Hello, and welcome to your SBIRT training sponsored by the Opioid Response Network. My name is Dr. Melissa Barbosa, and I will be presenting to you Screening Brief Intervention and Referral to Treatment, Community Collaboration for Success. The Opioid Resource Network is a SAMHSA-funded program that assists states, organizations, and individuals by providing resources and technical assistance they need locally to address the opioid and stimulus use crisis. Technical assistance is available to support evidence-based intervention, treatment, and recovery of opioid use disorders and stimulant use disorders. The ORN provides local experienced consultants in prevention, treatment, and recovery to communities and organizations to help address this opioid crisis and stimulus use. The Opioid Response Network accepts requests for education and training, and each state and territory has a designated team led by a regional technology transfer specialist who is an expert in implementing evidence-based practices. If you have any questions or you wish to submit a technical assistance request, please feel free to visit our website at www.opioidresponsenetwork.org or email us at ORN at AAP.org or you can call us at 401-270-49, I'm sorry, let me go back, 401-270-5900. 401-270-5900. So as already stated, the Opioid Response Network is funded in part by a grant from the Substance Abuse and Mental Health Services Administration. The views written in the conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices or organizations imply endorsement by the US government. As for myself, there are no disclosures for me to express at this time and there are no conflicts of interest. As far as accreditations for your continuing education units and for your continuing medical education, we have the following organizations that have provided accreditations for nursing, physicians and dental, as well as other health professionals. This particular presentation will allow you one credit of continuing education. If you need additional details, please refer to the slide or the information in your packet. Today, we will discuss the Continuum of Substance Use, what is SBIRT, implementing SBIRT in your practice and additional resources. So when we think of screening brief intervention and referral to treatment in regards to the substance use continuum, what we first have to understand is that we serve the entire population. And when we look at the entire population, the stratum of those individuals as it pertains to substance use issues are focused within these five areas. Now, the bulk of our patient population will typically fall within the abstinence and low risk use. However, the ones that we need to be concerned about when it comes to screening brief intervention and referral to treatment are those that fall in the stratum of high risk use, problem use and dependency. When we get into the areas of the top two tiers of problem use and dependency, the understanding is that these are the areas where diagnostically we can determine whether a substance use disorder is present, whether the severity is one of mild, moderate or severe. What we do understand is that health and social consequences do come as a result of problematic use and dependency. But dependency is the most severe because it also describes a loss of control. So when we look at low risk versus high risk, the one thing that we have to understand when it comes to alcohol and drugs is the aspect that there are parameters when it comes to what is considered low risk versus high risk. When we look at drinking, for example, we look at it from the standpoint of healthy drinking within males and females are typically for males less than four standard drinks in a week and for females less than three standard drinks in a week. When we get to anywhere between four and 14 standard drinks for men, you're in that moderate risk group versus females, which is that area between four and seven drinks, you're in that moderate risk group. But once we start broaching more than 14 standard drinks in a week for men or more than seven standard drinks in a week for females, now we are looking at high risk, especially if they are drinking more than four standard drinks in one sitting for men or three standard drinks in one setting for women. We're looking at now the propensity of a lot of problems to occur because of the risk has been elevated, which means impairment is possible and that accidents can occur and other adverse consequences that individuals may not be aware of. Now, when we go to the side of risk as far as drug use is concerned, even social use of substances puts the patient or individual at risk. High risk of use when we look at it from that standpoint of drug use is daily use of marijuana, misuse of potentially addictive prescription medications and any use of other illegal substances. When you look at the three of those together, just the activity alone puts an individual in a high risk category. Now, when we think about marijuana, we have to think about it in a context of a lot of, not only stigma, but also a lot in a way of the hype of what's been going on since states have been legalizing the use for recreational marijuana in addition to the medicinal use of marijuana. So when we start looking at the risk of use, we gotta also