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SBIRT in Public Health: A Comprehensive Approach for Social Work Students�Morgan State University

Nicole Luhanik, MS, LPC

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This presentation was prepared for the Central East Addiction Technology Transfer Center (Central East ATTC) Network under a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA). All material appearing in this publication, except that taken directly from copyrighted sources, is in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. Do not reproduce or distribute this publication for a fee without specific, written authorization from Central East ATTC. For more information on obtaining copies of this publication, email webinars@danyainstitute.org.�

At the time of this publication, Miriam E. Delphin-Rittmon, Ph.D, served as Assistant Secretary for Mental Health and Substance Use in the U.S. Department of Health and Human Services and the Administrator of the Substance Abuse and Mental Health Services Administration.

The opinions expressed herein are the view of TTC Network and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA. No official support or endorsement of DHHS, SAMHSA, for the opinions described in this document is intended or should be inferred.

This work is supported by grants 1H79TI080210 from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

Presented 2023

�Acknowledgment

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ATTC Network Resources

Addiction Technology Transfer Network

www.HealtheKnowlege.org (online courses)
National Registry of SBIRT Trainers
Request a training or technical assistance activity at www.ceattc.org

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Strength

In role as a ________________ one of the hardest feelings is realizing I (Job title)

might've overlooked an opportunity to truly help someone, which leaves me

�feeling ____________. I got into this field because of __________, and� (Emotion) (Reason)�making a difference in the community around me in important to me. Today,�� I turn to SBIRT, hoping it becomes another tool in my journey to� � ____________________.�(Specific aspiration or hope)

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SBIRT�Day One �11-10-2023�

Screening and its Importance

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The Shifting Landscape of Substance Use Understanding

Evolving Perspectives

Historical views saw substance use as a:

Moral issue
Individual challenge
Family concern
Social dilemma
Criminal justice issue
Or a mix of the above

Cause and Solution:

Our approach to solutions is deeply influenced by how we interpret the cause.

Moral Lens: What solutions come to mind if we see substance use as a moral issue?
Criminal Justice Lens: How might our solutions differ if we treat substance use as a criminal justice issue?

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Evolving Understanding: Over the years, our societal grasp of substance use has evolved, and it's crucial to acknowledge that this understanding will continue to shift. SBIRT stands as testament to our growing insights.�
Cause and Solution: The way we interpret a problem influences our approach to its solution.��Analogy: Imagine you're trying to solve a complex puzzle. If you believe that a piece should fit in a certain section due to its shape, you'll continue to try it in that area. However, if you step back, reassess, and realize the image on the piece fits better elsewhere, your approach changes. Similarly, our initial perception of substance use might lead us to one type of intervention, but upon further understanding, we might find a more fitting solution elsewhere. Just like re-evaluating the puzzle piece's placement leads to a better outcome, SBIRT re-evaluates our approach to substance use, leading to more effective interventions.

Interactive Session: To underscore this, let's engage in a thought experiment:

Moral Lens: If substance use was a moral dilemma, what might be the remedy? (Await answers like prayer, religious guidance.)
Criminal Justice Lens: If viewed as a criminal justice concern, what's our course of action? (Expect answers like arrest, rehab through legal means.)

Conclusion: This emphasizes how our shifting comprehension of an issue can reshape our entire approach to solutions. As our lens changes, so does our course of action.

�

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8

At-Risk Substance Use Is

A Public Health Problem

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Learning from Public Health

The public health system of care routinely screens for potential medical problems (cancer, diabetes, hypertension, tuberculosis, vitamin deficiencies, renal function), provides preventative services prior to the onset of acute symptoms, and delays or precludes the development of chronic conditions.

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Introduction to Historical Perspective:

"Throughout history, the best preventive healthcare practices have been about early identification. Just like a stitch in time saves nine, early detection can save lives and reduce long-term complications."

Comparison with Healthcare:

"Consider how often we get our blood pressure checked or go for routine blood tests. Why do we do this? To catch potential health issues before they escalate."

Using SBIRT in Substance Use:

"Similarly, with SBIRT, we're not waiting for substance use to become an acute or chronic problem. Instead, we're taking cues from the healthcare system's preventive approach. By identifying potential issues early, we can guide individuals toward the right interventions, avoiding more significant problems down the road."

The Blood Pressure Analogy:

"Let's think about a blood pressure test for a moment. Does anyone here know its primary purpose?"

