1. week 1 presentation

The Implementation of Screening, Brief
Intervention, and Referral to Treatment into
Practice (SBIRT-IP)
Week #1

Screening, Brief Intervention and
Referral to Treatment (SBIRT) in
Specialty Populations
Maridee Shogren DNP, CNM
Christina Boyd, LSCSW, LCAC

Upon completion of this session,
participants will be able to:
Identify applicable alcohol screening tools for use with adolescents
and pregnant women.
Demonstrate a brief intervention utilizing the FLO algorithm.

Background
Substance abuse is a growing problem in the U.S.
Clients in health care or social service settings most often do not self-
identify as substance abusers or at-risk drinkers.
Due to a variety of factors, many providers do not routinely screen for
risky alcohol use or substance abuse, ESPECIALLY IN SPECIALTY
POPULATIONS.
Patients are comfortable with being asked questions abut their use.

Why Don’t We Ask the
Questions?
• Difficult topic/stigma
• Lack of time
• Inexperience or lack of confidence with
screening
• No resources available
• Worry about hurting relationships
• Not convinced that anything will help

Primary Care Screening
• Screening Tool Brief Review

DAST-10
• The DAST is a brief, self-report instrument screening and
identifying drug problems
• The DAST is brief and inexpensive to administer
• Versions are being developed in different languages (e.g.,
French and Spanish)

The DAST-10
Taken by self-report or via interview
In the past 12 months…
Circle
1.  Have you used drugs other than those required for medical reasons?        Yes  No
2.  Do you abuse more than one drug at a time?      Yes  No
3.  Are you unable to stop abusing drugs when you want to?      Yes  No
4.  Have you ever had blackouts or flashbacks as a result of drug use?      Yes  No
5.  Do you ever feel bad or guilty about your drug use?      Yes  No
6.  Does your spouse (or parents) ever complain about your involvement with drugs?                        Yes  No
7.  Have you neglected your family because of your use of drugs?      Yes  No
8.  Have you engaged in illegal activities in order to obtain drugs?      Yes  No
9.  Have you ever experienced withdrawal symptoms (felt sick) when you stopped  taking drugs?
Yes  No
10.  Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? Yes  No
Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which
                   a “No” receives 1 point.  Score:

DAST-10 Scoring
Score Degree of Problems r/t Drug
Abuse
Suggested Action
0 No Problem Reported None at this time
1-2 Low Level Monitor, Reassess at a Later Date
3-5 Moderate Level Further Investigation
6-8 Substantial Level Intensive Assessment

Specialty Populations
• Adolescents
• Pregnant Women

Adolescents
• Seven reasons to Identify and Treat adolescent substance use

1. Adolescent Substance Use is
Common
• Adolescents are at the highest risk for experiencing health
problems related to substance use (Committee on Substance Abuse,
2015)
• Alcohol, marijuana, tobacco are the most commonly used by
youth
• Alcohol use tends to be episodic and heavy
• >90% consumed is in the context of binge

2. Short Term and Long Term Risks
• Adolescents tend to be more physically active when under the
influence of alcohol; greater risk of harm
• Unintentional injuries
• Decreased cognitive abilities
• Inaccurate perception of risk
• Impaired bodily control
• Association with other risky behaviors
• Unplanned sex
• Transition to other drugs

2. Short Term and Long Term
Risks
• Marijuana associate with:
• Symptoms of chronic bronchitis
• Addiction to marijuana and other substances
• Diminished lifetime achievement
• Motor vehicle accidents, in a number of studies

3. Vulnerability for brain
development and maturation
• Adolescence actually extends from age 9yr into third decade!!
• Adolescent brain particularly vulnerable to toxic effects
• Alcohol damages hippocampus (part of brain important for
memory and learning)
• Poorer school performance
• Stopping use doesn’t fully restore neuropsychological
functioning

4. Use increases over time
• IMPORTANT to start screening and brief intervention early
• Attempt to prevent or delay alcohol use as long as possible

5. Use in adolescence
associated with harm in
adulthood
• The earlier an adolescent begins using substances, greater
chance of continuing to use and of developing substance use
problems later in life
• People who begin to drink before age 15y are 5x as likely to
develop alcohol dependence or abuse
• Adolescents who try marijuana at 14 years or younger are 6 x as
likely to meet criteria for illicit drug dependence or abuse later in
life

6. Underestimation of prevalence
of adolescent substance use
• Even “GOOD” kids use
• Use of personal or clinical judgment alone underestimates
number of adolescents using
• Universal screening is necessary
• While 88% of pediatricians screen, only 23% use a validated tool
(AAP, 2014)

7. Pediatric providers can help
• Most adolescents visit a physician every year
• Universal screening = opportunity for education, to encourage
healthy and smart choices
• Confidential discussions may help adolescents avoid and/or
reduce use leading to a marked impact on future behaviors

