SBIRT (Screening, Brief Intervention and Referral to Treatment)
How to identify those in recovery...?
Some patients may reveal past drug/alcohol use and current abstinence.
sizable portion of the population faces increased risk of harm, or may in fact be experiencing harm, from consuming substances above certain limits or under certain circumstances SBIRT TARGET!
Substance Abuse Pyramid Middle (Hazardous/ moderate risk)
High Risk -Specific behavioral, psychological and physiologic changes which occur in response to repeated excessive alcohol consumption. - Will develop usually a tolerance
Substance use Pyramid Tip (High Risk)
Successful Referrals...
transitions to and from treatment and between levels of care are supported by active development of a working-relationship with your community substance abuse treatment providers. - help ensure these patients do not return unnecessarily due to not receiving the services needed.
How many Americans have an alcohol disorder...?
(1/8) or 12.7%
ASSIST (?'s 1-3) After Substances have been identified
* For each substance if there is multiple being used
Assist (?'s 4-7)
** Positive answer on 7 means direct intervention regardless of score.
ASSIST (?'s 1-2)
*** Question 1 not scored
To scale Readiness to change use...
A scale from 1-10 "How important is it for you to change your substance use?" "How confident are you that you can change your substance use?" "How ready are you to change your substance use?" Follow an answer with ?'s "What made you pick 3 v.s. a lower #?"
How is SBIRT a Paradigm shift?
Dentist goes from Director/ Executive --> Participant/ Observer - Collaborative, Non-judgmental
How does Gender explain drinking limits?
- Alcohol disperses in body water and women have less water in their bodies than men do. - Women and men metabolize alcohol at different rates.
Drug & Alcohol Treatment is...?
- Available to anyone specialized programs that specifically serve pregnant women, woman with children, and intravenous substance abusers.
Ways to move forward...?
- Avoid confrontation, labeling, stereotyping and forcing patients to accept a label or diagnosis.
How does treatment help patients...?
- Become aware of the drivers of substance misuse; - How to manage relapse; - Strategies for relapse prevention - Identification of triggers and how to avoid these triggers; as well as, - Assisting in the development of enhanced social skills and building a network of support.
Actively Assist Patients in Accessing Treatment
- Discuss range of treatment options. - Identify programs and providers by name and have contact information available. •Familiarize yourself with the following in your area: -Who offers local substance use disorder and mental health treatment providers and what do they offer and what insurance/payers they accept? -When and where local self help group meetings take place (time/days of the week)? -Where patients can access basic needs services (housing, transportation, child care, etc.)?
Document Screening
- evidence-based, structured screening instrument examples... •Feedback •Discussion of negative consequences •Motivation •Behavior change options •Agreed upon behavior change •Follow-up plan
Beneficial Outcomes of SBIRT
- Primary care setting: Small to moderate reductions in alcohol consumption that are sustained over 6-12 month periods or longer. - ED setting: Led to reduced hospital admissions, traumas and injuries up to 3 years post intervention
Oral Health Effects of Alcohol
- Risk of developing oropharyngeal cancer - Orodental trauma: increased likelihood of motor vehicle accidents or violence - Periodontal disease, caries, and mucosal lesions.
Screening in Dentistry
- Uncovers substance use patterns that may increase future disease risk and complicate the course and management of health problems. - Detects health problems related to at-risk substance use at an early stage - before acute or chronic disease result. - Provides the opportunity to reinforce positive behavior by persons who screen negative. - Prompts assessment of persons who screen positive for at-risk substance use.
Effective BI
- lead to incremental reductions in harm; they are not "one time" fixes. - Successful behavior change addresses something important to the patient, and about which patients are reasonably confident of being able to achieve - Regardless of how small the change may be, commitment to making a specific change is essential - Accepting lack of abstinence IS NOT the same as condoning.
When Combined tobacco and alcohol misuse...?
- oropharyngeal cancer risk is greater than the independent effects of these substances - Their joint effect appears to be multiplicative
Are dentists effective in SBIRT?
-PTs reacted well to brief interventions, 90% showed up for follow up -Quarter of PTs quit smoking and abstained after 6mo after dentists referred them to tobacco quitline -1/3 of PTs quit smoking and remained abstinent for 6mo after students provided brief intervention
Nearly ____ of all Americans have alcohol use disorder
1 in 8 or 12.7%
Validated Screening Instruments
1.Identify 2.Assess 3.Determine Level of Risk, and help the provider 4.Choose an Intervention
How many Americans smoke or use tobacco?