[Wait for responses]

"Exactly! It's a universal screen for hypertension. But remember, it doesn't directly diagnose heart disease. Instead, it's a flag – a sign that there might be a potential problem."

Linking Back to SBIRT:

"In the same way, SBIRT isn't necessarily diagnosing substance use disorders right off the bat. It’s about understanding patterns and signs, then guiding individuals to the appropriate next steps. This could mean immediate interventions or more specialized assessments. By aligning our approach to substance use with tried and true methods from the healthcare sector, we are prioritizing early intervention and holistic care."

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Substance Use Services: A Narrow Focus

Primary Prevention: Aims to prevent or delay the initial onset of substance use.

Tertiary Care: Devotes significant time, resources, and effort to treat those acutely or chronically affected by a substance use disorder.

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Primary Prevention: Aims to prevent or delay the initial onset of substance use.
Tertiary Care: Devotes significant time, resources, and effort to treat those acutely or chronically affected by a substance use disorder.

�

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Substance Use Disorder

No Problem

Traditional Treatment

No Intervention

Abstinence

Drink Responsibly

Primary Prevention

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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The Current Model�A Continuum of Substance Use

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Abstinence

Addiction

Responsible Use

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An Outdated Model

This model (paradigm) of substance use:

Fails to recognize a full continuum of substance use behavior.
Fails to recognize a full continuum of substance use problems.
Fails to provide a full continuum of substance use interventions.

WHY?

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The current model identifies a substance use problem as…

Addiction

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By defining the problem as addiction or dependence this outdated model fails to recognize a full continuum of substance use behavior, a full continuum of substance use problems, and does not provide a full continuum of substance use interventions. As a result, the outdated model has failed to provide resources around the greatest needs.

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The Problem?

There is a broader continuum of substance use behavior, problems, and interventions that address the areas that have historically been disregarded by the current system.

The recent changes in the DSM V – indicate a newer approach to viewing substance use. In the DSM V use of the word “abuse” has been replaced with mild substance use disorder, moderate substance use disorder and severe substance use disorder. This is combining 11 criteria into a single continuum of criteria.

The 11 criteria are:

1. Use in larger amounts or longer than intended

2.Desire or unsuccessful effort to cut down

3.Great deal of time using or recovering

4.Craving or strong urge to use

5.Role obligation failure

6.Continued use despite social/interpersonal problems

7.Sacrificing activities to use or because of use SUD Criteria

8.Use in situations where it is physically hazardous to be impaired

9. Continued use despite knowledge of having a physical or psychological problem caused or exacerbated by use

10. Tolerance

11. Withdrawal

It will take a while for the conversational language to change around terminology like using the term substance use disorders, dependence or addiction.

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The SBIRT model identifies a substance use problem as…

Excessive Use

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Consequence of Excessive Substance Use

Aggravation or onset of specific health conditions.
Worsening of mental health conditions.
Direct trauma and repeated trauma episodes.
Alcohol poisoning.
DUI (Driving Under the Influence).
Domestic and other forms of violence.
Increased risk of sexually transmitted diseases.
Unintended pregnancies.
Development of Substance Use Disorder.

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By defining the problem as excessive use the SBIRT model recognizes a full continuum of substance use behavior, a full continuum of substance use problems, and provides a full continuum of substance use interventions. As a result the SBIRT model can provide resources in the area of greatest need.

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The Solution

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Unveiling the Overlooked: The In-Between Challenge

Activity Objective:

Identify commonly overlooked populations within key societal sectors.
Analyze unique challenges these groups face.
Collaboratively develop potential support strategies.

Instructions for Breakout Sessions:

Each group will select a societal sector.
Discuss to identify an 'in-between' population within that sector.
Determine the unique challenges and brainstorm potential interventions.

Societal Sectors Examples:

Health: e.g., individuals with mild to moderate symptoms who don't qualify for certain programs.
Education: e.g., students who perform average but don't receive additional support or enrichment opportunities.
Workplace: e.g., mid-level employees who are often overlooked for development or advancement.
Group Presentation:

Begin by acknowledging the complexity of societal issues and the importance of recognizing those who don't always fit neatly into the categories we discuss.
Encourage students to draw from their academic knowledge, personal experiences, and critical thinking skills to identify these 'in-between' groups.
Emphasize the value of interdisciplinary thinking and the merging of theory with practice as they tackle this task.
Challenge them to think beyond surface-level solutions and to consider systemic changes that might better support the identified groups.
Reiterate that the goal is not only to recognize these populations but to consider actionable steps that can be taken to offer support.
Encourage a spirit of collaboration and open dialogue, stressing that the most effective solutions often come from diverse perspectives coming together.

