SCREENING AND BRIEF NEGOTIATED INTERVIEW SUMMARY
SBIRT:
Use with a Psychiatric Evaluation (new pt., not seen in a while and needing update in ROS/PFSH, or
whenever you would use a PROS):
•
•
Ask about substance use:
o Do you use tobacco products? Do you use opioids, cocaine, amphetamine, inhalants or
other drugs?
o Do you drink beer, wine or any liquors or mixed drinks?
o In a high-risk patient (e.g., population groups with high risk of SUD like BPD,
Schizophrenia, ADSM, incarceration or gang-affiliation, etc.) use ASSIST v3.0
https://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf
Use SBIRT approach
o Determine Spectrum of Alcohol Use. SBIRT steps 1 and 2
▪ Low risk: Drink within NIAAA guidelines. Congratulate and educate re normal
levels of drinking
▪ Hazardous, Harmful, Dependent: SBIRT step 3
o
o
o
Hazardous drinking: Exceed NIAAA consumption guidelines. Alcohol use puts them at
risk for injury/illness or social problems. Advise (step 3) re health risk and assess
willingness to abstain or cut back. Provide handouts, offer referrals, recommend AA,
SMART Recovery, or psychotherapy. Help make plan and follow-up appt.
Harmful drinking: Currently experiencing problems (medical/social) related to alcohol;
often exceed NIAAA guidelines for low-risk drinking. Advise (step 3) re impact on
current conditions, symptoms and/or medications. Strongly recommend abstinence.
Assess readiness using MI Ruler and discuss.
▪ If somewhat ready and hear change talk (DARN-CAT), focus on that, reinforce
and make plan (see above).
▪ If less ready/ambivalent (contemplative stage), focus on change talk then list
pros and cons of drinking or using. Do same with reasons for starting treatment.
If open, set reasonable goal for harm reduction or abstinence. Offer therapy and
recommend support group. Consider medication. Make plan. Order labs,
physical exam if relevant, make referrals and follow up appointment.
▪ If not ready/precontemplative: focus on keeping them talking; ask about pros of
drinking. Any drawbacks at all? What would have to happen for you to change
your mind? Is there anything you’re willing to do today? May we talk about this
at our next visit?
Dependent drinking (and higher risk harmful drinking and those with COD): See BNI
BNI:
Use with a patient who admits using, is referred for SUD or with a positive screener:
•
•
Determine Spectrum of Alcohol Use.
o Low risk: Drink within NIAAA guidelines. Congratulate and educate re normal levels of
drinking
o Hazardous drinking: Exceed NIAAA consumption guidelines. Alcohol use puts them at
risk for injury/illness or social problems. Advise re health risk and assess willingness to
abstain or cut back. Provide handouts, offer referrals, recommend AA, SMART Recovery,
or psychotherapy. Help make plan and follow-up appt.
o Harmful/Dependent Drinking: go to BNI
Start Brief Negotiated Interview
o Adjust the Basic Steps of 4-Step BNI based on stages of change relevant to your pt.
https://medicine.yale.edu/sbirt/implementation/tools/EBNI%20manualNREPP_178862_
284_21891_v1.docx
1. Raise the Subject
a. Establish rapport
b. Raise the subject of alcohol or drug use
c. Assess comfort
2. Provide Feedback
a. Review patient’s alcohol/drug use and patterns
b. Make connection between alcohol/drug use and negative consequences In a
variety of areas of life including: medical, legal, family and employment
c. Make connection between alcohol/drug use and the medical visit
d. Discuss issues related to physical dependence, such as tolerance and
withdrawal
3. Enhance Motivation
a. Assess readiness to change
b. Boost motivation
4. Negotiate and Advise
a. Negotiate goal
b. Give advice
c. Summarize and complete referral/or alcohol/drug agreement
o Document thoroughly. Consider using template. See
https://pubs.niaaa.nih.gov/publications/clinicianGuide/guide/tutorial/data/resources/
MedMgmtSupportTemplates.pdf
o Harmful drinking: Currently experiencing problems (medical/social) related to alcohol,
based on AUDIT questions. often exceed NIAAA guidelines for low-risk drinking. Advise
re impact on current conditions, symptoms and/or medications. Strongly recommend
abstinence. Assess readiness using MI Ruler and discuss.
