Kristy Barnes Le, MD David P. Miller, MD, MS, FACP
Magdelena Greene, MD
SGIM workshop
April 25th, 2014
An Effective Method for Identifying and Helping Hazardous Drinkers in the Primary Care Setting:
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Funded by: www.sbirtonline.org
Kristy Le, MD
Wake Forest UBMC IM Residency
Blanca Lopez, MD
Mercer University School of Medicine IM Residency
J. Paul Seale, MD
Mercer University School of Medicine FM Residency
Hunter Woodall, MD
AnMed Health FM Residency
Anderson, SC
Southeastern Consortium for Substance Abuse Training (NC, SC, GA)
Ann Barham, MD
Wake Forest UBMC FM Residency
Allen Tindol, MD
Memorial University IM Residency
Jill Mattingly, PA-C
Mercer University
Ed Evans, MD
Seneca Lakes FM Residency
Seneca, SC
J. Paul Seale, MD, Principal Investigator Department of Family Medicine
Mercer University School of Medicine Funded by Grant 1U79T1020278-01 Substance Abuse and Mental Health Services Administration (SAMHSA)
Objectives: By the end of the session, the attendee should be able to-
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Explain the importance of screening for at-risk drinking in primary care settings.
Identify the components of an effective SBIRT system in the primary care setting.
Demonstrate a brief intervention with at-risk, and possibly-dependent drinkers.
SECSAT www.sbirtonline.org
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What is SBIRT?
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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.
SECSAT www.sbirtonline.org
Background- started in 1980’s
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Substance abuse screening tests developed (CAGE, MAST-Michigan Alcohol Screening Test, DAST-Drug Abuse Screening Test)
Seminal study by Russell et al. demonstrated the significance of physician advice to help patients quit smoking
Swedish research showed screening plus brief intervention in primary care setting could benefit risky drinkers
WHO expanded research initiative
Babor et al. FOCUS 2011 SECSAT www.sbirtonline.org
SBIRT - 25 years later
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Overall > 100 trials have demonstrated efficacy and cost-effectiveness of SBIRT in emergency departments, primary care settings and trauma centers
Since 2008, SAMHSA has funded 17 medical residency cooperatives to disseminate SBIRT throughout graduate medical education
http://www.samhsa.gov/prevention/SBIRT/grantees/medres.aspx
Babor et al. FOCUS 2011
SECSAT www.sbirtonline.org
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Benefits of Moderate Alcohol Consumption
Definition: 0.5-2 drinks/day
Benefits
Decreased risk of coronary heart disease
Decreased all-cause mortality
Thun et al, NEJM 1997
7 SECSAT www.sbirtonline.org
At-Risk Drinking
National Institute on Alcohol Abuse and Alcoholism. “Rethinking Drinking,” 2010.
MMWR 2012:61:14-19.
“binge drinking”
8 SECSAT www.sbirtonline.org
Binge Drinking 12.5% among adult women • Women 18 – 24: 24% binge • Women 25 – 34: 20% binge
Current alcohol use in high school
girls: 38% • 55% of girls who drink, binge
drink
Vital Signs MMWR. Jan 11, 2013 9
SECSAT www.sbirtonline.org
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10
“At-risk”
Alcoholic
SECSAT www.sbirtonline.org
Beer: 12 oz = 1 16 oz = 1 1/3
22 oz = 2 40 oz = 3 1/3
Malt Liquor:
12 oz = 1 1/2 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
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What is a Standard Drink?
NIAAA, 2010
7.4% Alcohol
CAUTION
2 pints = 4 standard
drinks!
SECSAT www.sbirtonline.org
Drinking Patterns in the U.S.
http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA
2009; MMWR 2012:61:14-19.
No Risk
At Risk
Dependent 4%
37%
24%
Low Risk
35%
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HIGHEST rates of binge drinking are in:
Males
Age 25 – 34
Whites
Educated (some college or more)
Higher income (≥ $75,000)
SECSAT www.sbirtonline.org
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DUI’s
Injuries (intentional & unintentional)
Other substance use
Alcohol use disorders
Liver disease
Impaired physical health
Impaired mental health
Impaired cognition/ADL’s
Obesity/overweight
School problems
Unsafe sex/STD’s
Unintended pregnancy
Sexual victimization
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Most Morbidity & Mortality is from Binge Drinking (NOT Chronic Daily Drinking)
SECSAT www.sbirtonline.org http://www.collegedrinkingprevention.gov
Why is Management of Alcohol Misuse Important to Primary Care Physicians?