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Substance Use Disorder

No Problem

Traditional Treatment

Abstinence

Screening and Feedback

Drink Responsibly

Excessive Use

Brief Intervention

Brief Treatment

Primary Prevention

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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The SBIRT Model�A Continuum of Substance Use

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Abstinence

Experimental Use

Social Use

Binge Use

Abuse

Substance Use Disorder

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Drinking Behavior

Intervention Need

5%

20%

75%

Substance Use Disorder

Hazardous

Harmful

Symptomatic

Low Risk or

Abstinence

No Intervention or Screening and Feedback

Brief Intervention or

Brief Treatment

Brief Intervention and Referral for Additional Services

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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U.S. Population

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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Substance Use Disorder

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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Excessive

Hungerford, D. [Image developed by and used with the permission of]. Centers for Disease Control and Prevention, Atlanta: GA.

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5

1

Note that there is a 5 to 1 disparity between those who are at risk and those who have a substance use.

NOTE: The intent of these slides to is to break out individuals into 3 distinct groups: Abstinent/Low Risk, Excessive Use, and Addiction or those who have a substance use disorder (Green light, yellow light, red light). Yes, individuals with a substance use disorder are by definition excessive users who are at risk for consequences but for this conceptual framework we are focused on separating the red light people (those with a substance use disorder) from the excessive use yellow light people. The red light people have moved into what the outdated model defines as the addiction. The yellow light people meet the criteria for having a problem in the SBIRT model (excessive use) and are at risk for all of the consequences that can result including being diagnosed with a substance use disorder.

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The Costs of Substance Use

The bulk of the societal, personal, and health care related costs are not a result of addiction but of excessive substance use. Until such time as we acknowledge this fact, and address it appropriately, we are unlikely to make significant progress towards a solution.

Consider This

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If we could provide a 100% cure to every substance dependent person in the United States, we wouldn’t be close to solving most of the substance related problems in our country.

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The SBIRT Model - A Continuum of Interventions

Primary Prevention – Precluding or delaying the onset of substance use�
Secondary Prevention and Intervention – Providing time, cost, and labor sensitive care to patients who are at risk for psycho-social or healthcare problems related to their substance use choices.�
Tertiary Treatment – Providing time, cost, and labor intensive care to patients who are acutely or chronically ill with a substance use disorder

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Primary Goal

The primary goal of SBIRT is not to identify those who are have a substance use disorder and need further assessment.�
The primary goal of SBIRT is to identify those who are at moderate or high risk for psycho-social or health care problems related to their substance use choices.

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National Institute of Alcohol Abuse and Alcoholism (NIAAA) Definitions

Low Risk:

Healthy Men < 65
≤ 4 drinks per day AND NOT MORE THAN

14 drinks per week

Healthy Women & Men ≥ 65
≤ 3 drinks per day AND NOT MORE THAN

7 drinks per week

Hazardous:

Pattern that increases risk for adverse consequences.

Harmful:

Negative consequences have already occurred.

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National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf. �

Babor, T.F. & Higgins-Biddle, J.C. (2001). Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf.

Reference: National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

Reference: Babor, T.F. & Higgins-Biddle, J.C. (2001). Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf.

So what constitutes being at risk? The National Institute of Alcohol Abuse and Alcoholism defines low risk for healthy men under 65 as less than or equal to 4 drinks per day (acute measure) AND not more than 14 drinks per week (chronic measure). For healthy women and men 65 and older, the cutoff is less than or equal to 3 drinks per day AND not more than 7 drinks per week. Drinking over these amounts places the individual at risk for psycho-social or health care problem related to their current substance use choices. In addition to being at risk for psycho-social or health care problems SBIRT also recognizes levels of risk (hazardous) and use that is already resulting in problems (DUI, etc.)These are the agreed upon standards for low risk (non-excessive) use. Any use above this amount (and all illicit drug use or use of Rx drugs other than prescribed) constitutes risk. If negative consequences have yet to be experienced the use is hazardous. If negative consequences are occurring the use is harmful.

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The SBIRT Concept

SBIRT uses a public health approach to universal screening for substance use problems.

SBIRT provides:

Immediate rule out of non-problem users;
Identification of levels of risk;
Identification of patients who would benefit from brief advice;
Identification of patients who would benefit from further assessment, and;
Progressive levels of clinical interventions based on need and motivation for change.