▪ If somewhat ready and hear change talk (DARN-CAT), focus on that, reinforce
and make plan (see above).
▪ If less ready/ambivalent (contemplative stage), focus on change talk then list
pros and cons of drinking or using. Do same with reasons for starting treatment.
o
If open, set reasonable goal for harm reduction or abstinence. Offer therapy and
recommend support group. Consider medication. Make plan. Order labs,
physical exam if relevant, make referrals and follow up appointment.
▪ If not ready/precontemplative: focus on keeping them talking; ask about pros of
drinking. Any drawbacks at all? What would have to happen for you to change
your mind? Is there anything you’re willing to do today? May we talk about this
at our next visit?
▪ Consider MAT now or at follow-up after labs:
https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4907.pdf
Dependent Drinking: Physically dependent on alcohol, based on AUDIT questions
▪ See above steps for Harmful drinking
▪ if willing to reduce or abstain then
• Assess for withdrawal symptoms and signs
o Use CIWA-AR (may need to assess for other drug/substance
withdrawal)
o Determine setting to manage medical detox. See ASAM
criteria.
o If pt. at risk of complications due to withdrawal, do not
recommend abstinence at this point until further evaluation.
• Perform PE and labs, or refer
o Indirect biomarkers: GGT, AST, MCV
o CDT has higher sensitivity; distinguishes heavy drinkers.
Often combined with GGT for better results
o Direct biomarkers often specialized; EtG and PEth
o See pg. 8 of Medication for the Treatment of Alcohol Use
Disorder: A Brief Guide Consider MAT now or at follow-up
after labs:
https://store.samhsa.gov/sites/default/files/d7/priv/sma154907.pdf
o and/or https://emedicine.medscape.com/article/285913workup
• Diet considerations: sound nutrition essential. Add folate, B12
▪ Consider MAT now or at follow-up after labs:
https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4907.pdf
▪ Schedule labs, referrals, follow-ups
▪ At return visit,
• assess adherence to plan. Use MI
• MI Sheet: Reducing alcohol risk and harm with MI
https://drive.google.com/file/d/10VOcOs2TVyPBpHecKKYUh6xPoqpBB64/view?usp=sharing
• MI Sheet: SUD Decisional Balance https://drive.google.com/file/d/14vmdQVQkD4BqJkjcJu9NeMHkjyelBwf/view?usp=sharing
•
•
•
MI Sheet: URICA scoring for AUD https://drive.google.com/file/d/1B9puG3HXh-YGTym4qocDWPH1_teKjoR/view?usp=sharing
Start medication if appropriate
o https://store.samhsa.gov/sites/default/files/d7/priv/sma154907.pdf
o See COMBINE Medication Management template
o See supplemental/alternate med options, include.
Gabapentin and D-cycloserine (50 mg) for cravings
https://emedicine.medscape.com/article/285913-medication
Schedule routine follow-ups and remember to treat CODs. Ensure
adherence to psychotherapy and community support.
Common Problems
➢ Refusal to Engage in The Discussion Of The Topic Of Drinking
Most patients will agree to discuss the topic, because they have already consented to be in the
study, but in the unlikely event that someone outright refuses to discuss it at all, tell the patient
that you will respect their wishes and that all you will be doing is giving him 3 pieces of
information:
1. His drinking exceeds low risk drinking limits (or is harmful);
2. Low risk drinking limits recommended for pts age and sex; and,
3. You are concerned and that s/he should cut down to low risk
drinking limits to avoid future harm (Steps 2 and 4 only).
➢ Refusal to Self-Identify Along the Readiness Ruler
When this happens, it is usually a problem with understanding the numbers. There are several
ways of dealing with this:
1. Anchor the numbers with descriptors, such as “1” means not ready
at all or 0 per cent ready, and 10 means completely ready or 100%
ready to change.
2. Ask “What would make this a problem for you?” Or, “How important
is it for you to change any aspect of your drinking?”
3. Discussion of Pros and Cons (refer to list).
➢ Unwilling to Associate Visit with Alcohol Use
Don’t force the patient to make the connection but be sure that he/she hears that in your
medical opinion there is a connection. However, this connection may not be the thing that
ultimately motivates the patient to change. If this happens, try to find some other negative
consequence of drinking that the patient can agree is related to alcohol and bothersome enough
to consider drinking less.
