SBIRT Training
The BNI-ART Institute
Boston University School of Public Health
Boston Medical Center, Dept. of Emergency Medicine
Project Assert
BMC Emergency Department’s
Health Promotion Advocates :
• provide comprehensive care & prevention
• focus on substance abuse in context of other
health and safety issues
• offer info & health resources with emotional
support & advocacy;
• collaborates with staff to serve 5,000 + pts/yr
Funded in 1993 SAMHSA/CSAT; 1998
line item in BMC ED Budget; a model for
SBIRT in 2003
Lead HPA: Ludy Young., HPAs: John Cromwell, Dan
Heenen, Brent Stevenson,, & Moses Williams
Adm Dir, Emma Riley; Med Dir., Dr. Edward Bernstein,
What is SBIRT?
• SBIRT is a comprehensive, integrated public health
approach to the delivery of early intervention and
treatment services to persons with at-risk and
substance use disorders
• The primary goal of SBIRT is to identify and
effectively intervene with those who are high risk for
psycho-social or health care problems related to their
substance use.
• Primary care centers, hospitals, EDs and other
community settings provide excellent opportunity for
early intervention
The S-BI-RT
• Screening to identify patients with high-risk or
dependent drinking and drug use
• Brief Intervention: Conversation to motivate
patients who screen positive to consider healthier
decisions (e.g. cutting back, quitting, or seeking
further assessment)
• Referral to Treatment: Actively link patients to
resources when needed
Outline
• Why people use alcohol and drugs
• Different frameworks for viewing substance use
▫
▫
▫
▫
Moral failing
Biomedical model
Public health model
How SBIRT fits in
• Evidence for SBIRT
• Logistics of SBIRT in health care settings
Why do people use alcohol & drugs?
• Feels good/ not feel bad
• Socialize, hang out
• Feel outgoing, less shy
• Have fun, relax
• Celebrate
• Stay alert
• Tastes good
Why do people use alcohol & drugs?
• Environmental norms
• Work place
• Family, home
• Friends
• Peer pressure
Why do people use alcohol & drugs?
• Cope with stress
• Self-medicate
• Response to life trauma
• ACEs: Adverse Childhood Events
• Emotional, physical, sexual
abuse; neglect; household
dysfunction
How does society view…
…Alcohol and drug use / users?
• In the past?
• Currently?
• In your community?
A Moral Failing
•
•
•
•
•
•
•
•
•
Character flaw
Sign of personal weakness
Lacks values, strength
Menace, danger to society
Lazy, not contributing to society
Drugs are bad, deviant, criminal
Alcohol is acceptable up to a certain point
To be avoided; “Just say no”
Chose wrong path
Traditional Approaches
• War on Drugs, Just Say No
• Jail, prison, department of corrections
• Shame and blame confrontation
• Treat and street in medical encounter
• Stigmatization
Dr. Nora Volkow: NIDA Director
“STIGMA”
In years past, science discovered the
causes of epilepsy and leprosy and
helped free the afflicted of stigma.
“We are witnessing another instance
of one of the great moral
achievements of science: establishing
the right of people who have been
regarded as hopeless or untouchable
to full consideration as human
beings.”
Addiction Science & Clinical
Practice 2007; 4:1
Reward and Craving Pathways
Drugs can be “Imposters” of
Brain Messages
Cocaine increases dopamine levels by blocking re-uptake
into cells
dopamine
Natural Rewards Elevate
Dopamine Levels
DA Concentration (% Baseline)
Food
% of Basal DA Output
200
NAc shell
150
100
50
Empty
Box Feeding
0
0
60
120
Time (min)
180
Sex
200
150
100
Sample 1
Number
Female Present
2
3
4
5
6
Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience,
7
8
Functionally…
Dopamine D2 Receptors are Decreased by Addiction
Cocaine
Meth
Alcohol
Heroin
Control
Addicted
Dopamine is only part of the story
• Scientific research has shown that other
neurotransmitter systems are also affected:
▫ Serotonin
 Regulates mood, sleep, etc.
▫ Glutamate
 Regulates learning and memory, etc.
Genetic, Developmental and Environmental Interaction
Addicted sibling
Striatum
Non addicted sibling
Non addicted unrelated
Precuneus
Amygdal
Orbitofrontal a
cortex
Risk factors
Risk factors
Risk factors
Protective factors
Protective factors
Protective factors
Stop impulse response
Stop impulse response
Stop impulse response
Volkow ND, Baler RD. Science 2012; 335:546.
Ability to stop an impulse to act is
determined by the overall balance of
risk factors and protective factors
• Maladaptive risk factors
▫
▫
▫
▫
high impulsivity, stress reactivity
novelty seeking, conditioning/habits
negative emotionality
poor reality awareness
• Adaptive protective factors
▫ positive emotionality
▫ robust inhibitory control and executive function
▫ strong coping skills and good frustration
management temper cues for potential reward
SAMHSA CSAT
Jack B. Stein, MSW, PhD
Drug overdose deaths were second only to motor vehicle crash
deaths among leading causes of unintentional injury death in
2007 in the United States. (27,658)
Addiction similar to other Chronic Illnesses
• <30% of patients adhere
to prescribed
medications & diet or
behavioral changes
• 50% recurrence rate
• Substance abuse should
be insured, monitored,
treated and evaluated
like other chronic
diseases
Hypertension
Diabetes
Asthma
Addiction
Paradigm Shift = Innovative Approaches
Shift from moral failing to addiction as a chronic
and recurrent condition:
• Chronic disease management
• Integration with behavioral health
• Expanding treatment options
▫ Medication assistance : suboxone, methadone, naltrexate
▫ Intensive outpatient services
▫ Sober housing
▫ Drug court and treatment in prison
Treatment success depends on:
A comprehensive model that considers
•
Interpersonal relationships
•
Employment options
•
Housing options
•
Mental health services
•
Safety and support
•
Human rights, dignity
…and more
Learning from Successful Examples:
The Cardiac Care Chain of Survival
?
Saving lives & promoting recovery, cardiac & addiction require:
• community involvement, screening and access
• structural changes informed by evidence
• $ and monitoring of access & quality
• workforce development
• an integrated, coordinated, collaborative system
• public education, and advocacy & de-stigmatization
Biomedical Model Isn’t Enough
• Chronic illness model doesn’t take high-risk use
into account
o
o
Many people who use alcohol and drugs do not meet
criteria for dependence
Intervention still needed for preventing future injury,
illness, or possible dependence
• Substance use doesn’t happen in a vacuum
o
o
cost society over $600 billion annually
have far-reaching implications for family, workplace,
community, and health care system
SBIRT Addresses Both
• Continuum of Use
o
o
o
Low-risk use
High-risk / unhealthy use
Abuse and dependence (substance use disorders)
• Continuum of Care
Brief intervention, action plan
o Wrap-around services
o Detox, treatment types
o
SBIRT: Part of a Public Health Solution
• It attempts to identify those who are high-risk for
psycho-social or health care problems related to
their substance use
• It attempts to effectively intervene in a
nonjudgmental, empathic, and motivational way
• It offers an opportunity for finding and connecting
to additional services
• It’s a holistic way of addressing the many ways the
individual affects and is affected by its
environment/society
Does SBIRT work?
Evidence
Research Demonstrates Effectiveness
• A growing body of evidence about SBIRT’s
effectiveness, including cost-effectiveness, has
demonstrated its positive outcomes.
• The research shows that SBIRT is an effective
way to reduce alcohol and drug related health
and social/ legal problems.
Making a Measurable Difference
• Since 2003, SAMHSA has supported SBIRT
programs with over 1.5 million persons screened.
• Outcome data confirm a 40% reduction in harmful
use of alcohol by those drinking at risky levels and a
55% reduction in negative social consequences.
• Outcome data also demonstrate positive benefits for
reduced illicit substance use.
Based on review of SBIRT GPRA data (2003-2011).