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The Moving Parts

✅ Quick identification of non-problem users.�
🔍 Detecting varying levels of risk.�
🗣 Pinpointing those who would benefit from brief advice.�
🔬 Identifying those needing a deeper assessment.�
📈 Offering tailored interventions based on individual need and readiness for change.

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Let’s Review

SBIRT is a systems change initiative requiring us to re-conceptualize, re-define, and re-design our entire approach to substance use problems and services.�
SBIRT uses a public health approach.�
The current model defines the problem in terms of addiction.�
The SBIRT model defines the problem as excessive use.�
SBIRT recognizes a continuum of substance use behavior, a continuum of substance use problems, and a continuum of substance use interventions.

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Screening�Module Two

Re-defining the Identification of Substance Use Problems

This module will go over the screening process and specifically address using the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test – 10 (DAST – 10).

Module 2: Re-defining the Identification of Substance Use Problems

Objectives:

• Understand the information screening does and does not provide.

• Recognize the 2 levels of screening.

• Recognize the 4 interventions based on screening results.

• Become familiar with the AUDT C, AUDIT, and DAST-10 screening tools.

• Encourage active participation.

Instructional Methods (IM):

Didactic – the instructor explains the content knowledge.

Collaborative – the instructor asks the learners to process the content knowledge through facilitated

discussion.

Role play – participants will practice screening role plays.

Practice:

Direct delivery – there are multiple roles plays for participants to practice with the AUDIT and the DAST.

Animated Slides: Yes

Video: Yes

Materials: Copies of slides; copies of standard drink chart, copy of AUDT -C, AUDIT, and DAST-10.

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A Standard Drink

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National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

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Screening Does Not Provide

A Diagnosis

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Two Levels of Screening

Universal:

Provided to all adult patients.
Serves to rule-out patients who are at low or no-risk.
Can (should) be done at intake or triage.
Positive universal screen = proceed with full screen.

Targeted:

Provided to specific patients (alcohol on breath, positive BAL, suspected alcohol/drug related health problems)
Provided to patients who score positive on the universal screen.

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Screening Does Provide

Immediate rule-out of low/no risk users.�
Immediate identification of level of risk.�
A context for a discussion of substance use.�
Information on the level of involvement in substance use.�
Insight into areas where substance use may be problematic.�
Identification of patients who are most likely to benefit from brief intervention.�
Identification of patients who are most likely in need of referral for further assessment.

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Four Types of Intervention

Feedback only.
Brief Intervention.
Extended Brief Intervention or Brief Treatment.
Referral for further assessment.

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Substance Abuse and Mental Health Services Administration. (2011). Screening, brief intervention, and referral to treatment (SBIRT) in behavioral healthcare. Retrieved from http://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf.

Reference: Substance Abuse and Mental Health Services Administration. (2011). Screening, brief intervention, and referral to treatment (SBIRT) in behavioral healthcare. Retrieved from http://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf.

Individuals who score below the first cut off point of a full screen (such as the AUDIT) receive feedback on their current status and encouragement to stay below the NIAAA guidelines.

Those who score above the first cut off and below the second cut off receive a brief intervention. This is a 5 to 15 minute discussion focused on assisting the individual to recognize their risk and supporting them in making behavioral changes to reduce their risk.

Those who score above the second cut off but below the third cut off receive a brief intervention and are encouraged to have additional (extended) brief interventions or to engage in brief treatment.

Those who score above the third cut off receive a brief intervention and are encouraged to accept a referral for further assessment.

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Validated Screening Tools

AUDIT: Alcohol Use Disorder Identification Test.

World Health Organization. (1982). The Alcohol Use Disorders Identification Test.

DAST: Drug Abuse Screening Test.

The Addiction Research Foundation. (1982). The Drug Abuse Screening Test.

POSIT: Problem Oriented Screening Instrument for Teenagers.

National Institute on Drug Abuse. (1991). The Problem Oriented Screening Instrument for Teenagers.

CRAFFT: Car, Relax, Alone, Forget, Family or Friends, Trouble (for adolescents).

Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607-614.

ASSIST: Alcohol, Smoking, and Substance Abuse Involvement Screening Test.

World Health Organization. (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 97(9), 1183-94.

GAIN or GAIN-SS: Global Appraisal of Individual Needs.

Dennis, M. L., & Rourke, K. M. (1998). Global appraisal of individual needs. Bloomington, IL: Chestnut Health Systems.

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Each of these screening tools are valid (they measure what we want them to) and reliable (they measure accurately over a broad group of individuals).