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Prevalence
Morbidity and mortality
Barrier to treatment of chronic conditions
Potential functional impairment
High associated cost
SECSAT www.sbirtonline.org
Moore et al, 2003 Bouchery et al, 2011
But, few physicians address it!
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CDC survey data from 2011 (166,753 US adults)
only 16% of patients overall report ever discussing alcohol use with their physician
only ~25% of binge drinkers report ever discussing alcohol use with their physicians
McKnight-Eily et al, MMWR 2014
SECSAT www.sbirtonline.org
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Brief Intervention Works!
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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, 2009 SECSAT www.sbirtonline.org
2013 USPSTF Review
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23 randomized controlled trials reviewed (11 U.S.)
In general, show that primary care interventions reduce binge drinking Meta-analysis 7 trials
12% fewer patients reported no risky drinking episodes at 1 year follow-up
Meta-analysis 10 trials Reduced average weekly consumption from 23 to 19 drinks
Meta-analysis 3 trials (younger/ college-age) Reduced frequency of heavy drinking days by one per month at
6-month follow-up
Moyer, Annals 2013; USPSTF 2013
SECSAT www.sbirtonline.org
US Preventive Services Task Force: SBIRT Recommended for All Adults Over 18 yo
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Recommended since 2004
“…adequate evidence that numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity”
“…adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes…. These interventions also reduce weekly alcohol consumption…”
Moyer, Annals 2013; USPSTF 2013
SECSAT www.sbirtonline.org
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SBIRT Can Be Effectively Implemented in Primary Care
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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
SECSAT www.sbirtonline.org
Key to Implementation: Systems Approach Targeting Both The Clinicians & Office System
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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
SECSAT www.sbirtonline.org
5 Basic Components of an Effective SBIRT System
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Prescreening (nurse screening questions) Screening (Alcohol Use Disorders
Identification Test =AUDIT) Clinician Intervention 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
SECSAT www.sbirtonline.org
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Prescreen is routinely performed
every 6-12 months
Nursing questions:
1. “Do you sometimes drink beer, wine, or liquor?”
2. “How many times in the past year have you had more than x drinks in a day?”
X = 4 for men
X = 3 for women
22 SECSAT www.sbirtonline.org Smith et al, 2009
Patterns of alcohol use among U.S. at-risk drinkers: 28% of population at-risk
Exceed only daily limits (> 3 OR 4
drinks/day)
Exceed only weekly limits
(>7 or 14 drinks/wk)
2%
http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/ Rethinking_Drinking.pdf, NIAAA 2009;
http://www.collegedrinkingprevention.gov/; NESARC Wave 1 study
Prevalence is higher in college students: 44%
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16%
10%
SECSAT www.sbirtonline.org
When Prescreen is Positive,
Administer AUDIT
Patient is given the Healthy Lifestyles Screen (AUDIT)
Patient completes the AUDIT and gives it to his/her clinician
Physician performs brief intervention (BI)
24 SECSAT www.sbirtonline.org
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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
or less
2-4 times a
month
2-3 times a
week
4 or more
times a
week
2. How many drinks containing alcohol do you have on
a typical day you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3. How often do you have four or more drinks on one
occasion? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
4. How often during the last year have you found that
you were not able to stop drinking once you had
started?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
5. How often during the past year have you failed to do
what was expected of you because of drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
6. How often during the past year have you needed a
drink first thing in the morning to get yourself going
after a heavy drinking session? Never
Less than
monthly
Monthly Weekly
Daily or almost daily
7. How often during the past year have you had a
feeling of guilt or remorse after drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
8. How often during the past year have you been unable to remember what happened the night before because
of your drinking? Never
Less than monthly
Monthly Weekly Daily or
almost daily
9. Have you or someone else been injured because of
your drinking? No Yes, but
not in the
past year
Yes, during
the past year
10. Has a relative, friend, doctor, or other health care
worker been concerned about your drinking and
suggested you cut down?
No Yes, but
not in the
past year
Yes, during
the past year
Adapted from World Health Organization
3 quantity & frequency questions (1-3)
3 questions probing signs of dependency (4-6)
4 questions about alcohol-related problems (7-10)
Score Range: 0 - 40
SECSAT www.sbirtonline.org Babor et al, 2001.
