WIXLIB

Clark’s (real) AUDIT answers:Questions0123Monthly 2-4 times 2-3 timesor lessa month a week1. How often do you have a drink containing alcohol?Never2. How many drinks do you have on a typical day when drinking?1 or 23 or 45 or 67 to 93. How often do you have six or more drinks on one occasion?NeverLess thanmonthlyMonthlyWeeklyNeverLess thanmonthlyMonthlyWeeklyNeverLess thanmonthlyMonthlyWeeklyNeverLess thanmonthlyMonthlyWeeklyNeverLess thanmonthlyMonthlyWeeklyNeverLess thanmonthlyMonthlyWeekly4. How often during the last year have you found that you were notable to stop drinking once you had started?5. How often during the last year have you failed to do what wasnormally expected of you because of drinking?6. How often during the last year have you needed a first drink in themorning to get yourself going after a heavy drinking session?7. How often during the last year have you had a feeling of guilt orremorse after drinking?8. How often during the last year have you been unable to rememberwhat happened the night before because of your drinking?9. Have you or someone else been injured because of your drinking?No10. Has a relative, friend, doctor, or other health care worker beenconcerned about your drinking or suggested you cut down?NoYes, butnot in thelast yearYes, butnot in thelast year44 or moretimes aweek10 ormoreDaily oralmostdailyDaily oralmostdailyDaily oralmostdailyDaily oralmostdailyDaily oralmostdailyDaily oralmostdailyYes, duringthe lastyearYes, duringthe lastyear

Clark’s AUDIT score: 15

Full screen: DAST Drug Abuse Screening Test DAST-10 version Validated for adults Cut-off score of 3 has highvalidity for drug “abuse”Skinner, 1982.Yudko 2007.

Scoring the DAST Each question has yes or no answer Yes answers get one point

DAST zones and scoresSevereHarmfulRiskyIVIIIIII6 3-51-2

Circling the zone of use

Questions added to the DAST Types of drugs used Frequency of use Injection drug use Status of drug treatmentwww.sbirtoregon.org

DAST and CannabisBrief intervention may not be necessarywhen: No daily use of any substance No weekly use of opioids, cocaine, ormeth No injection drug use in the past 3months. Not currently in treatment.

Case study: Stacey 30yo female, single, works atrestaurant, lives with housemate Takes Aderall for ADHD past twoyears Presents every few months for inperson follow up, usually no medicalcomplaints. Uses a “bump” of cocaine mostweekends

Exercise:Take a minute to fill out a DAST, circlingwhat you think might be Stacey’sresponses.

xxxxStacey’spossibleDASTanswers

CRAFFT screening tool Validated for ages 12 – 21 Widely implemented Self administered or delivered viainterview Number of “Yes” answerscorrelate with SUD

CRAFFT questions #1 - 4 John R. Knight, MD, Boston Children’s Hospital

CRAFFT questions #5 - 10 John R. Knight, MD, Boston Children’s Hospital

Interpreting the CRAFFTAnswersRiskAction“No” to questions 1-4No riskPositive reinforcement“Yes” to Car questionRiding riskDiscuss alternatives to riding with impaireddrivers (Contract for Life)CRAFFT score 0Low riskBrief adviceCRAFFT score 1Medium riskBrief interventionCRAFFT score 2High riskBrief intervention(offer options that include treatment)

CAR question Car accidents leading cause of accidentaldeath among teens Study: 17% of students report having riddenin a vehicle in the last 30 days driven bysomeone who had been drinking alcohol Discuss safer alternatives Option: Ask teen to take home the“Contract For Life” to discuss with parent(s)or adult. Offer to facilitate conversation.CDC, 2018

5Ps tool Designed for patients who arepregnant Asks about use by Parents, Peers,Partner, pt’s Past, and during pt’sPregnancy Also screens for tobacco, emotionalhealth, and intimate partner violence. Administered through interview

Other screening tools CAGE: poor sensitivity for riskydrinking ASSIST: covers alcohol as well as druguse, but too complex for manysettings MAST: poor sensitivity for riskydrinking; long; outdated terminology

Screening via patient portalPros: Can be completed before visit Questions answered withoutconversation with clinicianCons: Results may get lost in EHR Can’t ensure pt privacy Proxy accounts for younger teens breakconfidentiality