The AUDIT was developed by the World Health Organization (WHO) and evaluated over a period of two decades. It has been found to provide an accurate measure of risk across gender, age, and cultures.

The DAST includes questions about possible involvement with drugs not including alcoholic beverages during the past 12 months. “Drug use” refers to the use of prescribed or over the counter drugs in excess of what’s directed and any non-medical and/or illegal use of drugs. While the full DAST consists of 28 questions, this curriculum uses the DAST-10.

The POSIT was designed to identify problems and potential treatment or service needs in 10 areas, including substance abuse, mental and physical health, and social relations.

The CRAFFT is a behavioral health screening tool for use with children under the age of 21 and is recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents. It is a short, effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted.

The ASSIST is a brief screening questionnaire to find out about people’s use of psychoactive substances. It was developed by the World Health Organization (WHO) and an international team of substance use researchers as a simple method of screening for hazardous, harmful and dependent use of alcohol, tobacco and other psychoactive substances.

The GAIN is a progressive and integrated family of instruments with a series of measures and computer applications designed to support a number of treatment practices. A GAIN License must be obtained in order to use any of the GAIN family of instruments. The GAIN-SS (Short Screener) is an initial screening instrument.

Sources:

World Health Organization. (1982). The Alcohol Use Disorders Identification Test.

The Addiction Research Foundation. (1982). The Drug Abuse Screening Test.

National Institute on Drug Abuse. (1991). The Problem Oriented Screening Instrument for Teenagers.

Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607-614.

World Health Organization. (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 97(9), 1183-94.

Dennis, M. L., & Rourke, K. M. (1998). Global appraisal of individual needs. Bloomington, IL: Chestnut Health Systems.

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CAGE-AID Screening tool

The CAGE-AID is a version of the CAGE alcohol screening questionnaire, adapted to include drug use.

It assesses likelihood and severity of alcohol and drug use
Can be used for adults and adolescents
Easy to administer
4 items
Administered by patient or self-report
Primary care or other settings
Any answer of yes is a positive screen.

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Reference: Substance Abuse and Mental Health Services Administration. (2011). Screening, brief intervention, and referral to treatment (SBIRT) in behavioral healthcare. Retrieved from http://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf.

Individuals who score below the first cut off point of a full screen (such as the AUDIT) receive feedback on their current status and encouragement to stay below the NIAAA guidelines.

Those who score above the first cut off and below the second cut off receive a brief intervention. This is a 5 to 15 minute discussion focused on assisting the individual to recognize their risk and supporting them in making behavioral changes to reduce their risk.

Those who score above the second cut off but below the third cut off receive a brief intervention and are encouraged to have additional (extended) brief interventions or to engage in brief treatment.

Those who score above the third cut off receive a brief intervention and are encouraged to accept a referral for further assessment.

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The CRAFFT

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�CRAFFT Screening Tool�

The CRAFFT is a validated screening tool for use with adolescents
Because it screens for both alcohol and other drug problems simultaneously, it is especially handy for providers
CRAFFT consists of
Part A: 3 pre-screening questions and
Part B: 6 items
Scoring Algorithm
A positive CRAFFT means the student should be assessed for alcohol/drug use severity (mild, moderate or severe).

Source: Arch Pediatr Adolesc Med. 2002;156:607-614

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CRAFFT - Part A Review��Ask: During the Past 12 months, did you:

1. Drink any alcohol (more than a few sips)?

2. Smoke any marijuana or hashish?

3. Use anything else to get high? (“Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”.)

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If answers NO to all, Ask the CAR question in Part B, then STOP.

If answers YES to ANY, ask all of Part B

First, the clinician asks 3 specific opening questions to determine if the adolescent has used alcohol or other drugs in the previous 12 months, and the answers to these questions determine what portion of the CRAFFT screen is indicated (Fig 1 [start at the top center]). Adolescents who answer “no” to all 3 opening questions (Fig 1, upper left) are still asked the “C” (or “car”) question to determine if they have placed themselves at risk by riding with an alcohol- or drug-“influenced” or intoxicated driver. Those who answer “yes” to any of the opening questions are asked all 6 CRAFFT questions (Fig 1, upper right).

This 2-step screening may be accomplished by interview with the physician or office staff or by self-administered written or electronic survey. As with all psychosocial interviews, screening for substance use is most informative when conducted confidentially without a parent or guardian present. Before screening, both students and parents should be well informed about the confidentiality practice setting, including the safety related limits that justify whether to continue or break confidentiality.