understand that even though it's slated to be medicinal or if it's slated to be for recreational, individuals can incur some of these adverse reactions such as hindrance in thinking, memory and learning. It can cause irreversible reductions of IQ for individuals that use marijuana on a regular basis. And if it's a heavy use individual, it can also cause respiratory problems. It harms development of the fetus in utero. It may trigger or exacerbate panic attacks. And then you also have a whole medical condition called Cannabis Hyperemesis Syndrome. One study found that up to 6% of people that visited the emergency department for vomiting, in fact, had Hyperemesis Syndrome from the use of cannabis. From a mental health standpoint, it may trigger or cause schizophrenia. It may cause psychosis. It may exacerbate any number of mental health issues and leads to dependence in one in eight users. I'm sorry, I misspoke. One in 11 users, it could become a dependency. And for those that are as opposed to an alcohol users, one in 20. When we look at it at a younger age, one in six users who started in their teen years becomes dependent. And then ultimately 25 to 50% of daily users also can become dependent. So when we look at the risk of marijuana use is not as innocent as many would think. And when we look at the risk of other drugs, we see here from the NIDA website, the list of current drugs that are in our communities right now. We have opioids, which is considered the prescription medications that have been adversely used. We have fentanyl, which has become a big problem within our communities. And now the introduction of xylosine with fentanyl, that combination alone has now caused that walking zombie epidemic that many communities are faced with when they mix the two medications together. Kratom once was problematic in some places, it still is a problem, but we've started seeing Kratom taper off simply because of the readily availability of fentanyl. Kratom has kind of fallen off that wagon of popularity. We spoke about cannabis, hallucinogens we have, we have nicotine and tobacco products. And traditional and by way of vaping, methamphetamines are still there. And then on a lower tier, you have the cocaine, your heroin and your molly ecstasy, also known as MDMA. So when we think about it from the prospect of us as medical providers, we have to think about it from the aspect of when we're with our patients on a daily basis, how often do we address issues as it pertains to alcohol use? Here we come to understand from some studies and from some surveys that most medical providers don't talk to their patients about alcohol use. And the proportion of adults who have reported to a healthcare professional about the whole discussion of their use, we find that it's very dismal and it's very minute. So according to this graphic here, one in six adults in general are asked about their alcohol use. Then when we get down one tier, we see one in five current drinkers are being asked about their alcohol use. Now we get to one in four when it comes to binge drinkers and one in three are frequent binge drinkers. So when we look at it in this whole totality, we're seeing that out of 100% of current drinkers, we're only reaching 20% of them. We're missing the other 80%. And when we're looking at the binge drinkers, we're missing 75% of them. And then frequent binge drinkers, we're missing 66% of those individuals. So when we don't take the time to sit down and have a simple conversation about alcohol and our patient's relationship with alcohol, we're missing a great opportunity to intervene and to provide information and resource. So that's why we have SBIRT. What is it? It's a comprehensive, integrative public health approach to the delivery of early intervention and treatment services for individuals with substance use disorder, or for those that are at risk of developing this disorder. We know that we have these services available in some primary care centers, trauma centers, and other community settings, but we're now looking to reach out to other centers such as dental services and other like chiropractic and other services within the community that touch our patients every single day to provide opportunities for early intervention with at-risk people who use substances before more severe consequences can occur. So why should you implement SBIRT within your practice? Well, because we understand that risk and problematic use of substances are very common. We also understand that when we don't approach it, leaving these individuals left to their own devices, that negative consequences do ensue, not only for the patients, but it also affects the communities where they come from, their families, and our nation as a whole. But not only that, SBIRT can be very effective and it can reduce the healthcare costs. So not only are we doing what is right for the patient, but we're also affecting our community of healthcare to help minimize the cost that's involved when we don't intervene early. So the prevalence of substance use patterns in the U.S. amongst the adults are seen here on the slide. When we look at the high risk, problem risk, the problem use independence populations, we see that our alcohol patients is sitting somewhere around 22% between, excuse me, our high risk