SBIRT Identifying and Addressing Unhealthy Substance Use Rhode Island

SBIRT Identifying and Addressing Unhealthy Substance Use Rhode Island College School of Social Work RI-SBIRT Resource Center

RI-SBIRT Training & Resource Center Supported by RIC SSW and BHDDH: to build statewide SBIRT awareness and capacity to implement and integrate SBIRT into diverse settings and organizations, and promote clinician SBIRT skills and competency.

AGENDA What is SBIRT? Why is it important? How is it done? How/where is it implemented? SBIRT & your profession

Introductions Name Where you work/intern; your position On a 1-10 scale, how much do you know about SBIRT What would you like to learn about SBIRT today?

What is SBIRT? Screening: Identify patients with unhealthy substance use Brief Intervention: Conversation to motivate patients who screen positive to consider healthier decisions (e.g. cutting back, quitting, or seeking further assessment). In schools: BI for prevention for all who are screened. Referral to Treatment: Actively link patients to resources when needed

Unhealthy Substance Use in Clinical Settings 1 in 6 patients talk with their doctor, nurse or other health professional about their drinking1 1. CDC Vital Signs. National Center for Chronic Disease Prevention and Health Promotion. January 2014.

Addiction: Historical Perspective Problem No Problem

What is addiction anyway? Short Definition of Addiction: (American Society of Addiction Medicine, 2011) Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. 8

Paradigm Shift: Chronic Disease Disease Pre-Disease/ Higher Risk Low / No Risk Unhealthy Alcohol and Drug Use

What’s a Drink?

Maximum Drinking Limits For People Over 21 Non-Pregnant Women Pregnant Women areconditions advised toand abstain from use should speak with their People with medical people on alcohol medications doctor about alcohol use. People under 21 should not drink at all.

What is a ‘standard’ drink? Refs: National Institutes of Health, NIAAA. http://rethinkingdrinking.niaaa.nih.gov/whatcountsdrink/whatsastandarddrink.asp; Adapted from SBIRT Montana Poster: www.dphhs.mt.us Drinking Guidelines Explained: http://ireta.org/2013/09/30/low-risk-drinking-guidelines-where-do-the-numbers-come-from/

SBIRT Addresses the Full Spectrum of Substance Use Patients may not understand the impact of alcohol and drug use on their health Patients are not aware of NIAAA low-risk drinking guidelines SBIRT opens up a dialogue between provider and patient that can improve the patient’s overall health

SBIRT Goals Addiction: Treat and/or refer for specialty addiction treatment Risky Use: Educate to decrease risk of negative health & safety consequences and progression of disease Low/No Risk: Educate about risks and reinforce/ promote healthy norms

The SBIRT Model : A Continuum of Substance Use Social Use Abstinence Experimental Use Abuse Binge Use Substance Use Disorder 16

What is the prevalence of unhealthy substance use?

Spectrum of Alcohol Use Abuse or Unhealthy Alcohol Use 6% Dependence At risk 17% Lower risk 29% Abstain 1. Data from: NSDUH, SAMHSA, 2013 48 % 23%

Spectrum of Drug Use Dependent Any Drug Use Abstain 91 % 1. Data from: NSDUH, SAMHSA, 2013 2% 7% Illicit Drug Use 9%

Why is SBIRT important?

Health Consequences of Substance Use Fetal Alcohol Spectrum Disorders Cancer Breast Throat Mouth Esophagus Liver Hypertension Cardiovascular disease Stroke Cardiomyopathy Arryrithmias Diabetes mellitus Osteoporosis Liver disease Fibrosis Cirrhosis Alcoholic hepatitis HIV/AIDS Renal disease Hepatitis C Pancreatitis Accidents/Injury Overdose Depression Source: UpToDate 2015 Mukamal KJ. Overview of the risks and benefits of alcohol consumption . Up To Date 2015. Weaver MF, Jarvis MAE. Substance use disorder: Principles for recognition and assessment in general medical care. http://pubs.niaaa.nih.gov/publications/Hangovers/beyondHangovers.pdf

Why is SBIRT Important? The impact of unhealthy substance use goes beyond physical health: Social & Behavioral influences o decreases access to preventive health care (e.g., flu vaccines in adults2, mammograms in women2) o reduces adherence with prescribed medical treatment o adversely affects housing and employment 1. Gordon A, Alford DP. Subst Abuse 2012. 2. Lasser KE, Kim TW, Alford DP, et al. Is unhealthy substance use associated with failure to receive cancer screening and flu vaccination? A retrospective cross-sectional study. BMJ Open 2011;1:e000046.