SECSAT Risk Zones
26 SECSAT www.sbirtonline.org
High
Risk
At Risk
Low/No Risk
1-13
≥ 14
AUDIT Score:
Intervention
Clinician identifies level of intervention based on Healthy Lifestyles Screen (AUDIT)
Clinician conducts the intervention using the intervention card as a guide
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Intervention card adapted from Oregon Health & Sciences University
SBIRT Primary Care Residency Initiative
Not at all Extremely 0 10 5 6 7 8 9 2 3 4 1
cm
Lower Risk Drink Limits
No drinking/using if driving, pregnant, possibly dependent or otherwise
contraindicated
What is a standard drink? Do you sometimes drink beer, wine or liquor?
How many times in the last 12 months have you had X or
more drinks in one day?
Men: X = 5 Women: X = 4
How many times in the past year have you used an illegal
drug or used a prescription medication for nonmedical
reasons?
The percent of “pure” alcohol expressed here as alcohol/volume varies by beverage.
~5% ~7 % ~12% ~40%
12 oz
Beer
8-9 oz
Malt
Liquor
5 oz
Wine
1.5 oz/
1 shot
liquor
Your Risk Level: AUDIT
≥ 14
1-13
0
DAST
3-10
1-2
0
Per
Day
Per
Week
Healthy
Men
4
14
Healthy
Women
3
7
All ages
>65
3
7
SECSAT www.sbirtonline.org
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Intervention Guide
Intervention card adapted from Oregon Health & Sciences University
SBIRT Primary Care Residency Initiative
Zone I: At Risk
AUDIT 1-13 (≥ 1 binge); DAST 1-2
Zone II: High Risk, Possibly Dependent
AUDIT ≥ 14; DAST 3-10
www.sbirtonline.org
Rev. Mar 2012
Funded by:
Ask Permission “I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”
Provide Feedback Refer to pyramid & provide patient’s AUDIT/DAST score & risk level(s). [As your physician] “Drinking/using at this level can be harmful to your health and possibly responsible for the health problem for which you came in today. What do
you make of that?”
Enhance Motivation
& Elicit Change Talk
“What are the good things/not so good things about your alcohol/drug use?” (Decisional balance)
“On a scale of 0-10, how important is it that you cut back or quit your alcohol/drug use?”
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 cutting back/quitting?”
Provide Advice Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines (or offer advice to quit or cut back
drug use).
Zone II Additional Steps:
Ask: “If you go a day or 2 without drinking/using do
you ever get sick, shaky, have
tremors/seizures/cramps, or see/hear things that are
not there?”
Offer menu of options for more help:
► Medication (naltrexone, acamprosate,
disulfiram, methadone, Suboxone)
► Referral
•Counseling/Brief treatment •Support group (e.g., AA, NA, Celebrate
Recovery)
•Treatment or substance abuse program
Discuss Next Steps “If you were to make a change, what would be your first step?”
Close on Good
Terms
Summarize, emphasize patient strengths, highlight change talk and decisions made. Arrange for follow-up as appropriate.
28 SECSAT www.sbirtonline.org
Motivational Interviewing - Definition Collaborative, goal-oriented method of
communicating with patients.
Intended to strengthen patient’s personal motivation.
promote commitment to their own goal for behavioral change
Uses patients ambivalence and own feelings about their behavior to help them move forward, rather than physician being directive.
Miller & Rollnick, 2008
29 SECSAT www.sbirtonline.org
The MI Shift
From feeling responsible for changing
patients’ behavior to supporting them in thinking & talking about their own reasons and means for behavior change.
30 MI Basic Training
32 SECSAT www.sbirtonline.org
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Stratified Intervention Protocols: Zone I: At Risk Drinker/User
At risk drinker with limited or no consequences (AUDIT score 1-13)
Brief intervention Ask permission
Provide feedback
Enhance motivation
Provide advice
Discuss next steps
Close on good terms
31 SECSAT www.sbirtonline.org
Step 1: Ask for Permission
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“I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”
SECSAT www.sbirtonline.org
Step 2: Provide Feedback from Prescreen and AUDIT questionnaire
Refer to graph & provide patient’s AUDIT score
“Drinking at this level can be harmful to your health.”
“What do you make of that?”
AUDIT
≥ 14
1-13
0
33 SECSAT www.sbirtonline.org
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Step 3: Enhance Motivation: Decisional Balance
Ask, “What are some of the good/not-so-good things about your alcohol/drug use?”
Summarize both sides of their thinking On the one hand… and on the other hand…
SECSAT www.sbirtonline.org
Step 3: Enhance Motivation: Rulers
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“On a scale of 0 to 10, how important is it for you to cut back or quit your alcohol/drug use?” [Clarify whether discussing quitting or cutting back.]