and problematic use, and 3% that are totally independent. When we look at our, from the drug aspect, we have about 8% that falls in that category of high to problematic use, and 2% that sit in the dependency. So when do we sit down and have that talk with them? Well, brief interventions have been shown to be very much effective in the problematic use and high risk populations. And then referral to treatment definitely is what is needed when we have individuals that are actively using and are dependent on the substances. So in totality, when we look at patients that could benefit from SBIRT, you're looking at at least a good 30% or more of your patient population that could really benefit from this service. So common adverse consequences for the patients will be along the lines of psychological consequences, the deterioration of their family relationships and other social relationships. They can experience difficulty both at school and at work. Financially, they will have a strain because resources are being utilized for the attainment of the substance at hand, as opposed to taking care of their responsibilities. Legal, we see that aspect happening simply because of their interaction with the law as a result of either a DUI or as a result of a possession charge. Morally, from a spiritual or religious aspect, there's injury there because of them knowing that they're doing something to themselves that's not healthy. So it's like an assault to the body for themselves by using this. And then biomedically, we also see this occur. The whole different, the entirety of the changes of the internal environment as a result of this. And when we look at the families, the families are not immune to the adverse consequences because they also unfortunately reap the benefit of the addiction from or the abusive use of substances from their family member. This could lead to violence in the home, divorce or discord. Children in these homes will experience behavioral problems and problems at school. There may even be abuse and neglect. And then not only is it psychologically damaging to the individual, but you also have family members that deal with mental health problems in the form of somatic symptoms and other situations that may occur. When we look at the community and we look at the adverse consequences within a community, intoxicated driving, leading to disability and death and injuries, crimes against property and people. And we also see homelessness occurring simply because things have been neglected. Then this leads to an overwhelm of social services, law enforcement. It leads to overwhelm in the courts and the correctional systems. Ultimately these negative impacts have an impact on the workplaces themselves because now we don't have people that's showing up to work. So it adversely affects the workforce. It increases workplace injury because they're not able to operate safely being under the influence. There's a reduction in productivity. So the work that needs to get done in a given timeframe is not being accomplished. And then you have the whole issues of absences and turnover for which the employers are paying for because they cannot reap the benefits of the employee being on the job to do their work. So when we look at the adverse economic consequences here in the United States, between alcohol and drugs and productivity loss, we're looking at a total of 300 billion, billion with a B, of dollars that are lost due to lack of productivity. In the healthcare space, we see $3.8 billion that applies to alcohol use. Criminal justice, we see $83 billion being spent for the prosecution and everything that goes along with DUIs and driving of the influence and illegal seizures. Well, not illegal seizures, but the illegal attainment of these drugs, which then leads to the investigations and the search and seizures and the manpower that's spent on all of that. And so ultimately, when you look at the totality of what's being spent in the United States due to loss of productivity, healthcare expenditures, and the expenditures within a criminal justice system, we are spending on average $440 billion. So where does that help? What is the effectiveness of brief interventions? When we look at the case for alcohol alone, we see with intervention that alcohol drinking is reduced by 20%. Business to emergency rooms are also reduced by 20%. Injuries are down by a third. Hospitalizations are down by 36%. Arrests are down by almost 50%. We have MVCs or MVAs that are reduced by 50%. That's just on the alcohol side. And when you look at heavy use of drugs, an individual that uses more than five days up to 30 days with brief intervention, that reduces by 40%. So it does pay to have these brief interventions in place because we start seeing the changes ensue. And a couple of these studies that were done in Wisconsin and Washington State, also bear this cost saving that's occurring when effort has been employed. Within the Wisconsin Primary Care Project Treat Study, the interventionists were physicians and nursing staff, and it showed the cost of using the nurses to be around $205, but then the savings were that of $523 per patient per year. And when we look at what was going on in Washington State, amongst the disabled Medicaid patients, drug and alcohol counselors were used as the