1/7 or 14% 2X more likely to have poor oral health.
a large portion of the population abstains, or consumes alcohol or drugs at levels that, in general, present little risk.
Abstinence/low level use
Referreal to Treatment
Actively assisting patients with appropriate treatment and linkages to recovery support for patients who require more extensive treatment and access to specialty care.
Drink Scale
Ask the patient what he or she's standard drink is...?
Brief Intervention Definition
Brief dialogues with patients exploring the consequences of substance use with the intent to strengthen the patient's own motivation and commitment to positive behavior change.
CAP
Capable Autonomous Prepared
Summarization
Clarifies conflicts. Focuses on modifiable risks. Reinforces positive beliefs. Formulate a follow up plan
Brief intervention steps
Empathy and compassion Worth and affirmation Partnership and autonomy
What does SBIRT employ?
Empirically-based and clinically useful practices to circumvent harmful consequences from substance use, including impeding the development of alcohol and other drug use disorders.
FLO Sequence
Feedback: Make a simple factual statement about individual's risk for harm, pause for reaction and obtain agreement to enter into discussion. Listen: Prompt patient to verbalize (think out loud) his/her understanding of risk level, responsibility for personal choices, ability to choose to behave differently, the relative importance of new behavior options and his/her level of confidence in achieving specific new behaviors. Options: Actively encourage expanded thinking about options for different/safer choices and commitment to the most important and realistic option identified.
Developing a plan
List Options Offer Guidance Provide Affirmation Assure Follow up
Binge Drinking, in about 2 hours time
Males: 5 or more, Female: 4 or more,
Drugs shown to affect oral health
Methamphetamine Cocaine Marijuana
Benefits of brief intervention
Minimal time is needed Cost-effective Long-term reduction in harm
What does pausing do...?
Provide feedback by voicing concerns and fostering responsibility and control of the conversation by taking a little
Brief Screening Questions
Question 1: Men: "When was the last time you had 4 or more drinks in one day?" Women/ Elderly: "When was the last time you had 3 or more drinks in one day?" Positive answer: "Past 3 months" Question 2: "How many drinks do you have per week?" Positive answer: Men: More than 14 Women/ Elderly: More than 7
Negative screen --> ___ Positive screen --> __
Reinforcement; Audit
a comprehensive and integrated public health approach to the delivery of early screening, intervention, and treatment services
SBIRT definition
SBIRT stands for...?
Screening Brief Intervention Referral to Treatment
When is low-risk still too much? Safest to avoid alcohol altogether when:
Taking meds Managing medical conditions Underage Planning to drive/machinery Pregnant
Automatic positive screen
Those who should not be drinking -Pregnant women, children, adolescents
Ways to protect the patient's privacy and confidentiality...?
Those with SUD continue to face issues of stigma and discrimination. •Document using general terms describing behavior, not diagnoses. •Confidential information should be accessed only by persons directly involved in the care of the patient. •This information cannot be released to another provider without the specific signed release of information from the patient.
T/F: A small proportion of the overall population (5%) will meet the diagnostic criteria for hazardous use or dependence.
True
T/F: Any tobacco use is considered positive screening
True
Active Withdrawl
When a patient relapses or starts up the habit again.
SBIRT has been successful in helping PTs
decrease drug, alcohol, and tobacco use
Harmful use of alcohol
men up to age 65: >14 drinks/week Binge: > 4 drinks in one day for women or men older than > 65: > 7 drinks/week Binge: > 3 drinks in one day
Ambivalence:
not indecision but rather the equal desire for two opposing realities at the same time - the patient identify his/her ambivalence regarding changing to a healthier behavior. Listen for but and if statements .
Screening
process for identifying patients whose substance use puts them at increased risk for harm.
W/O the patient's consent...
substance use related records cannot be released without a subpoena.
Meth affects oral health by...