If > 0, ask “Why that number and not a lower one?” [N-2]
May also use rulers to ask about confidence and readiness
0
10
SECSAT www.sbirtonline.org
Step 4: Provide Advice
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Low-Risk Drinking (NIAAA Guidelines) Healthy men ≤ 65 years old No more than 4 per day or 14 per
week
Healthy women of all ages No more than 3 per day or 7 per
week
All healthy individuals >65 years of age No more than 3 per day or 7 per
week
Per Week
Per Day
Men
14
4
Wome
n
7
3
All
ages >65
7
3
Per Week
Per Day
Men
14
4
Wome
n
7
3
All
ages >65
7
3
Lower Risk Drink Limits
No drinking if driving, pregnant or possibly dependent
7 3 All ages >65
7 3 Healthy Women
14 4 Healthy
Men
Per Week
Per Day
SECSAT www.sbirtonline.org
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Step 5: Discuss Next Steps
37
“If you were to make a change, what would be your first step?”
SECSAT www.sbirtonline.org
Step 6: Close on Good Terms
38
Summarize
Emphasize patient strengths
Highlight change talk
List decisions made regarding next steps
Arrange for follow-up as appropriate
SECSAT www.sbirtonline.org
Funded by: www.sbirtonline.org
Video: BI for At-risk Drinking
Clinician Intervention for At-risk Drinker
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Practice At-Risk Brief Intervention
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PATIENT: María Lopez
REASON FOR
VISIT: Sore throat
HISTORY: 47 years old
No current medical problems
PHYSICAL
EXAM FINDINGS: Height 5'7"
Weight 130 lbs.
BP 140/90
Pulse 70 and regular
DRINKING
INFORMATION See Prescreen and Screen
• Mrs. Lopez replied that she has never smoked. • She replied that several times a week she has
four or more drinks. • She indicates that she has never used any other
substances.
SECSAT www.sbirtonline.org
41
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
or less
2-4 times a
month
2-3 times a
week
4 or more
times a
week
2. How many drinks containing alcohol do you have on
a typical day you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3. How often do you have four or more drinks on one
occasion? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
4. How often during the last year have you found that
you were not able to stop drinking once you had
started?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
5. How often during the past year have you failed to do
what was expected of you because of drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
6. How often during the past year have you needed a
drink first thing in the morning to get yourself going
after a heavy drinking session? Never
Less than
monthly
Monthly Weekly
Daily or almost daily
7. How often during the past year have you had a
feeling of guilt or remorse after drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
8. How often during the past year have you been unable
to remember what happened the night before because of your drinking?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
9. Have you or someone else been injured because of
your drinking? No Yes, but
not in the
past year
Yes, during
the past year
10. Has a relative, friend, doctor, or other health care
worker been concerned about your drinking and
suggested you cut down?
No Yes, but
not in the
past year
Yes, during
the past year
PROVIDER USE ONLY
1. On average, how many days a week do you have an alcoholic drink?_____ X
2. On a typical drinking day, how many drinks do you have?______ = ________(weekly average)
3. How many times in the past year have you used an illegal drug or used a prescription medication for non-medical
reasons? None__ 1 or more__ Which ones?______________________ Any others? _____________
__________________________________________________________________________
Total
ZONE I (1-13) ZONE II (≥ 14)
BI performed Blue brochure given
BI performed Red brochure given
W/D precautions discussed
Medication (naltrexone, acamprosate or disulfiram)
Referral (check all that apply)
Counseling/BT
Support group
Tx/SA program
Physician signature: ____________________________________
Provider Name: ________________________________________
Description of plan:
Lopez, Maria
47 F SECSAT www.sbirtonline.org
Dealing with Time Pressure
42
An ounce of prevention is worth a pound of cure.
Benjamin Franklin
SECSAT www.sbirtonline.org
15
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
43 SECSAT www.sbirtonline.org
Zone II: 3 Added Steps for Those Patients with Possible Dependence & Polysubstance Abuse
Advice is to stop
Assess withdrawal risk
Discuss other resources available if patient is interested
44 SECSAT www.sbirtonline.org
Intervention Steps for Possibly Dependent Patients (AUDIT ≥ 14)
45
Brief intervention Ask permission
Provide feedback
Enhance motivation
Provide advice encouraging abstinence
Assess & address possible withdrawal risk
Discuss next steps including information about getting help
Close on Good Terms
SECSAT www.sbirtonline.org
16
Withdrawal Assessment:
46
“Some people have the following after a day or two without drinking/using. Have you ever had these symptoms?” Felt sick or shaky
Tremors
Nausea
Heart racing
Seizures
Seen or heard things that were not there
“When did you last quit drinking? For how long?”