interventionists. And they saw a reduction of more than $4,000 by spending only $15 on the intervention. So that is significant. That was more than $4,000 per patient per year. And finally, when we look at the Medicaid patients within Wisconsin at primary care centers, they utilize health educators. And health educators, they spent about $48, but over a two year period, they were able to save more, almost $80 per patient. So we can see that the goals can be met if we start intervening with the call. So the goals of SBIRT is to increase the care and access to care for patients with substance use disorder and for those that are at risk. It also fosters a continuum of care by integrating prevention, integration and treatment services. And it also improves the linkages between healthcare services and drug and alcohol treatment facilities. So SBIRT, we're about to launch in now to understanding why we can do SBIRT in a rationale but I just wanna take a quick review on each term. So screening is a brief set of questions that identify the risk of substance use related problems. Your brief intervention is inclusive of brief counseling that raises awareness of risk and it also motivates the patient towards acknowledgement of the problem. Brief treatment is a cognitive behavioral work with patients who acknowledge the risk and are seeking help. And lastly, referral is merely procedures to help patients access specialized care. So the rationale for SBIRT is simple. It's a brief survey, so to speak that can be administered in different cultural settings. All healthcare providers are generally respected and trusted. So when we have healthcare providers involved with this it helps to minimize the stigma of substance use and substance abuse and it also improves the intervention outcomes. So how would one go about implementing SBIRT within a practice? You have access to screening and brief assessments, understand that it is a team approach and also quality improvement to the practice as a whole. And when we look at this sample of the patient flow which you understand is that when you're doing a screening this screening is inclusive of all adults and teenagers because teenage years, the adolescent years is where we are seeing a lot of high risk behaviors begin. So you wanna be able to jump in and intervene with that encouragement if they're not active in any substances or you wanna start planting the seeds to help them reduce the risky behavior. So if everything screens out negative, the patient is low risk or they're abstinent you just reinforce the good behavior. If they screen positive but they don't screen as high risk or dependence then that would be considered false positive screen. And again, that goes back to just reinforcement and encouraging them to keep on doing what they're doing. But if they go into high risk or problematic use you have a brief intervention tools and then you reassure them that they can continue to follow up as needed if they have questions. Once we get to the dependency side then that's where referrals you pull the trigger for the referrals and you also follow up with them how things are going. If they were able to get in to see the specialist and see how you can assist if need be to get them to where they need to go. So when we look at SBIRT for alcohol and the major impact on morbidity and mortality we see overwhelmingly that there's an improvement in the status when SBIRT has been implemented. Within trauma patients we see that there were 40% fewer injuries and 50% were less likely to be hospitalized. When screenings were done from the emergency room it reduced the UI arrest and they saw a reduction in one they saw one arrest prevented in every nine screens. In physician offices, they saw a deep they saw 20% less of motor vehicle crashes over a 48 month period. They also found that interventions also provide effective public health approach to reducing risky use within individuals. There's reduced use of alcohol and drugs they have improved social outcomes and the interventions are reducing mortality. When we look at SBIRT for drugs and we look at the impact on morbidity and mortality we see that the rates of illicit drug use were reduced by 67% over a six month period. We see improvements in general health and mental health and we look at social factors have been improved. We see that within certain healthcare centers that the feasibility of accomplishing this goal did not adversely affect the operations of the practice. We also saw a significant less use of illicit substances and alcohol. It also helped reduce the homelessness issue improved mental health and increased employment. And in Colorado, they saw that the days using illicit drugs were reduced by 47% over six month period and reduction of alcohol was also reduced over six months by 49%. So screening to identify patients at risk for substance use problems. When we look at screening, it's a universal screening. It's basically the first step to implement SBIRT within a practice. Typically this is done by self-reporting questionnaire and it's also is recommended simply because it's ease of use within both primary care and dental settings. We prefer this because we also understand that these practices are time limited as far as what services that they can offer and to go on to