• Acidity of drug leads to erosion • have more missing, broken and overtly carious teeth
Oral Health effects of smoking/tobacco use
•About 90% of people with oral cancer use tobacco •Causal factor in 75% of deaths in the U.S. from oral and pharyngeal cancers •Causal factor in 50% of adult periodontitis •Associated with poorer standards of oral hygiene and premature tooth loss •Implicated in delayed wound healing, coronal and root caries, sinusitis and a wide range of oral and soft tissue changes
Document BI
•An evidence-based, structured screening instrument: - Feedback - Discussion of negative consequences - Motivation - Behavior change options - Agreed upon behavior change - Follow-up plan
FTND (Fagerström Test for Nicotine Dependence)
•Brief screening questionnaire that is self administered or done via interview. •Developed by K Fagerström and N Schneider in 1989 and modified by T Heatherton in 1991 •second version, called the FTND-ST, developed in 2006 for users of smokeless tobacco Strengths: - Valid screening for tobacco dependence - Simple to understand questions - Only 6 items very brief Weaknesses: - Limited to Nicotine dependence
ASSIST (Alcohol, Smoking, Substance, Involvement, Screening Test)
•Brief screening questionnaire that is self administered or done via interview. •Developed for World Health Organization (WHO). Strengths: •Comprehensively screens for alcohol, tobacco, and illicit drugs. •Test and manual are free. •Validated in multiple settings. Weaknesses: •May take up to 10 minutes to complete. •Asks about a wide variety of substances, some of which may be unfamiliar.
Devil's Lettuce affects oral health by...
•Carcinogens from smoke can contribute to oral cancers •May cause gingival enlargement
Goals of SBIRT
•Healthier patients at lower risk for a SUD. •Promptly relate SUD to clinical findings. •Prevent early substance use prior to severe and permanent harm. •Identify substance dependence and provide appropriate referral to specialized treatment, when medically stable.
Universal Screening
•Increases the ease and speed of data collection from the patient. •Evidence-based tools, with documented sensitivity and specificity, are widely available. •Routine screening opens the door for the provider and reduces patient resistance to exploring substance use. •Promotes documentation of identified substance use issues and supports billing.
Cocaine affects oral health by...
•Palatal perforation •Bruxism •Gingival lesions
When to refer a patient...?
•Patients screened as having the most severe levels of alcohol or other drug use and/or have the diagnostic criteria for abuse/dependence. •Patients screened as having identified concerns or risky behaviors associated with alcohol or other drugs may be referred for assessment to determine whether treatment is appropriate or if they should be connected to educational intervention services.
Asking Permission does what...?
•Respects patient autonomy •Keeps focus on the patient •Minimizes resistance
Audit-C
•Shortened version of AUDIT containing the first 3 AUDIT questions on consumption. •May be either self-administered or done via interview. •Valid to detect heavy drinking and alcohol use disorders (abuse and dependence).
DAST-10
•Shortened version of DAST 28 containing 10 items completed by self report or via interview. Yields a quantitative index of problems related to drug misuse. Strengths: - Sensitive screening tool for @ risk Drug use - Can be administered in 5 minutes Weaknesses: •Does not include alcohol use. •Obvious question content may lead to specious responses.
Feedback (FLO)
•Straightforward task that introduces the topic. •Concern is disclosed and explained briefly. - Risk level - Disease state - Medications •Signals transition to a collaborative approach. •Hands the patient the reins to lead the conversation. Use RANGE: Range Audit and DAST Normal Audit-C Give result Elicit reax
Options (FLO)
•Tasks the patient has identified they are most ready to address. •Specific, relevant, and realistic options lead to achievable goals. •A plan that falls short of abstinence is not the same as condoning substance use.
Audit
•Ten questions, self-administered or done via interview, about recent alcohol use, alcohol dependence symptoms, and alcohol related problems. - Developed by WHO Strengths: •Test and manual are free. •Validated in multiple settings including primary care. •Brief, rapid, flexible. •Focuses on recent alcohol use. •Consistent with ICD-10 definitions of alcohol dependence and harmful alcohol use. Weaknesses: - Only screens for alcohol abuse.
Audit scale intervention levels
•The cut-off score for "Moderate Risk" using the AUDIT is lower for individuals over 65 years of age, at 7 points. - Relying on the AUDIT-C, screening thresholds of ≥4 for men and ≥ 3 for women are effective in implicating alcohol misuse and warrant further investigation
Listen (FLO)
•The patient as "Expert" does the talking. •Narrative remains focused under the provider's guidance. •Behavioral change opportunities are revealed. - Info to assist patient in developing a plan that will put them on course for a less risky behavior During this process you can guide/ direct the narrative with OARS... Things to look for... (Important and Confident) Open ended questions Affirmative ?'s Reflective Statements Summarization
Referral to Treatment
•determining the appropriate level of care. •Patients may also need to be referred for treatment for other mental and physical health problems. •Ideally, treatment for all conditions should be integrated and coordinated.