Screening via online interviewPros: Can clarify questions in real timeResults entered in EHR immediatelyAn opportunity to build rapport, setthe stage for BICons: Takes up time during visit Pt has to answer questions directly toclinician

Tips on screening via online interview Try to confirm that pt is in privatespace and can't be overheard Can be done during any portion ofthe visit Explain reason behind screening Raise the subject and ask permission Read validated questions as written

III. Reimbursement and EHR tools

Screening-only billing CPT96160G0442DescriptionAdministration and interpretationof a health risk assessmentinstrument.Screening for alcohol misuse inadults once per year. Codes above should be appended to E/M service with modifier 25 ICD-10 diagnosis codes are poorly suited for most SBIRT patient scenarios and can break confidentiality. Twooptions: Z13.89: “Encounter for screening for other disorder” Z13.9: “Encounter for screening, unspecified”

Screening BI codesServicePayerCodeDescriptionMedicareG2011 5-14 minutes of aggregate clinic time spentadministrating and interpreting a validatedalcohol or drug screening tool, plus performing aface-to-face brief intervention the same day. MedicaidCPT 99408briefinterventionMedicareG0396MedicaidCPT 99409Full screen Same as above, 15 – 29 minutes. Same as above, 30 minutes.MedicareG0397 Codes above should be appended to E/M service with modifier 25 ICD-10 diagnosis codes are poorly suited for most SBIRT patient scenarios and can break confidentiality. Twooptions: Z13.89: “Encounter for screening for other disorder” Z13.9: “Encounter for screening, unspecified”

Documentation supporting screening-onlywith adult pts (CPT 96160)www.sbirtoregon.org

Documentation supportingscreening-only with adolescent pts (CPT 96160)www.sbirtoregon.org

Documentation supporting SBI with adultswww.sbirtoregon.org

Documentation supporting SBI with adolescentswww.sbirtoregon.org

Who’s allowed to independentlybill for SBIOregon MedicaidMedicarePhysicians (MD, DO, ND)Physicians (MD, DO)Physician AssistantsPhysician AssistantsNurse PracticionersNurse PracticionersLicensed Clinical PsychologistsLicensed Clinical PsychologistsLicesned Clinical Social WorkersLicesned Clinical Social WorkersLicensed Professional CounselorsCertified Nurse MidwivesLicensed Marriage and Family TherapistsClinical Nurse Specialists

Incident-to billingAny clinic employee under supervisioncan bill for SBI. Examples:–CADCs, Health Educators, RegisteredNurses, Clinical Nurse Specialist,Students or Graduates enteringmedical profession, Community HealthWorkers–Some limitations apply to certain clinicsettingsOHA, 2014

Oregon CCO metric: SBIRTRATE 1:Patients with either a negativebrief screen or a full screen.Pts 12 years visit in last yearRATE 2:Pts who received a brief intervention, orreferral to treatment within 48 hoursPts with a positive full screen.OHA

Oregon CCO metric: IETInitiation and Engagement of Alcohol and Other Drug Abuse orDependence TreatmentInitiation rate:Engagement rate:Pts who received AODTreatment within 14 daysPts who received 1 or 2 AOD treatmentswithin 34 days of initiating treatmentPts 13 years with a new AOD dxPts 13 years with a new AOD dxA brief intervention with a BHS counts as satisfying the numerator in both ratesOHA

IV. Brief intervention

Large brief intervention study Study question: is BI associated withtreatment for AUD? Analysis of VA pt records 2009-2013 830,825 outpatients screened positive forunhealthy alcohol use, 74% haddocumented BI within 0-14 days Result: BI was associated with lowerlikelihood of receiving specialty treatmentFrost MC, Glass JE, Bradley KA, Williams EC. “Documented brief intervention associated with reduced linkage to specialty addictions treatment in a national sample of VA patients withunhealthy alcohol use with and without alcohol use disorders”. Addiction. 2019 Oct 22.