provide quantitative testing such as urine and saliva test can be time consuming. It can be very expensive. And if you're not practicing addiction medicine is actually impractical for your practice. So the goal of universal screening is to identify the appropriate clinical intervention for your patients. The severity of substance use and the appropriate SBIRT interventions. We're looking here at this slide and we see that if they're low risk or abstinent, then you're doing positive health messaging. You're just reinforcing and telling them again to keep up the good work. If they're risky or harmful use, then you're gonna go into your brief intervention and you're gonna do the brief intervention or you may have options to do brief intervention follow-up along with brief treatment if there's some delay for them to get into care. But if they're in the top 5% of severe use, then what you're gonna think about is that it's going to be brief intervention and referral for addiction treatment and recovery support services because they need to have these two contingents together in order to be successful. So when we're looking at self-reporting, we want to get the most accurate data from our patients as possible. How do we do this? We gotta make sure that they're not under the influence. So free of both alcohol and drugs, we have to assure them that any information that they are sharing with us is gonna be held confidentially. You wanna make sure that your verbiage is very clear and that your questions are very objective. And if possible, you wanna provide memory aids like calendars and response cards just to get their bearings straight if they're trying to report time in the last day of use or last time they used anything. The pre-screening is very quick and the approach is simply to identify who needs help. And if they do need help, then a longer screen and brief intervention is basically what's going to be the next call. So your pre-screening question would be for alcohol, how many times in the past year have you had X or more drinks in a day? And this is from the National Institute of Alcohol Abuse and Alcoholism. It's a one item pre-screen for unhealthy alcohol use. This screen is positive if they say one or more times, which means your next step would be brief intervention. For men, this number would be five or more drinks and for women, this would be four or more drinks, which indicates unhealthy use. For drugs, this question would be how many times in the past year have you used an illegal drug or a prescription medication for non-medical reasons? This is from the National Institute on Drug Abuse and it's also a one item pre-screen for drug use. This is identifying all drug use. And if it's positive for one or more times, you're providing brief intervention. So the screening tools are universal. They are quick and they are non-judgmental. They are used to detect risky or problematic use. These tools are only for screening. They are not diagnostic. And some of the tools that are available to you would be PAGE, Audit, the DAST and CRAP. PAGE and Audit are around alcohol use and abuse. Your DAST is for drug abuse and your CRAP is your adolescent screening tool for all of the above. So what is the audit? The audit is the Alcohol Use Disorders Identification Test. It's a 10 question screening instrument that is used for adults. This targets medical patients, accident victims, DWI offenders and mental health clients. And it's been designed for primary care settings. So introductory questions, as you're going in to talk about the audit, this is some of the verbiage that you can use to approach your patient. And as you see here, it's very conversational, it's non-judgmental and you are reinforcing the fact that their responses are gonna be confidential, that this is a universal screen that you use for all of your patients and that they have the right to not answer if they're not feeling comfortable, okay? So that way you disarm them and you give them options to understand that they can opt out of asking any of these questions at any point in time. So here are your 10 questions that the audit provides. It asks about the quantity and frequency of use it also talks about the frequency of heavy drinking. It also deals with aspects of whether or not how they're feeling when it comes to their drinking habits and it gets into the problematic use as well. So we look at the domains, the first three questions coupled together is indicative of hazardous alcohol use. These are the at-risk questions. Frequency of drinking, the typical quantity of drinking, the frequency of heavy drinking. Your questions four, five and six deals with the dependency aspect. It deals with the impaired control over drinking, the failure to meet their expectations because of the drinking and they need that morning drink. And then your last set of questions which are questions seven, eight, nine and 10 are the harmful consequences of drinking. And so it deals with the guilt after drinking, your blackouts, your alcohol related injuries and other concerns about drinking. When you look at the zones and the scoring for this, under seven is low risk. You're gonna basically educate them about alcohol, support their low use and low risk of drinking and you're gonna encourage them to continue on this healthy lifestyle. If their score is seven to 15, you're going to now break into your brief intervention and you're going to be focused primarily on reducing the hazardous drinking behavior. 