Why is SBIRT important? Annual Per Capita Cost Impact of Behavioral Health Comorbidities on Per Capita Costs among Medicaid-Only Beneficiaries with Disabilities 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 D P O rC re u il a F ab i t D r /o a d n No Mental IllnessHeand No Drug/Alcohol a e No Drug/Alcohol a Mental Illness vand m ti th es s No Mental Illness and Drug/Alcohol g A n Mental Illness and Drug/Alcohol Co es t e Hy io s n tr e pe n Boyd C, Leff B, Weiss C, Wolff J, Hamblin A, Martin L. Data Brief: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations, Center for Health Care Strategies, Inc. December 2010

Co-occurring Disorders Of individuals with a MH disorder: 1/3 will experience unhealthy substance use at some point1 Of those with severe mental illness: 50% will develop a substance use disorder 2-5 Of women with unhealthy substance use: As many as 2/3 of women may have a MH disorder 6 Adapted from: IHR Co-Occurrence of MH with Physical & Sexual Abuse Fact Sheet. 1. Sacks S et al. Substance Use & Misuse 1997. 2. Drake RE et al. Psych Rehab Jour 2004. 3. Barry KL et al. Schizophrenia Bull 1995. 4. Kessler RC et al. Arch Gen Psych 1997. 5. Mueser KT et al. Acta Psychiatrica Scandinavica 1992. 6. Alexander, M.J. American Journal of Orthopsychiatry 1996.

Trauma and Addiction Prevalence of PTSD and Substance Use Disorders Among persons who develop PTSD, 52% of men and 28% of women are estimated to develop an alcohol use disorder. 35% of men and 27% of women develop a drug use disorder.(Najavits, 2007) The numbers are even higher for veterans, prisoners, victims of domestic violence, first responders, etc. (Najavits, 2004a, 2004b, 2007) Individuals with PTSD are 3 to 4 times more likely to develop SUD’s than individuals without PTSD have earlier histories with A & D, more severe use, and poor treatment adherence. (Khantzian & Albanese, 2008) 25

Substance Use and Mental Illness in US Adults Nearly 1 in 12 US Adults had a Substance Use Disorder in the past year US Adults had any mental illness in the past year 43.8 MILLION 20.3 MILLION Ref: SAMHSA. www.SAMHSA.gov Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The CBHSQ Report: Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings. Rockville, MD. 1 in 5 Nearly 7.7 MILLION Co-Occurring

SBIRT Effectiveness SBIRT has been found to be most effective: with lower severity alcohol use identified in primary care may increase the percentage of patients who enter specialized care and decrease hospital days Ongoing research to determine effectiveness of SBIRT for drug use, other settings, severities, and adolescents Kaner, E Drug Alc Review 2009 Krupski, A Drug Alc Dep 2010 Saitz, JAMA 2014 Hingson R, JAMA 2014 Saitz, R Ann Intern Med 2007 Estee, S Medical Care 2010 Roy-Byrne, JAMA 2014 Bogenschutz, JAMA Int Med 2014

Why SBIRT For Youth? Reduces substance use related harm during adolescence Provides education and intervention for both primary and secondary prevention to keep all patients healthy Provides early identification of risky behaviors to assist providers with treatment planning Identifies need for referral to prevent harm at the earliest possible stages among patients

P e rce n ta g e L ife ti m e D ia g n o s is A lco h o l D e p e n d e n ce Prevalence of Lifetime DX of SUD by Age of Onset of Drinking: It’s Bad To Start Drinking Early 50 47 45 45 40 38 35 32 30 28 25 20 15 15 17 11 10 9 5 0 Age Began Drinking 13 14 2007 Center for Adolescent Substance Abuse Research, Children’s Hospital Boston. All rights reserved. 15 16 17 18 19 20 21 Source: Hingson et al., 2006

Teens and Substance Use; Some Good News Most students go through school & don’t ever use drugs or get drunk. The Monitoring the Future (MTF) survey found that 53.3% never used any illegal drug 58% never smoked marijuana.