SECSAT www.sbirtonline.org
Two Options for Addressing Potential Withdrawal
47
Higher risk Arrange withdrawal treatment immediately
Follow institutional protocols
Lower risk Tell patient what to do if these symptoms occur
Arrange outpatient SA treatment
Document what you do in the patient’s chart
SECSAT www.sbirtonline.org
Red Zone Offers Information on Getting Help
48
Menu of options
Medication: (naltrexone, acamprosate, or disulfiram for alcohol, buprenorphine or methadone for opioids)
Referral to Treatment Self-help/support group (e.g., AA/NA, Celebrate Recovery, etc.)
In-house counseling (brief treatment)
Treatment or substance abuse program
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
SECSAT www.sbirtonline.org
17
Practice Possibly-Dependent BI
49
PATIENT: Robert Johnson
REASON FOR VISIT: Routine physical
HISTORY: 42 years old
Several previous visits because of falls w/sprains
PHYSICAL
EXAM FINDINGS: Height 5'10"
Weight 178 lbs.
BP 142/96
Pulse 84 and regular
DRINKING
INFORMATION: See Prescreen and Screen
ADDITIONAL
INFORMATION: Patient has no symptoms of withdrawal.
Patient is not yet ready to quit drinking but may consider cutting back.
• Mr. Johnson replied that he is a current smoker. • He replied that he drinks more than 5 drinks most
days. • He indicated that he does not use any other
substances.
SECSAT www.sbirtonline.org
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
or less
2-4 times a
month
2-3 times a
week
4 or more
times a
week
2. How many drinks containing alcohol do you have on
a typical day you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3. How often do you have four or more drinks on one
occasion? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
4. How often during the last year have you found that
you were not able to stop drinking once you had
started?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
5. How often during the past year have you failed to do
what was expected of you because of drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
6. How often during the past year have you needed a
drink first thing in the morning to get yourself going
after a heavy drinking session? Never
Less than
monthly
Monthly Weekly
Daily or almost daily
7. How often during the past year have you had a
feeling of guilt or remorse after drinking? Never
Less than
monthly Monthly Weekly
Daily or
almost daily
8. How often during the past year have you been unable
to remember what happened the night before because of your drinking?
Never Less than
monthly Monthly Weekly
Daily or
almost daily
9. Have you or someone else been injured because of
your drinking? No Yes, but
not in the
past year
Yes, during
the past year
10. Has a relative, friend, doctor, or other health care
worker been concerned about your drinking and
suggested you cut down?
No Yes, but
not in the
past year
Yes, during
the past year
PROVIDER USE ONLY
1. On average, how many days a week do you have an alcoholic drink?_____ X
2. On a typical drinking day, how many drinks do you have?______ = ________(weekly average)
3. How many times in the past year have you used an illegal drug or used a prescription medication for non-medical
reasons? None __ 1 or more __ Which ones?______________________ Any others? _____________
__________________________________________________________________________
Total
ZONE I (1-13) ZONE II (≥ 14)
BI performed Blue brochure given
BI performed Red brochure given
W/D precautions discussed
Medication (naltrexone, acamprosate or disulfiram)
Referral (check all that apply)
Counseling/BT
Support group
Tx/SA program
Physician signature: ____________________________________
Provider Name: ________________________________________
Description of plan:
Johnson, Robert
42 M
SECSAT www.sbirtonline.org
All materials can be found at:
Questions ?
& Comments 51
18
References:
52
See distributed list
SGIM WORKSHOP April 25, 2014
An Effective Method for Identifying and Helping Hazardous Drinkers in the Primary Care Setting:
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Kristy Barnes Le, MD David P. Miller, MD, MS, FAACP
Magdelena Greene, MD
References
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2. www.samhsa.gov/prevention/SBIRT/grantees/medres.aspx
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http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.
5. Payne, Cathy. CDC: Binge drinking is serious problem for girls, women. USA Today. Jan
8, 2013
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Alcohol Consumption in the U.S., 2006. Am J Prev Med. 2011; 41(5): 516-524.
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force. Ann Intern Med. 2004;1 40(7):557-568.
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