Screening and brief treatment for alcohol and illicit drug use

in primary care

1

Elizabeth Byrne, NCC, LPC

Adam Brooks, PhD

Kimberly Malayter, LCSW

Research-Based Solutions Disclosure

As part of its mission, TRI develops and markets research-

derived products and solutions designed to advance evidence-

based practices and policies.

Proceeds from dissemination of these products are returned to

the organization to support future research in accordance with

TRI’s mission and values.

The TRI products discussed in this presentation are:

SBIRT Toolkit

Keep it Moving™ Graphic Novel

2

Collaborating Partners/Institutions

National Nursing Centers Consortium

Treatment Research Institute

Public Health Management Corporation

Family Practice and Counseling Network

Resources for Human Development

Drexel University

University of Pennsylvania

Lincoln University

3

Acknowledgements Pennsylvania Department of Health SAP No. 4100055578

Scientific Team:

Adam Brooks, Ph.D., David Metzger, Ph.D., Kimberly Kirby, Ph.D., Brenda Curtis, Ph.D., Jennifer Lauby, Ph.D., Daniel Polsky, Ph.D., Kevin Favor, Ph.D., Judith Thomas, Ph.D., Patricia Gerrity, Ph.D., Donna Torrisi, M.S.N., Thomas McLellan, Ph.D.

Collaborators:

Denise Gaither-Hardy (Lincoln University), Elizabeth Byrne (NNCC/PHMC), Mary Malnimow (PHMC), Tracy Weant (RHD), Michelle O’Connell (FPCN), Anne Kelly (PHMC), Ariel Adams (Drexel), Laura Line (RHD), Lisa Bond (PHMC), Caryn Gratz (PHMC)

Team Members:

Carolyn Carpenedo, Dan Knoblach, Jaclyn Chambers, Graham DiGuiseppi, Emily Ball, Christina Cruz, Nicolas Joseph, Roxana Arango, Tameka Williams

4

SUDs and Chronic Health Problems

SUDs related to increased risk:

Hypertension, heart failure, etc.

Renal and GI (liver failure, cirrhosis, Hep B and C,

kidney failure)

Neurological (stroke, ischemic events, TBI)

Pulmonary (pneumonia, edema, TB)

Perinatal, postnatal complications

Endocarditis

HIV transmission

5

What is SBIRT?

Screen Everyone for Risk in Primary Care

Brief Intervention (for those at Risk)

Give Feedback

Be Empathic

Give Advice / Offer a Menu of Change

Referral To Treatment (for Dependent Users)

Brief Treatment

Specialty Care / Detox / Rehab

6

Basic SBIRT Model Assess 2-3 min

Advise (Feedback) 1-2 min

REFER TO BHC?? OR:

Agree (Responsibility, Empathy) 5 min

Advise 2.0 (Advice, Menu of Options) 1-2 min

Assist (Support Self-Efficacy) 2-3 min

Arrange

Real-time decision and intervention

Hierarchy of broad to focused screening / assessment

Brief screener (AUDIT-C / DAST-1)

Full screener (AUDIT / DAST)

Functional Analysis

Trained to Provide Brief Intervention Based on

Readiness

Quit, Cut-Back, Watch for a while, Do Nothing for Now

Support quit attempts or make referrals

Provided support tools

SBIRT for Alcohol Use

Three decades of research supporting the efficacy of

brief intervention for alcohol

Strong evidence for brief intervention in primary care

and office based settings

Mixed or weak evidence for brief intervention in

hospitals and EDs

Possible that effect largely comes from reductions of

“at risk” drinkers who reduce

SBIRT for Illicit Drug Use More mixed evidence for the efficacy of SBIRT for

illicit drug use

Designs with straight controls have limited efficacy:

Screen only vs. Screen + BI

Screen + printed info vs. Screen + BI

Some indication that participation in more intensive

interventions yields results

Research Strategy

Decided to test a more intensive on-site approach

against classic SBIRT

Needed a flexible approach:

Met patients’ felt needs

Would respond to a variety of substance and

health issues

To facilitate implementation:

Toolkit to assist in patient communication

Guide clinicians to deliver with fidelity

What is SBIRT+? 2-6 sessions, based on client need

Based off of Motivational Enhancement Therapy

Multiple motivational interviewing sessions

Brief quit / reduction strategies

Relapse Prevention / Cognitive Behavioral Therapy

12-Step Facilitation

Focus on assisting severe users with accessing

specialty care treatment (multiple referrals, follow-up,

case management)

Ongoing follow-up by telephone

What are we studying?

Screening, Brief Intervention, Referral to Treatment

(SBIRT) in primary care

Is one brief-intervention session enough?

Will drug-users return for additional sessions?

Is expanded brief intervention (SBIRT+) more cost-

effective than traditional SBIRT?

Study Design

Test SBIRT vs. SBIRT+

Identify 1000+ Harmful Users

Consent and Randomly Assign 600

300 to SBIRT 300 to SBIRT+

3, 6, 9, and 12 mo. Follow-up Assessments

Screen 5000 Patients at 3 Clinics for Drug or Alcohol Use

SBIRT Training

Supervisors and staff trained by IRETA in December of

2011

Trained BHCs in SBIRT protocol in four 4-hour

trainings

Trainings included:

Readings

Didactics

Video Examples

Role Play

SBIRT Training Accomplishments

BHCs were identifying dependent users—and referring

Pushed BHCs to rethink – and rededicate to – a brief

consultation model

New tools and education for identifying risky users

Knowledge gaps on standardized drinks / healthy

drinking limits

How to intervene when risky use was detected

How to use standardized assessments for decision

support

SBIRT+ Training

Conducted two 4-hour trainings in SBIRT+

Used Standardized Patient in place of live practice

cases:

All BHCs saw an actor for 4 SBIRT+ sessions

Audiotaped plus feedback

Ongoing supervision with tape review of BHCs with

SBIRT and SBIRT+ cases

Participating Heath Centers

Three Urban Federally Qualified Health Centers

PHMC Care Clinic

FPCN Abbottsford-Falls Clinic

11th Street Family Health Services of Drexel Univ

Clinics provide comprehensive primary care, family

planning, social services, out-patient counseling (Abb-

Falls and 11th Street) and complimentary care (11th St)

Care is delivered primarily by nurse-practitioners

Annual unduplicated patients: 2,000 (CC); 4,000 (AB);

6,500 (11th St) in 2009

Involving the Entire Team

Clinical staff (nurse practitioners, physician assistants,

nurses, social workers) were trained on the delivery of

the SBIRT intervention

Primary care teams (clinical personnel, medical

assistants, front desk) received all-staff trainings about

SBIRT and presentations about the study

Clinics created their own huddle teams of essential staff

for weekly or monthly SBIRT huddles

Additional support and training was made available as

the study progressed

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Starting the Conversation

Concerns about asking drug and alcohol use questions

without a warm up

Concerns about length of time of screening

Who starts the conversation? BHC? MA? PCP?

Clinics individualized their process to suit their particular

clinic flow and staff engagement

Various initial screeners created

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Wellness Screeners Please take a moment to answer a few questions so that we may best serve you.

1. Generally, how is your physical health?

2. Do you have High Blood Pressure, Diabetes, Asthma, HIV/AIDS, Hepatitis C, or any other chronic conditions?

3. How often do you keep up with the changes your providers recommend, like adjusting your diet, exercise habits, medication routine, etc.?

4. Do you take prescription medication?

4a. How often do you take your medication as prescribed?

5. How often do you get 30 minutes of exercise during which your heart beats faster or your breath speeds up?

6. Which of the following best describes your food situation?

7. Do you smoke cigarettes, cigars, or use any type of tobacco?

8. How often do you have a drink containing alcohol?

9. How many drinks containing alcohol do you have on a typical day when you are drinking?

21

10. How often in the past year have you used an illegal (street) drug?

11. How often in the past year have you used a prescription medication in order to get high, or in greater amounts than recommended by your provider?

12. How stressed have you felt in the past week?

13. How many times in the past 3 months has any partner, ex-partner, relative, or friend: Pushed, grabbed, or shoved you? _________ Slapped or hit you? ________

14. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you had nightmares about it or thought about it when you did not want to?

15. How interested are you in working with your provider to make some changes to improve your health?

16. How do you feel about the progress you have made for your health recently?

17. Is there anything else we can help you with today at the clinic?

Thanks so much for answering these health questions.

Your provider may want to talk with you about some of your answers.

Please feel free to raise any areas of concern with your primary care team.

22

23

Health Questionnaire – Clinician Guide Version

J. How often do you have a drink containing alcohol?

1) 3 days or more per week* 2) 1-2 x per week 3) Less than Weekly 4) Monthly or less 5) Never 6) Prefer not to answer*

*Refer to BHC for further screening if response is 1 or 6

K. How many drinks containing alcohol do you have on a typical day when you are drinking?

1) 5 or more* 2) Usually 3 or 4* 3) Usually 2 4) Usually 1 5) Prefer not to answer* *Refer to BHC for further screening if response is 1, 2, or 6

L. How often in the past year have you used an illegal (street) drug?

1) 3 x per week or more* 2) 1-2 x per week* 3) Less than weekly* 4) Less than monthly* 5) Once or twice* 6) Never 7) Prefer not to answer*

*Refer to BHC for further screening if response is 1, 2, 3, 4, 5, or 7

M. How often in the past year have you used a prescription medication in order to get high, or in greater amounts than recommended by your provider?

1) 3 x per week or more* 2) 1-2 x per week* 3) Less than weekly* 4) Less than monthly* 5) Once or twice* 6) Never 7) Prefer not to answer*

*Refer to BHC for further screening if response is 1, 2, 3, 4, 5, or 7

What Is One Drink?

BEER or COOLER

12 oz. ~5% alcohol

12 oz. = 1 40 oz. = 3.3

MALT LIQUOR

8-9 oz. ~7% alcohol

12 oz. = 1.5 40 oz. = 4.5

TABLE WINE

5 oz. ~12% alcohol

1 bottle (750ml) of Moscato = 5.5 1 Magnum (1.5L) = 7

SPIRITS AND LIQUOR

1.5 oz. ~40% alcohol

1 shot or mixed drink = 1 a pint (16 oz.) = 11

AUDIT (Alcohol Use Disorders Id Test)

How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have six or more drinks on one occasion?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of drinking?

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guild or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Have you or someone else been injured because of your drinking?

Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

24

DAST (Drug Abuse Screening Test)

Have you used drugs other than those required for medical reasons?

Do you abuse more than one drug at a time?

Are you always able to stop using drugs when you want to?

Have you had “blackouts” or “flashbacks” as a result of drug use?

Do you ever feel bad or guilty about your drug use?

Does your spouse (or parents) ever complain about your involvement with drugs?

Have you neglected your family because of your use of drugs?

Have you engaged in illegal activities in order to obtain drugs?

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Have you had medical problems as a result of your drug use (memory loss, hepatitis, convulsions, bleeding, etc)?

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Motivational Enhancement Therapy

3-4 sessions

2 sessions in first two weeks

Develop a solid, well negotiated, realistic change

plan

Follow-ups at week 6 and 12

To examine progress, renew motivation, redo

commitment

Evaluate if a further referral is needed

40 minute sessions

Greater emphasis on the client’s reaction to feedback

Possible involvement of 1-2 sessions with a significant

other

Phase 1 - MET Exploring and Resolving Ambivalence

Set the stage – “personal health coaching”

Provide feedback based on screening

Link habits and problems

Explore past times when client has made or tried

habit change, affirm their efforts

Help the client weigh the pros and cons of making a

change

What does the client think they’ll do about the

situation?

This process can begin and resolve in session one, but

is cyclical – throughout the coaching, across weeks,

client will return to ambivalence

Phase 2 - MET Strengthening Commitment to Change

How important is this change? Scale of 1-10

How confident are you that you could make this

change?

What are your next steps?

What has worked before?