➢ Not Ready to Change Drinking Patterns into Safe Limits
Tell the patient that the best recommendation is to cut back to low risk drinking limits, but that
any step in that direction is a good start. The patient’s goal is then written on the drinking
agreement. Regardless of the individual goal, the patient also receives the practitioner’s advice
for low risk drinking on the patient health information handout.
Above information taken from the Yale Project Ed Health II BNI Training Manual, 2005
https://medicine.yale.edu/sbirt/implementation/tools/EBNI%20manualNREPP_178862_284_21891_v1.docx
Use Readiness Rulers: https://www.quitlinenc.com/docs/provider-resources/readinessruler5014.pdf?sfvrsn=4
HANDOUTS
Pros & Cons of Drinking
Reasons to Quit or Cut Down on Drinking
To live longer, and feel better
To consume fewer empty calories
To sleep better
To be less likely to have a stroke
To improve blood pressure control
To reduce the possibility of death from liver disease
To prevent problems with medications
To decrease the likelihood of falls or other injuries
To prevent memory loss that may lead to loss of independence
To be able to care for myself longer
To be a better parent or grandparent
To reduce the possibility that I will die in a car crash
Other reasons:___________________________
Reasons for Drinking
I enjoy the taste
It enhances meals
For pleasure in social situations
To more easily socialize
Other people expect that I will drink with them
To relax or relieve stress
To cope with feelings of anger
To cope with feelings of boredom
To deal with momentary feelings of depression
To deal with momentary feelings of loneliness
To deal with feelings of frustration
To relieve the stress of arguments with family members or friends
It’s something I do when I’m smoking
It’s something I do when I’m watching T.V.
It’s something I do with certain friends or relatives
To help me sleep
To relieve pain
To make me feel better
Other reasons:____________________
Drinking Agreement
DRINKING AGREEMENT
Date: ___________________
I, ______________________________, agree to the following drinking limit:
Number of drinks per week:
_______________________________________
Number of drinks per occasion: _______________________________________
Patient signature:
_____________________________________________
Remember: It is never a good idea to drink and drive and it’s
Illegal to drink if you’re under the age of 21.
Health Information Handout
Please read the following important information, about reducing risky health behaviors, which may
apply to you.
Health Risk
Smoking
What we know…
• It’s not healthy to smoke.
• There are many options available to help you stop.
Exercise
• It’s healthy to exercise on a regular basis.
• The amount of exercise recommended on a daily basis is 30 minutes.
Alcohol Use
• Drinking above low risk limits will increase your risk for illness and/or injury.
• Please see the drinking information for your sex and age, on the back of this paper.
• It’s never good to drink and drive.
Safety Issues
• It is always healthy to take safety precautions.
• Always use a seatbelt when in a car.
• Always wear a helmet while biking, riding a motorcycle or rollerblading.
• San Diego County Access & Crisis Line: 888-724-7240 TDD: 619-641-6992
• Directory Of Substance Use Disorder Programs For Adults And Older Adults:
https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/bhs/homepage/BHS_SUD_Brochures/
EN%20AOA%20-%20SUD%202019%20rev%2005.10.19.pdf
• Directory Of Substance Use Disorder Programs for Adolescents:
https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/bhs/homepage/BHS_SUD_Brochures/
EN%20Adolescents%20-%20SUD%202019%20rev%2005.10.19.pdf
WHAT IS A STANDARD DRINK?
1 Standard Drink equals:
1 regular beer
12 oz.
1 glass of
wine
5 oz.
or
mixed drink made with
12 oz. Beer
5 oz. wine
1.5 oz. of alcohol
(whiskey, gin, etc.)
How Much Is Too Much?
If you drink more than this, you can put yourself at risk for illness and/or injury
# Drinks
Week
Men
Women
All age >65
14
7
7
Occasion
4
3
3
Sometimes even 1 drink is too much! If you are:
▪ driving or planning to drive
▪ at work or returning to work
▪ pregnant, or breast feeding
▪ on medication
▪ have certain medical conditions
Handout pages adapted from the Yale Project Ed Health II BNI Training Manual, 2005
https://medicine.yale.edu/sbirt/implementation/tools/EBNI%20manualNREPP_178862_284_21891_v1.docx
Notes:
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