Brains Develop Back to Front

Generalizability of SBIRT Concepts SBIRT: – Identify unhealthy behaviors The language of SBIRT is key – Nonjudgmental – Open-ended – Goal-oriented Behaviors extend beyond SUDs including: – – – – – Medication compliance Diet & exercise Behavioral Health Trauma Holistic picture of healthy behaviors

Why Screen Everybody?

Introducing Screening to Patients Screening is universal Contributes to quality healthcare Confidential as part of your medical / school record Ask permission to screen: Think MI (Motivational Interviewing)!

Universal Precaution- Trauma Informed Care Histories of abuse and trauma should be expected, not considered the exception. Many treatment “failures” or “non-starters” may well have unresolved trauma. We can do better at talking about the trauma that patients experience and creating safety. 35

Definition of Trauma Trauma occurs when an external threat overwhelms a person’s internal and external positive coping skills. 36

Word of the day

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Feminine Emotional Intelligence (EQ) Masculine Intellect Retreat/Isolation/Internalization Response to Trauma Logical Intelligence (IQ) Aggression/Externalization Collaboration/Decentralized Power Control/Hierarchy Process/Intuition Information Analytical/Rational Relational Self-Development Individuation Surrender/Intimacy Sex/Love Conquest/Performance Codependence Relationships Independence Socialization Process 39

Cultural Humility

Screening Adults: Alcohol Screen Single Item Alcohol Question AUDIT C Assess AUDIT ASSIST S MAST- G CAGE /AID

NIAAA Single-Item Alcohol Question Do you sometimes drink beer, wine, or other alcoholic beverages? NO YES How many times in the past year have you had 5 (men)/4 (women or men over 65) or more drinks in a day? If one or more times, continue with assessment , i.e. AUDIT, CAGE-AID, ASSIST Sensitivity/Specificity: 82%/79% Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. J Gen Intern Med 2009; 24(7):783-8 (unhealthy use)

AUDIT RESPONSES: (0) Never, (1) Less than monthly, (2) Monthly (3) Weekly, (4) Daily or almost daily 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more 3. How often do you have five or more drinks on one occasion? How often during the last year have you 4. found that you were not able to stop drinking once you had started? 5. failed to do what was normally expected from you because of drinking? 6. needed a first drink in the morning to get yourself going after a heavy drinking session? 7. had a feeling of guilt or remorse after drinking? 8. been unable to remember what happened the night before because you had been drinking? 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year The AUDIT was developed by the World Health Organization

AUDIT Translating Scores into Practice Total the numeric values for each answer Positive Risk Level AUDIT score 7-15 ( ) At Risk 8-15 ( ) Harmful Use 16-19 20-40 Likely Dependence Recommendation Brief Intervention (simple advice) Brief Intervention & Extended Intervention(s) or Brief Treatment Referral to specialist for assessment and treatment 44 Partners in Integrated Care

Screening Adults: Drugs Screen Single Item Alcohol Question Single Item Drug Question Assess DAST 10 ASSIST . CAGE /AID

BH Integration Specialist: Case - Mr. A. 20 min. session 42 y.o. male; history of major depression; Now, wanting to get a job Phys. Exam normal except high blood pressure 160/90; Behavioral health screen o Drug Question negative o MS: oriented, alert. No overt psych symptoms. o Taking meds regularly for past 2 years Alcohol questions o Drinks 2-3x/week; 1-2 drinks on typical drinking day o Has 5 or more drinks 1x/month o No negative consequences reported o AUDIT Score 10. A score of 8 or more is considered to indicate hazardous or harmful alcohol use. Based on the behavioral health screen What is your diagnosis? What will you do next?