Table: Percent of VA pts who received treatment within 365 daysAdjusted*%95%CIRateratioP-value.84 0.001.83 0.001Overall sample: (N 1,172,606 positive screens)No documented BI12.6(12.5-12.7)Documented BI10.5(10.4-10.6)AUD diagnosis in the past year: (N 421,244 positive screens)No documented BI19.9(19.7-20.1)Documented BI16.5(16.4-16.6)*“Adjusted for sex, age, race/ethnicity, marital status, VA eligibility status, mental health and drug use disorderdiagnoses, tobacco use, AUDIT-C category, alcohol use disorder diagnosis, alcohol-specific condition, and fiscal yearin which positive AUDIT-C screen occurred.”Frost, et al. Addiction. 2019

Study takeaways BIs in the VA were defined asonly giving information andadvice Conclusion: poor BIs may causeharm with pts with SUDs. The quality of the BI matters!Frost, et al. Addiction. 2019

How do you discuss behaviorchange with your patients?

Video:The Ineffective Clinicianhttps://www.youtube.com/watch?v cSBsgmgYm8oUniversity of Florida, Psychiatry Dept.

Characteristics of a directive style ofcommunicationRollnick and Miller, 2008

Common patient reactions to thedirective pless, overwhelmedAshamedTrappedDefensiveJustifyingNot understoodDisengagedNot come back – avoidUncomfortableProcrastinateNot heardRollnick and Miller, 2008

Characteristics of a guidingstyle of communication Respect for patient’s autonomy,own goals, values Gauge readiness to change Comfort with ambivalence Recognize pts expertise Empathy, non-judgment, respect

Some reasons people use substancesEscape from griefEscape from stressPeer pressureTo fit inTo experimentTo relaxTo deal with boredomNot ready to quitAvoid withdrawalEnjoyment of feeling highEscape fromnegative thoughtsEnhanceperformanceCareer pressuresEscape feelings oflonelinessFeeling of controlInstant gratificationFamilydemands

Brief Interventions in medical settings Should employ motivationalinterviewing (evidence-based) Even three minutes can haveeffect Can be performed by any trainedclinic employee 2 hours of training can makedifferenceHumeniuk et al, 2010. Cunningham et al, 2014. Whitlock et al, 2004.

Textbook definition ofmotivational interviewingA person-centered counseling style foraddressing the common problem ofambivalence about change.-Miller and Rollnick, 2012.

Two central goals of MI “To create and amplify, from the client’sperspective, a discrepancy betweenpresent behavior and broader goals andvalues.” “To evoke statements indicating reasons for,desire to, or intent to change (changetalk)”Lozano, et al, 2010

How MI works Eliciting and affirming change talk helpspts move towards resolving ambivalence People become more committedtowards change when they hearthemselves give voice to change Respect, collaboration and empathycreate conditions for change to occur

Motivational interviewing towardsother health behaviorsMorton, et al, 2015.

Warm introduction principles In-person introduction tobehavioral health specialist Refer to as “colleague” or“specialist” Brief intervention deliveredduring same visit Avoid “counseling” label

Steps of the brief ivationIdentifyplan

Steps of the brief intervention Ask permission to discuss patient’sRaisesubjectsubstance use Convey transparency about yourrole

Transparency exampleThank you for giving me permission to discuss your substance usewith you. Just so you know, I will not ask or advise you to stop orchange your use in any way you do not want to. Instead, myfocus is to understand what your goals or visions for your futureare. I can share information with you so you can improve yourquality of life on your own terms and on your own timeline.How does that sound to you?HaRRT Center

Steps of the brief intervention Ask permission to discuss patient’sRaisesubjectsubstance use Convey transparency about yourrole Ask the patient to describe theiruse

Steps of the brief interventionShare info about:Shareinformation The pt’s score on the screening tool Any association between use andhealth complaint General risks of useAsk pt what they think about theinformation shared

Pitfalls of giving advice or recommendations Implies judgement, risks furthering stigma Clinician-driven rather than patient-driven Patients with SUDs may already feeltrapped Giving advice is different thanbrainstorming options

Steps of the brief intervention Elicit and summarize pros and consEnhancemotivation- What pt likes and doesn’t like about their use

Pros and cons example“So on one hand, I hear you say that your cannabis use makesyou feel relaxed after a day of work, and it reduces your anxietyin the short term. On the other hand, you wonder sometimes ifyou’re becoming addicted to cannabis, and you don’t like itwhen your partner nags you about smoking pot. Is that correct?”HaRRT Center

Steps of the brief intervention Elicit and summarize pros and consEnhancemotivation- What pt likes and doesn’t like about their use Elicit goal(s)- What change the pt would like to see

Questions that elicit patient goals “Over the next few (weeks, months)what would you like to see happen foryourself?” “What would you like to do about youruse?” “Where would you like to go with yourdrinking/drug use?”