Screening Recommendations
• American Academy of Pediatrics recommends screening at
EVERY annual physical exam
• Other opportunities:
• ER visits
• New patients or those not seen in a while
• Youth who smoke
• Have conditions associated with increased risk for substance abuse
• Depression, anxiety, ADD/ADHD, conduct problems
• Those with alcohol related problems
• STIs, accidents, injuries, pregnancy, chronic pain, GI problems
• Substantial behavioral changes

Screening Tools Validated for
Use with Adolescents
• S2BI
• Frequency screen for tobacco, alcohol, marijuana, illicit drug use
• NIAAA Youth Alcohol Screen
• 2 questions; screens for friends use and own use
• CRAFFT 2.0/2.1
• Quickly identifies problems associated with substance use
• BSTAD
• Screens for tobacco, alcohol, other drugs
• GAINNS
• Assesses both SUDs and mental health disorders
• AUDIT
• Assesses risky drinking

CRAFFT 2.1 (updated 2017)
• Screening tool for use with children under the age of 21
• Three pre-screen questions followed by a series of 6
questions
• Developed to screen adolescents for high risk alcohol and
other drug use disorders simultaneously
• Available in several different languages and templates for
clinician interview or self-administered version
• Reproduce the CRAFFT:
• https://ceasar.childrenshospital.org/crafft/reproduce-the-crafft/

https://ceasar.childrenshospital.org/wp-content/uploads/2018/04/CRAFFT-2.1_Clinician-Interview_2018-04-23.pdf

Pregnant Women
• Substance use during and after pregnancy can create
significant harm for mothers and infants
• Most prevalently used substances:
• Tobacco
• Alcohol
• There is no known safe amount of alcohol use during pregnancy
HOWEVER as many as 10.2% of pregnant women have reported
using alcohol, and 3.1% would be considered heavy drinkers.
• Cannabis
• Other illicit drugs

Maternal / fetal transfer of
licit/illicit drugs
Google images, 2017
BBB

Effects of Alcohol on Fetus
• Effects are not reversible
• No area of the brain is resistant to alcohol exposure
• Thinning or absence of the corpus callosum leading to deficits in
attention, intellectual function, reading, learning, verbal memory,
and executive and psychosocial functioning.
• Preterm delivery
• Craniofacial abnormalities
• Impaired motor development
• Growth deficiencies (Behnke, 2013; Brimacombe, 2009; Brown, 2016)
• FAS/FASD

Screening Pregnant Women
• Most women presenting for primary care visits and/or
prenatal care will not ask questions about alcohol use or self-
identify at-risk drinking behavior.
• Screening for substance abuse should be universal during
prenatal care
• Screening based only on late entry into prenatal care or prior
history of poor birth outcomes could potentially lead to missed
cases and worsen stigma.

Screening Recommendations
• American College of Obstetricians and Gynecologists
recommends that all women should be screened for alcohol
use within the first trimester of pregnancy
• The CDC expert panel (2012) recommends that alcohol
screening should be repeated subsequently throughout
pregnancy; at least every trimester for women who screen
positive for any alcohol use

Fears
• Pregnant women seeking prenatal care are often reticent to
disclose information about their drinking behavior due to the
stigma and/or fear of punitive consequences
• i.e. charges of child abuse or civil commitment
• Non-judgmental screening skills are imperative!

Screening Tools for Use in
Prenatal Care
• AUDIT-C
• T-ACE
• TWEAK
• One-Question Prenatal Alcohol Use Assessment

T-ACE
• 4-item measure that takes less than one minute to administer.
• The first validated sensitive screen for at-risk drinking
developed for maternity care and gynecologic practices
• Assesses alcohol tolerance and emotions regarding an
individual’s alcohol use
• Recommended by ACOG and NIAAA

T-ACE Interpretation
• One point is given for each affirmative answer to the A,
C, and E questions.
• Two points are given when a pregnant woman reports a
tolerance of three or more drinks to feel high.
• A positive screen is a score of 2 or more points.
• Note: A positive screen does not indicate diagnosis of an alcohol
use disorder, but does suggest the need for further intervention.

TWEAK
• 5-item tool that screens for drinking during pregnancy
• Sensitive regarding tolerance to alcohol effects.
• Highly sensitive for heavy alcohol drinking in white women
but less sensitive for populations who are diverse.
• Still appropriate for universal use

TWEAK Interpretation
• Scored on a 7-point scale.
• On tolerance question:
• 2 points are given if she reports she can consume more than five
drinks without falling asleep or passing out.
• A positive response to the worry question
• 2 points
• Positive responses to the last three questions yield 1 point
each.
• A woman who has a total score of 2 or more points is likely to
be an at-risk drinker.