Single Item Drug Question How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?* (*because of the experience or feeling that the drug(s) caused) None Score of 1 : continue with assessment, i.e. CAGE-AID, DAST 10 Smith P.C., Schmidt S.M., Allensworth-Davies D, Saitz R. A singlequestion screening test for drug use in primary care. Arch Intern Med Sensitivity/Specificity: 100%/74%

DAST-10 1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you able to stop using drugs when you want to? 4. Have you ever had blackouts or flashbacks as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parents) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)? Partners in Integrated Care DAST Copyright 1982 by Harvey A. Skinner, PhD, and the Centre for Addiction and Mental Health, Toronto, Canada 48

DAST-10 Translating Scores into Practice Add 1 point for each “yes,” except for #3, for which 1 point is added for “no.” Positive Degree of Recommendation DAST score Problems Related to Drug Abuse 2 Low Brief Intervention 3-5 Moderate 6-8 Substantial 9-10 Severe Brief Intervention & Extended Intervention Brief Intervention, Extended Intervention, and Referral Referral to specialist for assessment and possible treatment Partners in Integrated Care 49

Pre-Screen Questions: High School How many times in the past year did you Drink any alcohol? Smoke any marijuana? Use anything else to get high? (“Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”.) If all answers are “No”, ask CAR question; then stop Source: http://www.ceasar-boston.org/clinicians/crafft.php

Pre-Screen Questions: Middle School 1. Do you have any friends who drank beer, wine or any drink containing alcohol in the past year? 2. How about you ? – in the past year how many days have you had more than a few sips of beer, wine or any drink containing alcohol in the past year? 3. What about other substances? Do you have any friends who use tobacco, marijuana, inhalants, prescription drugs that were not prescribed to them or anything else to get high? 4. How about you ? – in the past year how many days have you used tobacco, marijuana, inhalants, prescription drugs that were not prescribed to them or anything else to get high?

CRAFFT During the PAST 12 MONTHS, 1.Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? No Yes 2.Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? No Yes 3. Do you ever use alcohol or drugs while you are by yourself, or ALONE? No Yes 4. Do you ever FORGET things you did while using alcohol or drugs? No Yes 5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? No Yes 6. Have you ever gotten into TROUBLE while you were using alcohol or drugs? No Yes

CRAFFT Scoring Probability of Substance Abuse/Dependence Diagnosis 100% 90% 80% 70% 50% 30% 1 2 3 4 5 CRAFFT SCORE Source: http://www.ceasar-boston.org/clinicians/crafft.php 6 Each “yes” 1 point A total score of 2 is a positive screen and indicates a need for additional assessment (brief intervention)

Mr. A’s Audit Score 10 RESPONSES: (0) Never, (1) Less than monthly, (2) Monthly (3) Weekly, (4) Daily or almost daily 1. How often do you have a drink containing alcohol? 2-3x/week “weekly (3)” 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more 3. How often do you have five or more drinks on one occasion? “monthly” (2) How often during the last year have you 4. found that you were not able to stop drinking once you had started? never 5. failed to do what was normally expected from you because of drinking? less than monthly (1) 6. needed a first drink in the morning to get yourself going after a heavy drinking session? never 7. had a feeling of guilt or remorse after drinking? never 8. been unable to remember what happened the night before because you had been drinking? never 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

Motivational Interviewing (MI): A Review A collaborative conversation style for strengthening a person’s own motivation and commitment for change. Source: Miller & Rollnick, 2013

MOTIVATIONAL INTERVIEWING (MI) PHILOSOPHY . When a client seems unmotivated to change or to take the sound advice of practitioners, it is often assumed that there is something the matter with the client and that there is not much one can do about it. These assumptions are usually false. No person is completely unmotivated.” Rollnick, Miller, Butler 2008

Motivational Interviewing (MI): A Review Patient-centered Goal-directed (behavior change) Helps to resolve ambivalence A-C-E Affirms patient’s autonomy Collaboration between patient and provider Evokes patient’s own motivation and reasons for change

The Spirit of Motivational Interviewing Evocation o Change is within the client – to be discovered o Focus on strengths and resources rather than deficits o Evoke and strengthen the person’s own reasons for change

The Spirit of Motivational Interviewing Partnership / Collaboration o Not DONE TO a passive recipient –MI is done FOR or WITH a person o Recognize the person is the expert o Specific methods or techniques are not prescribed o Let go of the assumption that the clinician is the expert with the solution –avoid the expert trap

The Spirit of Motivational Interviewing Acceptance / Autonomy Not to be confused with approval or disapproval Accepting the worth of individuals as they are Therapist assuming responsibility increases chances of tug-of-war Honoring the person’s autonomy Affirming the person’s strengths and

MOTIVATIONAL INTERVIEWING

How can you incorporate Motivational Interviewing into your everyday practice?