Brief Intervention in the Clinical Setting
Reduces Cocaine and Heroin Use
Testing the ASSERT Model- Randomized Control Trial in
Heroin-Cocaine Users
• Intervention group more likely to be abstinent at 6 months
(n=778 + hair at baseline) follow-up rate 82%
 cocaine alone (22.3% vs 16.9%)
 heroin alone (40.2% vs 30.6%)
 both drugs (17.4% v s 12.8%)
 adjusted OR of 1.51-1.57
• Cocaine levels in hair reduced
 29% intervention group vs 4% control group
Bernstein et al. Drug & Alcohol Dependence, 2005;77:49-59
Academic Emergency Medicine
SBIRT Collaborative
New England Med.
Boston Medical
Univ. of Michigan.
Rhode Island Hospital
Yale Univ.
Denver Health Medical
Cooper Health
Univ. of Southern California
Univ. of Virginia
Charles Drew Univ.
Univ. of California
Univ. of New Mexico
Howard Univ.
Emory University
26% screened positive for
at risk drinking
Patient Response to SBIRT
at 3 month F/U Summary (n=1173)
At 3 months, controlling for baseline drinking
levels, patients receiving the intervention
• 2x as likely to drink within the NIAAA low risk guidelines
as the controls (39% vs. 19%).
• had 3 fewer ‘typical number of drinks per week’ than
controls
• providers reported greater utilization of SBIRT in their
practice
Meta-analyses of BI and MI
Alcohol only
▫ Kaner et al. (Cochrane), 2007
 I vs C ↓4 drinks/wk
▫ Vasilaki et al, 2006
 aggregate .18, .60 at 3 months
▫ USPSTF, 2004
 69% vs. 57% drinking risky amts; 38 grams/wk
• Alcohol/drugs
▫ Dunn et al, 2001
▫ Hettema et al, 2005 (.30 at 1 yr)
A Ten Minute Brief Negotiated Interview By
Practitioners Reduces Hazardous and Harmful
Drinking Among ED Patients
( Donofrio et al. Ann of Emerg Med. 2012) N=889
Mean # drinks/ past 7 days
•
•
BNI BL 19.8
SC BL 20.9
12 mo 14.3
12 mo 17.6
# Binge drinking days/past 28
•
•
BNI BL
SC BL
7.5
7.2
12 mo
12 mo
4.7
5.8
Driving after >3 drinks
•
•
BNI BL
SC BL
38%
43%
12 mo
12 mo
29%
42%
Recognizing the treatment gap and the need for
prevention with a nationwide movement to a
standard of care
• US Preventive Services Task Force
• Level I and II Trauma Centers
• Millions in federal SBIRT funding for
state & residency training programs
• NIH funding
• Joint Commission hospital SBIRT standards
• reimbursement codes - Centers for Medicare &
Medicaid Services; the AMA (CPT codes) and
E&M codes
What does SBIRT look like?
Screening
Brief Intervention
Referral to Treatment
Screening
What
• NIAAA Qs, NIDA Qs, DAST, AUDIT-C, AUDIT, CRAFFT ,
ASSIST, Health Needs History
When
• Triage, while patient awaits medical attention
Who
• Health promotion advocate (HPA), health educator,
medical assistant, triage nurse, social worker, doctor
Where
• Triage, bedside, waiting room, private room/office
Brief Intervention = the BNI
What
• BNI = Brief Negotiated Interview (5-steps)
When
• Patient screens positive for risky alcohol/drug use
Who
• Health promotion advocate (HPA), health educator, nurse,
doctor, social worker, medical assistant
Where
• Bedside, private room/office
5 Steps of the BNI
1. Build rapport
▫ Bringing up the topic, being nonjudgmental
2. Pros & Cons
▫ Ask what is liked/disliked about the behavior
3. Information & Feedback
▫ Give facts and feedback about the behavior, ask for thoughts
4. Readiness Ruler
▫ Assess readiness to make any changes (to be healthier, safer)
5. Prescription for Change
▫ Ask for action steps, create a plan together
Referral to Treatment
(or other services)
What
• Calling service providers, getting medical clearance (for
detox), calling about insurance, arranging transportation,
giving information: handouts, brochures, contact info., safety supplies
When
• Patient wants (and is good match for) additional services
Who
• Health promotion advocate (HPA), health educator, social
worker, nurse, doctor, medical assistant
Where
• Bedside, private room/office
Next, we'll break it down...