One-Question Prenatal
Alcohol Use Assessment
“When was your last drink?”
• Quickly determines if the woman is at a no-risk status if
alcohol was not consumed in the pregnancy.
• Helps focus individual education on exposure risk and
implementing the best referral and treatment plan as soon as
possible
Burd, 2010

Postpartum
• Do not neglect screening for at-risk alcohol use in the
postpartum period
• Many women who abstained from alcohol in pregnancy will
rapidly resume alcohol use in the postpartum period and
should be assessed at their follow up visits.

Brief Intervention
• Short dialogue focused on prevention, reducing/stopping
substance use
• The goal is to identify and effectively intervene with those
at moderate or high-risk for psychosocial or health care
problems related to their substance use by
• Moderating alcohol consumption
• Eliminating harmful drinking practices in clients who
have less severe
alcohol use
• Decreasing or eliminating drug use
• Providing client education

More About That ………
• Just how brief is it?
• Only 5-10 minutes may be needed
• A “single session or multiple sessions of motivational
discussion focused on increasing insight and
awareness regarding substance use and motivation
toward behavioral change” (AHRQ, 2011, p.3)
BRIEF
INTERVENTION

Brief Negotiated Interview:
Patient’s Voice and Choice
• A collaborative conversation about health promotion
• Patients as experts in their lives
• Listening not telling
• Silence…It’s OK
• OARS
• Open-ended questions
• Affirmations
• Reflection
• Summaries

Would you mind taking a few minutes to
talk about your [X] use? Before we go
further, I’d like to learn a little more
about you.
What is a typical day like for you?
Where does your [X] use fit in?
https://www.youtube.com/watch?v=v3_uxCpZ7wg
1. Build rapport
BNI Steps with an Adolescent
Help me understand through your eyes
the good things about using [X]?
https://www.youtube.com/watch?v=dLGYfADKYJo
What are some of the not so good things
about using [X]?
2. Ask about Pros &
Cons
So on the one hand you said <PROS>,
and on the other hand <CONS>.
Summarize

Ask permission
Give information
Elicit reaction
BNI ALGORITHM
I have some information on low-risk
guidelines for drinking, would you mind
if I shared them with you?
We know that drinking
• 4 or more (F)/ 5 or more (M) in 2hrs
• more than 7(F)/14(M) in a week
• use of illicit drugs
can put you at risk for illness and injury.
It can also cause health problems like
[insert medical information].
What are your thoughts on that?
https://www.youtube.com/watch?v=h5bpAvmjrcs
3. Feedback

4. Readiness to Change
BNI ALGORITHM
This Readiness Ruler is like the Pain Scale
we use in the hospital. On a scale from 1-
10, with one being not ready at all and
10 being completely ready, how ready
are you to change your [X] use?
You marked ___. That’s great. That
means you’re ___% ready to make a
change.
https://www.youtube.com/watch?v=oVVociJ0P8o
Why did you choose that number and
not a lower one like a 1 or 2? (Always go
down)
Readiness ruler
Reinforce positives
1 2 3 4 5 6 7 8 9 10

Another way to start the conversation…
(It’s OK to CUS)
• I am Concerned about………….
• I am Uncomfortable with……….
• I believe (whose) Safety is at risk ……..

Or maybe you’d rather just Go
With The Flo!
• The FLO (Feedback, Listen, Options) mnemonic was developed
to encompass the three major elements of a brief
motivational intervention.

Single Question Pre-Screen:
Do you sometimes drink beer, wine or other alcoholic beverages?
No
Education: Standard drink size, consequences of alcohol use
Yes
How many times in the past year have you had 4 or more drinks in a day?
None1 or more
Suspected alcohol use disorderAt-risk alcohol use
Feedback: screening
results, consequences
of current use
Listen: patient
questions and
decision making
Options: goal
setting, reduce
drinking amounts/
days
F.L.O.
Referral to
Treatment
F
L
O
Screening Tool

Education: Consequences of drug use
How many times in the past year have you used an illegal drug or used a
prescription medication for non-medical reasons?
None1 or more
Suspected drugs use disorderAt-risk alcohol use
Feedback: screening
results, consequences
of current use
Listen: patient
questions and
decision making
Options: goal
setting, reduce
drinking amounts/
days
F.L.O.
Referral to
Treatment
F
L
O
Screening Tool: DAST

Give Feedback
Ask Permission:
“Is it ok if we talk about your answers?”
Give Information:
“We know that drinking 4 or more drinks in a sitting/use of
illicit drugs can put you at risk for illness and injury. It can
also cause health problems like [insert].”
Elicit Reaction:
“What are your thoughts on that?”

Listen
Answer questions
Assist with decision making

Options
Conclude the Interaction
“What are some options/steps that will work for you?”
“What do you think you can do to stay healthy and safe?”
“Tell me about a time when you overcame challenges in the
past. What kinds of resources did you call upon then?
Which of those are available to you now?”

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