Rating MI Spirit: Thumb Up or Thumb Down? Patient: You want me to take more meds! It’s too much. I can’t remember to take all this medication. I don’t know what to do. I don’t want to get more sick. Clinician: I know it’s hard but you can do this! It’s really important and not taking our meds will only make things worse for you.

Rating MI Spirit: Thumb Up or Thumb Down? Patient: I like having a couple of drinks at the end of the day. It helps me relax and feel better. I don’t get why the doctor wants me to stop drinking. Clinician: Drinking helps you relax and you don’t know how else to relax. I can understand how you think that. From Building Motivtional Interviewing Skills: A Practitioner Workbook by David Rosengren. 2009

Rating MI Spirit: Thumb Up or Thumb Down? Patient: My doctor said this diabetes could lead to me losing my eyesight! I got to get a grip on this. What should I do? Nurse: I have some ideas about what you could do to lower the risk of that happening, but let’s start with what you’ve been thinking about. From Building Motivtional Interviewing Skills: A Practitioner Workbook by David Rosengren. 2009

Key MI Communication Skills: O.A.R.S. Open Questions Affirmations Reflections Summaries

Key MI Communication Skills: O.A.R.S. Open Questions Elicit a range of responses beyond yes/no Prompt patients to think, reflect, and share feelings/opinions Encourage patient autonomy “Do you want to stop drinking?” “What are your thoughts about your drinking?”

Key MI Communication Skills: O.A.R.S. Statement and gestures that recognize strengths and acknowledge behaviors that lead to positive change Affirmations Must be specific and genuine “It’s great that you watching how much you’ve been drinking.” TED Talk: Rita Pierson) (3:58-5:08)

Key MI Communication Skills: O.A.R.S. Reflections Statements, not questions Express empathy Elicit change talk Two levels: Simple: Repeat/Rephrase Complex: Paraphrase Patient: “I’ve tried to cut back on my own before, but nothing is going to work for me. I just can’t stop drinking.” Provider: “You’ve tried to quit drinking in the past and it hasn’t worked. You’re wondering if it’ll be different this time.” Video: It’s Not About The Nail Everybody Loves R Parent Effectiveness

Reflective Listening SIMPLE REFLECTIONS COMPLEX REFLECTIONS Miller & Rollnick, 2013. Exercise: Hypothesis Testing

Key MI Communication Skills: O.A.R.S. Summaries Transition or ending statements Longer reflection; overview of what patient has shared during conversation Present patient’s own reasons for change “Here is what I’ve heard so far What did I miss?” “We’ve gone over quite a bit. Let me make sure I am understanding you ”

Change Talk Statements about change Linked to a specific behavior Typically comes from patient Phrased in the present tense Source: Rosengren, 2009. Desire I want to Ability I could or might be able to Reasons Things would be better if I Need I really should Commitment I am ready to Steps This week I started

What is Pushback? Absence of collaboration between two people Normal part of adolescence and change process Product of interpersonal dynamics Cue to try something different (reflections) Less resistance more likely to change GOAL: Not to eliminate pushback, but to minimize it.

Tips to Decrease Patient Pushback 1. 2. 3. 4. Don’t try to convince them that they have a problem. Don’t argue about the benefits of change. Don’t tell them how they should change. Don’t warn them of the consequences of not changing.