Goals are more achievable when they are: Well defined Focused on reducing harmor improving quality of life Doable in a timeframe Patient-drivenHaRRT Center

Helping pts with abstract, or large goalsPatient: “I want to livehealthier.”?Livinghealthier?Clinician: “That’s a great goal. It’s also a big goal. So, let’s put thatup here on the top step. What could be the first step towards livinghealthier?”Slide: HaRRT Center

Some examples of pt-driven goals: alcohol Reducing or abstaining Counting drinks Eating before drinking, and during Spacing drinks Accepting meds for AUD or other treatment Avoid mixing drugs with alcohol Drinking in a safe place Choosing periodic abstinence Choosing lower-alcohol content beverages

Some examples of pt-driven goals: drugs Injecting more safely Minimizing sharing works orneedles Carrying Naloxone Using less Accept MOUD or other treatment Learning abscess care Getting more regular medicalcare and/or mental health care

Steps of the brief intervention Elicit and summarize pros and cons- What pt likes and doesn’t like about their useEnhancemotivation Elicit goal(s)- What change the pt would like to see Gauge readiness/confidence to achievegoal- Use readiness ruler

Readiness Ruler “On a scale of 0 to 10 . . .” “Why not a lower number?” Gauges level of motivation Answering the question enhanceexisting motivation

Steps of the brief intervention If patient sounds ready, ask: “WhatIdentifyplanwould a plan of reaching your goallook like for you?” Affirm pt’s readiness to change Ask to schedule follow-up

Follow upA continuing cycle of: Collaborative tracking of patientselected goals Sharing information about risks Eliciting new pt-driven harmreduction goalsHaRRT Center

Remember:Defer to thepatient’s wisdomThe more responsibility, autonomy andrespect people feel they have, the more theywill step up and forge their own pathway.HaRRT Center

Raise thesubject “Thanks for filling out this form – is it okay if we briefly talk about your substance use?” “My role is to help you assess the risks so you can make your own decisions. I want to help youimprove your quality of life on your own timeline.” “What can you tell me about your substance use?”Shareinformation Explain any association between the patient’s use and their health complaint, then ask, “Do youthink your use has anything to do with your [anxiety, insomnia,, etc,]?” Share information about the risks of using alcohol, drugs, and misusing prescription drugs. Askthe patient: “What do you think of this information?”Enhancemotivation Ask pt about perceived pros and cons of their use, then summarize what you heard. “Where do you want to go from here in terms of your use? What’s your goal or vision? Gauge patient’s readiness/confidence to reach their goal. If using Readiness Ruler: “Why do didyou pick on a scale of 0-10 instead of [lower number]?”Identifyplan If patient is ready, ask: “What steps do you think you can take to reach your goal?” Affirm the patient’s readiness/confidence to meet their goal and affirm their plan. “Can we schedule an appointment to check in and see how your plan is going?”

Adultreferencesheet(front & back)Available atsbirtoregon.org

Adolescentreferencesheet(front & back)Available atsbirtoregon.org

Pregnancyreferencesheet(Front & back)Available atsbirtoregon.org

Patient handouts Download at sbirtoregon.org English and Spanish Separate handouts based onsubstance and population Should reinforce, not replacebrief interventionswww.sbirtoregon.org

Case study: “Barbara” 60-year old female visiting anew PCP to discuss her antidepression meds Drinks 4x a week, 3-4 glassesof wine per occasion Lives alone Completed the AUDIT andscored 14

Video demonstration: “Barbara”

Case study: “Miguel” 35-year old presenting for atelehealth visit Complains of migraines Injects heroin 2-3 days perweek Completed the DAST andscored 4

Practice: “Miguel”Groups of three: Clinician Patient Observer

Video demonstration: “Miguel”

Case study: “Natasha” 16-year old presenting for aphys

Adult limits for alcohol use, U.S. Moderate drinking Binge drinking Women No more than 1 drink per day 4 drinks per occasion Men No more than 2 drinks per day 5 drinks per occasion Daily limits are "not intended as an average over several days, but rather the amount consumed on any single day." Standard drink in the U.S. defined as: