Screening, Brief Intervention,
Referral, and Treatment (SBIRT)
Training Session
OB/GYN
1.
2.
3.
4.
5.
6.
Review of the scope of problems due to alcohol
Review of screening and effective interventions
Break
Video demonstration of brief negotiated intervention
(BNI)
Role playing sessions (small group) and discussion
Complete post-program quiz
Several Truths

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Practitioners are reluctant to screen and
intervene
The primary care visit is an opportunity for
intervention
Treatment works!
Timely referral is effective
Alcohol: Scope of the
Problem
Why should we care?
Alcohol is the most commonly used drug in the
United States
Alcohol Fast Facts
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Alcohol related deaths
75,000/year
Annual economic cost
$185 billion
Homicides (alcohol involved) 60-70%
Suicides (alcohol involved)
40%
Fatal motor vehicle accident
50%
A risk factor for medical conditions

Hypertension, stroke, diabetes, liver, GI disease
Alcohol Fast Facts

Major risk factor for all categories of injury
 Problem
 Injuries
drinkers
per year
2x
 Hospitalizations
4x
for injuries
hospitalizations for injury
 Even
one alcohol-related visit predicts
continued problem drinking
Young Adults

Alcohol use in the past month
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17%
33%
47%
Binge drinking (>5drinks in a row) in last 2 weeks



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8th grade
10th grade
12th grade
8th grade
10th grade
12th grader
11%
21%
28%
Drivers between the ages of 16-25 account for 30% of
alcohol-related fatalities
Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey, 2005. www.monitoringthefuture.org
Adults over 18 years
10 million (5%)
 40 million (20%)
 70 million (35%)
 80 million (40%)

dependent drinkers
high risk drinkers
moderate drinkers
abstain
National Longitudinal Alcohol Epidemiologic Survey, 1992
High risk “At-risk” drinkers
Issues unique to pregnancy

Prevalence of alcohol use
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Prevalence of use (age 18-44)-non pregnant

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Binge drinking in a previous month
Binge drinking in a previous month
Many not using contraception
11%
2%
55%
13%
>50%
Pregnancy is a unique time, where motivation to reduce
alcohol use may be higher.

74% of women stop drinking during pregnancy.
Issues unique to pregnancy

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No known safe levels of alcohol intake
No exact dose-response relationship
Binge drinking may be more concerning than similar
volumes over time.
Increased stillbirth rate

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<1 drink per week
>/=1 drink per week
1.37 per 1000 births
8.83 per 1000 births
Current U.S. recommendation: abstinence
Fetal alcohol syndrome (most severe)

Prevalence with heavy drinkers

Offspring issues:
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Leading cause of developmental delay in the US.
Growth problems (<10% at any point in time)
Facial dysmorphia
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10-50%
Microcephaly
Smooth philtrum, thin vermillion border, small palpebral fissures
Maxillary hypoplasia
Central nervous system abnormalities


Average IQ 63
Fine motor dysfunction
Nation’s Public Health Agenda:
Healthy People 2010

Increase the proportion of persons who are
referred for follow-up care for alcohol
problems, drug problems, or suicide attempts
after diagnosis or treatment for one of these
problems in the emergency department
Ambulatory medical care survey
SCREENING
Screening for Alcohol use and abuse

ACOG Committee Opinion: Dec 2008
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“Obstetrician-gynecologists have an ethical obligation to
learn and use a protocol of universal screening questions,
brief intervention, and referral to treatment in order to
provide patients with medical care that is state-of-the-art,
comprehensive and effective.
Screening allows for early and effective treatment
Screening is cost-effective (saves $7 for every $ spent)
Primary care visit is an ideal opportunity to screen and
intervene as necessary
UNIVERSAL SCREENING
WIDENS THE NET
ABSTAINERS &
MILD DRINKERS
(70%)
MODERATE
(20%)
at risk drinkers
SEVERE
(10%)
Specialized Treatment
Brief Intervention
Primary Prevention
ASK Current Drinkers
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On average, how many days per week do you
drink alcohol?
On a typical day when you drink, how many
drinks do you have?
What is the maximum number of drinks you had
on a given occasion last month?
Remember that a “standard
drink” consists of:
Screen Positive: NIAAA Guidelines

Pregnant women
0 drinks
ASK Current Drinkers
CAGE
C
A
G
E
Cut Down
Annoyed
Guilty
Eye Opener
Detection and
Referral
Does it matter?
What do we do?
ABSTAINERS &
MILD DRINKERS
(70%)
MODERATE
(20%)
at risk drinkers
SEVERE
(10%)
Specialized Treatment
Brief Intervention
Primary Prevention
Brief negotiated intervention (BNI):
A motivational interview
For the “At-risk drinker”
Principles of Motivational
Interviewing
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Ask for permission to discuss problems
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Express empathy and avoid arguments
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Develop discrepancies
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Roll with resistance and provide personalized feedback
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Help patients understand the differences between their behavior and their
goals
“Reflective listening”
Support self-motivation
Motivational Interviewing: A Tool for
Behavior Change

ACOG Committee Opinion: Jan 2009

The goal is to “help patients identify and change behaviors
that place them at risk”

“motivational interviewing to everyday patient interactions
has been proved effective in eliciting “behavior change”

“ACOG encourages the use of motivational interviewing as
one approach to elicit behavior change.”
Fleming et al
JAMA 1997
“Brief physician advice for problem alcohol drinkers: a
randomized control trial in community-based primary
care practices”

Randomized controlled trial
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17 practices with 64 physicians
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Intervention included:
723 patients
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Educational workbook,
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15 minute visits one month apart x 2
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Nurse follow-up calls x 2 (2 weeks after the visit)
Fleming et al

JAMA 1997
Results at 12 months (n=723)
Alcohol consumption reduced with intervention:

Intervention group
19.1 drinks/wk  11.5

Control group
18.9 drinks/wk  15.2
Episodes of binge drinking during prior 30 days:

Intervention group
5.7  3.1

Control group
5.3  4.2
Brief Interventions are Effective…
How do we do it?
Video: Scenario 1
Components of the Brief Negotiated
Intervention
1.
Raise the Subject
2.
Provide Feedback
3.
Enhance Motivation
4.
Negotiate and Advise
Step 1: Raise the Subject
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Establish Rapport
Raise the subject of alcohol use
Step 1: Establish Rapport

To understand the patient’s concerns and
circumstances
“That car accident must have been scary”
 “Having your boyfriend hurt you must be awful”

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To explain the providers concern/role
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I am concerned regarding the effect alcohol may be having on
you.
To avoid a judgmental stance
Step 1: Raise the subject

Get the patient’s agreement to talk about the alcohol or
drug use
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Talk about the pros and cons of their use/abuse
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Do you mind if we just take a few minutes to talk about your
alcohol/drug use?
What is it that alcohol does for you?
Re-state what they have said regarding the pros and
cons
Troubleshooting:
What if the patient does not want
to talk about their use/abuse ?
“ Okay, I see you aren’t ready to talk about this today.
Remember that we are here 24 / 7 if you change your
mind”
Step 2: Provide Feedback

Review patient’s drinking patterns

“From what I understand you are drinking…”
Step 2: Provide Feedback
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Make connection to the visit if possible
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If the patient sees a connection:
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“What connection (if any) do you see between
your drinking and this visit?”
Reflect what they have just said.
If the patient does not see a connection:
Help make a connection with facts
 “Alcohol can slow your reflexes and predispose you to
accidents”
 “Alcohol may impair your judgment and …..

Step 2: Provide Feedback

Compare to National Norms and offer NIAAA
guidelines (show them)
Step 3: Enhance Motivation:
Assess the readiness for change
“On a scale of 1-10
(1 being not ready and 10 being very ready)
how ready are you to change any aspect your
drinking patterns?”
1
2
3
4
5
6
7
8
9
10
Step 3: Enhance Motivation
Develop Discrepancies
• If patient indicates she is ready for change:
> 2 : “Why did you choose that number and not a
lower one? What are some reasons that you are so
motivated to change.”
• If patient indicates she is not ready for change:
< 1:
“Have you ever done anything that you wish
you hadn’t while drinking: What would make this a
problem for you.” Discuss pros and cons
Step 3: Enhance Motivation
Develop Discrepancy
Explore Pros and Cons

Help the patient identify the discrepancy
between present behavior and important goals
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Use the discrepancy as a change motivator
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Let the patient name the problem and offer
solutions
The Ready Patient
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Help the patient to:
Name a solution for themselves
 Choose a course of action
 Decide how to achieve it
 Encourage patient choice

Not Ready for Change
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Don’t
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Use shame or blame
Preach
Label
Stereotype
Confront
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Do
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Offer information,
support and further
contact
Present feedback and
concerns, if permitted
Negotiate: “What would it
take you to consider a
change ?”
Not Ready for Change
Avoid arguments
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Counter productive
Defending breeds defensiveness
Perceptions can be shifted
Labeling is unnecessary
Resistance is a signal to change strategies

Rolling with resistance
Unsure patients
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Don’t
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Jump ahead
Give advice
Expect argument about
change
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Do
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Explore pros & cons
“help me to understand
what alcohol does for
you”
“Are there things you
don’t like about your
alcohol use?”
Step 4: Negotiate and Advise

Reinforce what the patient has stated are her
goals.
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Negotiate the goal/Elicit a response
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“What is the next step?”
Give advice
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“So… you would like to reduce your drinking to prevent….”
“If you can stay within the limits you just mentioned you
will be less likely to have a car accident..”
Summarize

“This is what I heard you say..
Step 4: Negotiate and Advise

Provide handouts
Drinking agreements
 Other support sources

Step 4: Negotiate and Advise

Suggest primary care follow up or referral
Social worker
 Psychiatric services
 Discharge sheet of possible centers and / or
programs and information

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Thank patient for their time
Summary

Alcohol problems are common, identifiable and
treatable disorders

Knowledge and skills for screening and
intervention can be learned
VIDEO
nd
2
and
rd
3
scenario
Discussion

To what degree do you discuss alcohol use with
your patients?
Discussion

Do you think you can incorporate SBIRT
(Screening, Brief Negotiated Interview, and
Referral to Treatment) into your practice?

If so, why? What parts seem to work well?

If not, why not? What barriers exist?
Small Groups