The Key to SBIRT: Brief Intervention o brief o non-confrontational o directive & collaborative conversation o uses Motivational Interviewing (MI) principles & strategies to enhance motivation to change use of alcohol (and other drugs) Video: BNI-ART ER effective MD

BI: Education & Information; Lower Risk Giving Feedback & Advice Determine the patient’s perception of his/her need to change and perceived ability to change “How do you see your drug use?” Gauge the patient’s reaction to the information “What do you think about this information?” Assess the patient’s stage of readiness to change behavior “On a scale from 0 to 10, how important is it for you to change? Why not a lower number?” Samet, JH, Arch Intern Med 1996

Giving Feedback & Advice: The MI Sandwich 1. Ask Permission “Is it OK if I share with you what is considered high risk drinking according to research studies?” 2. Give Information or Feedback 3. Ask for Response “What do you make of that?”

Brief Negotiated Interview An evidence-based algorithm that provides a structured format for using motivational interviewing skills in the context of clinical care Pros/Cons? Summary? Reflection? Ruler? Affirmation ? Open Question? Minimize Push Back? Action Plan? ? Feedback?

Brief Negotiated Interview (BNI) Patient Voice and Choice Guiding, not directing Avoid the “righting reflex” Patient as decision maker They’re in the driver’s seat

Brief Negotiated Interview (BNI) Five Steps: 1. Build Rapport/Engagement 2. Pros and Cons 3. Feedback 4. Readiness Ruler 5. Action Plan Developed by BNI-ART Institute,@ BU.edu and The Yale Brief Negotiated Interview Manual. D’Onofrio, et al. New Haven CT: Yale Univ. School of Med. 2005

Things to Note about the BNI Follows a scripted approach BNI is the skeleton, but you bring it to life! Not always linear; might need to adapt process as situation unfolds While ideal, it might not be possible to complete each step at every encounter

Brief Interventions are most successful when people can voice their own reasons for change aloud. Then, they are more likely to make the change.

Step 1: Build Rapport/Engagement Before we start, I’d like to know more about you. Would you mind telling me a little bit about yourself? What is a typical day like for you? How does your [x] use fit in?

Step 2: Pros and Cons Explore PROS and CONS Use reflective listening Summarize I’d like to understand more about your [X] use. What do you enjoy about [X]? What else? What do you enjoy less or regret about your [X] use? What else? If NO cons: Explore problems mentioned in screening. “You mentioned Can you tell me more about that situation?” So, on the one hand you said [PROS], and on the other hand you said [CONS].

Step 3: Feedback Ask permission Provide information Elicit response What do you know about the health effects and/or risks of [X]? Would you mind if I shared some additional information with you? Provide 1-2 salient substance specific health effects/risks. What are your thoughts on that?

Step 4: Readiness Ruler 1 2 3 4 5 6 7 8 9 10 Readiness ruler Envisioning change To help me understand how you feel about making a change in your [X] use, [show readiness ruler] On a scale of 1-10, how ready are you to change any aspect related to your [X] use? Why did you choose a [X] and not a lower number like a 1 or 2? If they choose “0”: What would need to happen in your life to consider making a change?

Step 5: Action Plan Develop plan What are you willing to do for now to be safe and healthy?.What else? Assess confidence On a scale of 1-10, how confident (1-10) are you that you could do that? Explore challenges Why did you choose a [X] and not a lower number like a 1 or 2? Summarize What are some challenges to reaching your goal? Thank client Let me summarize what we’ve been discussing, and you let me know if there’s anything you want to add [review action plan] Thanks for being so open with me today!

Confidence Scale Assesses client’s confidence Identifies potential barriers “What would you need to change for you to feel more confident?” Can discuss previous successes to build confidence “What changes have you made in your life?” “How did you accomplish that change?”

SBIRT BNI Steps Ask single item question Assessment if needed (AUDIT, CAGE, etc ) Ask for permission to provide information Reflect on their reaction to the information you provide them Use positive affirmation Ask if they are ready to make a change - If so gauge with Readiness Ruler. Once answer is given ask “Why not (lower number) .? Reflect on their response Summarize the interview- “Do you have any other questions? Did I miss anything? Make referral if necessary

BNI in Action Breakout into groups to practice BNI

Questions (C) 2016 GRE 91

Thank You!

RI-SBIRT Resource Center Contact Information Chris Dorval- Program Coordinator 401-626-0169 [email protected] Website.com Dorval, 2016 93