16 to 19, here you could be brief intervention or an extended brief intervention with the possibility of referral to treatment dependent on how much more information is disclosed in the conversation. If they're over 20 in the scoring, then this is an automatic trigger for referral to a specialist for a diagnostic evaluation and for treatment. Now, some of the questions that we saw in the audit mirrored to a certain extent the traditional CAGE questions that we learned when we were in training. And the CAGE is an acronym for cutting down, being angry or annoyed, guilty, or if they require an eye opener. So these are yes, no questions and a score of two or more, meaning if they answer two or more of these questions in the affirmative, then that means that we are considering it to be clinically significant, a positive result, and we need to take action as intervened in this individual. The DAST is the Drug Abuse Screening Test. It's also a 10-question tool that is concerned about the involvement with drugs in the last 12 months. And drug use in these questions may refer to the use of illicit drugs as well as the misuse prescribed or over-the-counter medications. So here in the DAST, these are the questions that are being asked. Simple yes, no with a zero and one scoring. When we go through these questions, we're pretty much asking them strategically about symptoms, whether or not they have been ignoring things in their life as far as their schoolwork, their work life, if their family have been concerned about them, if they've had any adverse effects like blacking out or just the propensity of the use or if they had any additional medical issues. So this is a good one to utilize. So again, score zero, that means there's no risk. You just congratulate them and you encourage them to continue on with their healthy lifestyle. If they are scoring one to two, you let them know that they are at risk and that even though they're not suffering from any adverse reactions or they haven't started causing harm to themselves or others, continued use in the manner will lead to these issues. And you just let them know that you're gonna continue to monitor them and check in from time to time just to make sure all is going well. If they're three to five, again, now we're getting into the extended brief intervention and referral to treatment. You let them know that they are in immediate risk for problematic use with their drugs or with their drugs. And so you want to talk to them about seeking out a professional that could work with them, that could help them get back on track and help them to rearrange their behavior and activity so that they don't go too far over into that high risk zone. Score a six or higher, they're basically going to be referred. There's no ifs, ands, or buts about it. You just need to make sure you put them in the hands of a specialist that could do the diagnostic evaluation and give and provide treatment and care. So the advantages of the DAS is that it is brief, it is inexpensive, it provides a qualitative index of the extent of problems related to drug abuse. This particular screen can be administered to both adults and adolescents, and you have the ability to do this as a questionnaire. Now the CRAB, this tool was specific for adolescents. And so it has evolved, hence the 2.1 plus N, because the CRAB initially was just six questions that were asked, and that was general. Over time, they have evolved and added part A and part C to this questionnaire so that they weren't missing anything. So when we look at part A, it deals with just the top four. In the past 12 months, how many days did you have any alcohol, use any marijuana? Did you use anything else to get high, like illegal drugs, pills, over-the-counters, sniffing, vaping, huffing, injecting? And did they use a vaping device that contained nicotine or use other tobacco products? So the whole purpose of this part A is to now stratify the big four that adolescents and teenagers get involved with, and then it helps to then inform you where to go for part B. Now, in part B, if they answered no, then you stop, you congratulate them, and you encourage them to continue with their healthy living. If they answer the first three questions with one or more, then you go into the CRAF. And the CRAF survey basically is an acronym for Car, Relax, Lone, Forget, Family, and Trouble. And basically it asks, have you been either under the, excuse me, either under the influence or have, while being in a car, or have you been with someone that has been under the influence while driving a car? Very important question because of the propensity of motor vehicle accidents and how our youth are getting involved with a lot of motor vehicle accidents that causes injury or death. You ask about if they're using drugs and alcohol to relax, are they using it by themselves alone? Are they isolating and getting away? Are they forgetting things when they're using drugs and alcohol? Are their family and friends concerned about the drinking or the drug use? And have they gotten in trouble? Have they been in trouble as a result of their drug and alcohol use? So when you think about it, if they're answering two or more of these questions with yes, then it's serious. It's a serious enough of a problem for them to go further to be assessed. And that's when we're getting into referral to treatment to make sure they get to where they need to be. Now, if they answer number, on the first page, if they answer with number four, I'm gonna go back and remind you what number four, which is the tobacco and nicotine and vaping question. If they answer that in the affirmative, then that's when we jump over to part C of this craft. And now we deal with everything. The following questions are dealing with any vaping devices containing nicotine and or flavors or the use of any tobacco products. So we ask if they're having trouble with quitting, but they can't, if they, they say, do you vape or use tobacco now? Because it's really hard to quit. Again, difficulty around the quitting, if they ever felt addicted to the vaping or tobacco, if they have strong cravings towards it, if they feel like they need to do it, it's just compulsive and they just can't get away from it. They're using it in places where they're not supposed to be like at school or at work or what have you. And then it gets down to their whole aspect of how much it's been affecting the biological aspect of them. If you haven't vaped in a while or use tobacco in a while, do you find it hard to concentrate? Do you feel more irritable? Is there a strong need or urge to use? Do you feel nervous, restless or anxious because you have it? These are signs and symptoms of withdrawal as a result of the use of the tobacco, the nicotine or the vape. So these things are showing the physical dependence and the physical withdrawal. And so answer of yes, of one or more of these in part C definitely requires further evaluation for nicotine use disorder that we would need to get our teenagers into services as soon as possible. So again, this kind of reiterates what I just said. So if they answer yes to the car question, then it's recommended that the patients and the parents devise a safe ride home plan because we don't want them to be in a car under the influence or driving with someone else that's under the influence. If they answered the questions, if they answered one or more of the questions with any affirmative, especially if they answered a car question, you're gonna do brief intervention around the car. If they answered two of the questions, then you do a brief intervention. You are basically up through the first three questions is all brief intervention as the intervention of choice. Once you get past the first three and you have four or five and six, basically at this juncture, you're looking at referral to treatment because you want to make sure that you're getting these individuals into care as soon as possible. And any time that's wasted not in care within an adolescent individual is adding years of addiction to them on the backend. So you wanna make sure that you wanna be a part of the solution and not contribute to the problem. So if you're a little bit skittish about talking about this with your teenagers, here's the five R talking points around brief counseling. You wanna first review the results and for every yes, you want to ask them, tell me a little bit more about that. That way you're encouraging them to share and it's not like you're dictating to them, but you want this to be as collegial as possible the conversation. The next one would be recommend not to use. And then you just let them know, it's like as your healthcare provider, I recommend that you don't use alcohol, nicotine, marijuana or other drugs because they can harm your brain development, interfere with your learning and memory and they can put you in embarrassing or dangerous situations so you're gonna provide that empathy and let them know that you are caring about them because you wanna see what's best for them. That riding and driving risk, you wanna make sure that they understand that motor vehicle accidents are the leading cause of death amongst young people and you want them to, you want to give them a contract for life. This can be found at the website, at the craft.org website, the link you see here on the screen that you can provide to them that they can then go home and talk to their parents or guardians and to create a plan to get a safe ride home because we want them to maintain safety at all times. When you want to respond to illicit self-motivational statements, you want to let your users understand that if they are using, you want to try to find out from them if they have insight into their use and you can do that by asking what would be some benefits of not using? Whereas if you have someone that's not a user, then you can help them kind of craft their argument against starting. So you can ask them, if someone asked you why you don't vape or why you don't drink or why don't you use tobacco or drugs, what would you say? And this kind of helps reinforce that positive behavior within them. Lastly, reinforce, I just said it, reinforce the self-efficacy. You want these adolescents, these teenagers to know that they are empowered and that they can reach their goals without having to use substances and let them know that they have the power to make the decisions to have a healthy life. And again, the contract for life is available at www.craft, spelled with two Fs, c-r-a-f-f-t.org slash contract. So SBIRT is a team approach. When you look at implementing this within your practice, you get all hands on deck to assist with this. It starts with the annual screening forms or new patient forms where you can provide them with this paperwork in advance to fill out and have available to you. Then your medical assistants could then review your patient responses. And if anything is flagged, it could be given over to a dedicated SBIRT staff person to conduct the remainder of the SBIRT session. And all of this can be done in advance of you coming into the office to see them. Now, how are you going to get paid for this? Well, commercial, Medicare and Medicaid all offer reimbursement for these services. For a commercial, you can get anywhere from $33 to $65 per interaction. And Medicare is about on par, is a little bit less. You're looking at about a little less than $30 for up to a 30 minute visit, up to $68 for greater than $30. And Medicaid will give you the screening flat rate, $24 in intervention of $48 per 15 minutes. So you can bill and you can be reimbursed for these services. So let's look at this example. You look at the annual revenue for SBIRT. So you look at the Medicaid paid per 15 minutes for brief intervention at $48. If you're doing 12, 15 minute brief interventions in your workday, and there's 240 workdays per year, you can stand earn around $138,000 for these brief interventions of 15 minutes. And this will help to fund itself. You calculate the staff that's needed to serve the patients, who will need to do the brief intervention, referral to treatment and follow-up sessions, and you ensure that your staff receives the appropriate training and ongoing support. But all of this, you can receive a little less than $140,000 a year, and that's just with Medicaid. So you can provide the service and have it not interfere with your practice financially. Not to mention for CMS, you can meet quality improvement measures to ensure that you are on par and on task for everything that's required. So quality improvement is key to ensure the effectiveness. So if you screen all eligible patients, you can screen all adults and teenagers. You can give brief assessments to the ones that screened positive. And then the ones that raised to the level to the aspect of requiring treatment, you can provide the intervention and a referral to treatment as appropriate. And the objective is to meet these measures by more than 90%. So having these things in place and having the talent and the staff in place to do it will help with the quality improvement and quality measures of your practice and helps with overall reimbursement. So in summary, SBIRT addresses a pressing public health problem. There's ample evidence within documentation that SBIRT is effective and it's cost effective as well. SBIRT has been important in preventing and preventative services, and it should be used and delivered to all teenagers and adults. Within the primary care space, it helps to improve outcomes of many physical and mental health problems. And the sweet spot of SBIRT is in the brief intervention for high and problem use patients. When referral to treatment fails, what you want to think about is initiating the treatment within a primary care setting by employing the behavioral changes and if need be medications used for alcohol and opioid use disorders to assist the patient until they can get into the specialist. To serve all your patients, especially between primary care and other healthcare environments, you need to employ a team-based approach that includes a dedicated SBIRT staff that can be funded through fee-for-service reimbursement. And finally, rigorous quality improvement program is essential for optimizing the SBIRT implementation. I want to thank you for spending your time with me on today to learn more about screening and brief intervention and referral to treatment. These are my references, and this is the wonderful team that did a good amount of work in developing the curriculum that was also the basis for this presentation. And finally, for you to receive your credits, you need to follow the information here. If you do not complete the evaluation, unfortunately, you will not receive your CME or CEU. So please follow the instructions here on the screen. And otherwise, there's also instructions within the website of this program for you to click the link in order for you to complete the survey in order for you to receive your CEUs and CMEs. Again, my name is Dr. Melissa Barbosa. I thank you on behalf of the Opioid Resource Network. I'm sorry, I keep saying that. It is a resource to me, but in respect to everything, it's the Opioid Response Network. So I thank you on behalf of the Opioid Response Network. If you'd like to have any of these trainings for your practice or for your organization, feel free to reach out to us at www.opioidresponsenetwork.org. You have a wonderful rest of your day. Take care.

SBIRT

Screening Brief Intervention and Referral to Treatment

Dr. Melissa Barbosa

Opioid Response Network

Substance use disorders

Early intervention

Healthcare settings

Screening tools

Brief interventions

Quality improvement measures