Selecting and negotiating a change plan

Securing social support

Securing commitment to stay with the coaching –

setting the next appointment

Ongoing Coaching / Support Phase 1:

MET- Explore

and Resolve

Ambivalence

Phase 2: MET-

Negotiate

Change Plan

Referral to Treatment

CBT

• Functional analysis

• Scheduling

• Stimulus control

• Drug refusal

• Coping w/ cravings

• Managing feelings, stress, and

sleeplessness

• Coping w/ withdrawal

12 Step Facilitation

• Meeting expectations

• Sampling menu

• Check yourself/check your

meeting

• Spirituality/Higher Power

+

SBIRT+ Follow-up

Check in on a monthly basis with SBIRT+ clients

In person

Telephone

10-15 minutes

Administer RecoveryTrack™ (computerized tool to

assess clients risk for relapse)

Give Feedback / Express Concern

Offer Referral / Encourage Continued Efforts

Why a Toolkit?

Improved fidelity and retention when counselors are

trained and equipped with a Toolkit

Provides a cost-effective dissemination approach

Improved counselor and patient satisfaction

Tailor interventions to primary care

Broaden use of interventions beyond substances

(health habit change)

Multimedia materials provide a chance to influence

what patients receive beyond the scope of this study

Make lasting impact in equipping BHCs to integrate

brief treatment in primary care

The SBIRT+ Toolkit 35 Brief Tools (in a box!)

8 SBIRT / SBIRT+ Cards for Phase I (Resolve

Ambivalence; for use with either condition)

8 SBIRT+ Cards for Phase II (Negotiate Change,

Strengthen Commitment)

9 SBIRT+ Cards for conducting Behavioral Change

4 SBIRT+ Cards for promoting 12 Step

6 SBIRT+ Cards for referring / promoting formal

treatment

Quick Guides to Help Clinicians Understand How to

Use Any of them

Keep it Moving™ Graphic Novel / Activity Book

Toolkit Examples

Toolkit Examples

Toolkit Examples

Toolkit Examples

Keep it Moving™ Features

Few health education communication materials are

designed specifically for this population

Theory-based

Exercises integrated into storyline

Serves as a workbook

Engaging

Culturally sensitive

Format

Low-cost

Revisable

Scalable

Text or Digital

Keep it Moving™ Example

Keep it Moving™ Example

Keep it Moving™ Example

Core RecoveryTrack™ Items

Substance Use

Medical/Emotional Issues

Risk Factors (e.g., Days of Craving)

Protective Factors (e.g., Days Attending Treatment or

Support Groups)

15 Questions = 5 minutes

Case Studies

Case presentation #1

African American male, 55 year old, veteran

Uses cocaine (1-2 occasions/week)

Initially denied use to Primary Care Provider

Reported use on paper wellness screener

Treatment limited to programs during incarcerations

Challenges

Strengths

Motivational Enhancement Therapy

Better relationships with

family

Not having to worry about

drug tests with parole

officer

More money

Forgetting about problems

Feeling high

Let’s me be by myself

Depression and Guilt

Legal problems

Upsets my family members

Drug screening for new jobs

Money

Avoiding my pastor and others

who try to help me

Not sure

- Quit using cocaine

- To know myself better

- I deserve to feel happier.

- I want to work and have my own place.

- Keep appointment next week -Spend time with family

- Go back to church >1x per week

- Consider IOP treatment & attending 12 step meeting

- Not judging me

- Listening to me and giving me honest feedback

- People/places/things

- Isolating

Shame

Guilt

Disappointing

my family

Worried about

legal issues

Used cocaine

By myself

Friday afternoon

My son’s home

Disconnected, not thinking

about my situation

-Feeling down

about situation

-Not wanting to

be around

people

-Thinking about

using

- Son asked me

to have dinner

with the family

- Friday night

Not thinking

about my

situation for a

few moments;

feeling high

- Son/Family

- Pastor

- Veterans

Resources

- Narcotics Anon

-Emotional/spending

time together

- Spiritual

- Understanding /

Link to resources

- Recovery support

- Say yes when they

ask me to spend time

with them

- Return phone call

- Go to multiservice

center

- Attend a meeting

Church

Computer

class

Veteran

Support

Group

Job

search

Job

search

Call

pastor Dinner

with

family

NA

Meeting

Read at

library

Walk

near

Penns

Landing

Spend

time with

grandson

Plan meals ahead of time.

Get something to eat.

Go for a walk. Call my pastor. Write

in my journal. Think of the big picture.

Write a letter. Spend time with my

son and grandson. Just “Be”

Prioritizing sleep. Taking a nap.

Resting.

Reach out to recovery supports. Go

to the library and get a new book.

Take pictures around the city.

Spend time with family. Think of big

picture. Call recovery supports.

Case Studies

Case Presentation #2

Caucasian male in his late 40s

Uses cocaine, ETOH, marijuana on an

almost daily basis

History of intravenous drug abuse

Last in substance abuse treatment 5 years ago

Challenges

Strengths

Factors Associated with

Successful Outcomes

Integrated Health Clinics

Primary Care Providers addressing substance abuse

as part of a person’s medical visit

Knowledge of available resources

Developing community partnerships with substance

abuse treatment facilities

Preliminary Results Screening and Enrollment Rates

Participant Characteristics

Demographic Characteristics of Sample

Substance Use Characteristics of Sample

Patient Engagement with Intervention

Satisfaction

Compliance with Intervention

Referral Rates

Screening and Enrollment Rates

Site 1 Site 2 Site 3 Total

Received Initial

Screener 5,112 1,769 3,575 10,456

Flagged for

Drug/Alcohol Use 1,382 772 1,083 3,237

Screened for Study

Eligibility 830 475 638 1,943

Ineligible 547 184 240 971

Eligible 280 289 397 966

Enrolled 113 223 227 563

SBIRT 57 111 115 283

SBIRT+ 56 112 112 280

Participant Characteristics Mean Age (SD) 39.69 (12.80)

Female 45%%

Black 81%

White 7%

Other 12%

Hispanic 8%

Less than HS 25%

HS/GED 61%

More than HS 14%

Employed (FT or PT) 30%

Married 10%

Widowed/Divorced/Separated 23%

Never Married 67%

Homeless 14%

• There were no

significant

differences

between

conditions on

any of these

characteristics

Substance Use Characteristics SBIRT SBIRT+

Primary Substance

Alcohol 33.0% 35.5%

Marijuana 37.9% 37.1%

Other Illicit Substances 29.1% 27.4%

Days of Any Alcohol Use (SD) 9.51 (9.77) 10.44 (10.07)

Days of Heavy Alcohol Use (SD) 5.39 (8.29) 5.33 (8.44)

Days Marijuana Use (SD) 11.29 (12.61) 11.45 (12.75)

Days Any Illicit Drug Use (SD) 14.44 (12.3) 13.81 (12.29)

Days Used Primary Substance (SD) 16.71 (11.12) 15.94 (11.48)

Previously In Treatment 49.2% 50.4%

• There were no significant differences between

conditions on any of these characteristics.

Substance Use at Baseline

Alcohol only 14.04%

Marijuana only

5.38%

Alcohol & Marijuana

only 30.38%

Other Substances

50.19%

Primary Alcohol Users

Primary Marijuana Users

Primary Other Substance Users

0%

20%

40%

60%

80%F

req

uen

cy

Primary Substance

Patient Satisfaction

How helpful was it to be asked about your drug and

alcohol use at the health center:

M=8.59 (SD=2.23) out of 10

How comfortable were you discussing your drug and

alcohol use:

M=9.29 (SD=1.55) out of 10

Intervention Engagement

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6

Sessions Completed

SBIRT

SBIRT+

Percent Attending Intervention Sessions

Treatment Referrals

57.8% of patients reported receiving a referral for

specialty services.

Of those, 59.5% reported that they did not receive

any services

20.4% of patients reported entering treatment

Conclusions

FQHC patients with substance use disorders will return

for brief treatment visits focused on harm reduction /

abstinence

Patients reported significant comfort and acceptability

of screening and brief treatment in primary care

Despite efforts to increase specialty care treatment

entry, actual engagement rates remained low

Our future reporting will analyze differences in

outcomes between SBIRT / SBIRT+ patients on

substance use and medical health variables

For More Information

67

Elizabeth Byrne 215-439-4549 ebyrne@nncc.us

Adam Brooks 215-399-0980 abrooks@tresearch.org

Kimberly Malayter 215-219-9661 kmalayter@phmc.org