Low Risk: Abstinence

Screening should be conducted whenever possible, regardless of visit type, and should always be included as part of the annual well-adolescent visit. Adolescents who report no use of tobacco, alcohol, or other drugs and answer “no” to the “car” question of the CRAFFT screen are at low risk of having a substance use disorder. It is important that these students receive praise and encouragement for making smart decisions and healthy choices (Fig 1, upper left [“no to all opening questions”]). 1Experience is showing that even a few positive words from a physician can delay initiation of alcohol use by adolescents. Anticipatory guidance to avoid riding with a driver who has been drinking or using drugs.

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IF: No to All Part A and No to Car question.

Praise and Encouragement: “You made some good choices not to use drugs or alcohol.”

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IF: No to All Part A and Yes to Car question.

“Please don’t ever ride with a driver who has had a single drink, because people can feel that it’s safe to drive even when it’s not.”

Moderate Risk: CRAFFT-Negative

Adolescents who have begun using alcohol or drugs and score 0 or 1 on the CRAFFT screen are considered at moderate risk of having substance use–associated problems (Fig 1, middle-left side). These adolescents may benefit from brief intervention consisting of both clear advice to stop alcohol and other drug use and educational counseling about the health effects of drug use (e.g., “Recent research has confirmed that brain growth continues into at least the 20s, and alcohol poisons developing brain cells”). Brief intervention for adolescents in this category should also include recognition of strengths and positive personal and family attributes (e.g., “You are such a good student, it would be a shame to let alcohol interfere with your education”).

No Signs of Acute Danger or Addiction

Adolescents who have had relatively minor consequences associated with their substance use should be engaged in a brief negotiated interview (BNI) based on motivational principles to encourage abstinence or risk reduction (Fig 1, lower-left rectangle). In contrast to brief advice, a BNI involves a negotiation that attempts to reduce substance use and related risk behaviors by using the negative aspects of substance use as reported by the adolescent. The BNI is based on the principles of motivational interviewing, which is a counseling approach in which a clinician encourages a student to explore the effects of his or her current behavior on personal interests or goals. These principles align well with established pediatric medical home practices of providing confidential care and building a trust relationship and rapport. Motivational-interviewing or BNI techniques are particularly useful for adolescents who have experienced problems associated with alcohol or drug use but remain ambivalent about continued use or have not yet considered the possibility of changing their behavior. A full review of motivational interviewing is beyond the scope of this statement; interested readers are referred to the seminal work by Miller and Rollnick. Brief negotiated interviews have been used successfully to reduce both alcohol cents in emergency care settings.

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THE CRAFFT

Part B:

Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
Do you ever use alcohol or drugs while you are by yourself, or ALONE?

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THE CRAFFT

Do you ever FORGET things you did while using alcohol or drugs?
Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into TROUBLE while you were using alcohol or drugs?

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THE CRAFFT

A score of 2 or greater is a “positive” screen and indicates that the adolescent is at high-risk for having a substance use disorder.

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CRAFFT Part B

IF: CRAFFT = 1

Brief Advice:
“I recommend that you stop (behavior) and now is the best time. Alcohol and drugs have a detrimental affect on your growing brain and you may do some things that you could come to regret.
Affirm their strengths and supports.

teens.drugabuse.gov/

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CRAFFT Part B

CRAFFT > 2 Brief Assessment

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“Tell me about your alcohol and drug use.

“Has it caused you any problems?”

“Have you tried to quit? Why?”

No Acute Danger or Red Flag

Red Flags for Addictions

Signs of Acute Danger

An adolescent who reports experience with certain risk behaviors, such as having a drug-related hospital visit, using intravenous drugs, combining sedatives (including alcohol, benzodiazepines, barbiturates, or opioids),consuming a potentially lethal volume of alcohol (14 drinks), or driving or engaging in other potentially dangerous activity after alcohol or drug use, shows clear signs of acute danger that warrant immediate intervention (Fig 1, lower-right rectangle). If any sign of addiction is also present, the corresponding lower-middle portion of the Fig 1 algorithm will guide the medically indicated action, which is treatment referral. The next step when addiction is not yet a concern is to ask the adolescent to commit to avoiding the behavior(s) and consider using a simple written contract to document this commitment. If the adolescent is unwilling or unable to commit or seems to underestimate the significance of alcohol or other drug use, consider breaking confidentiality to protect student safety. Adolescents who choose to disclose such high-risk behaviors to a clinician might be asking for help. If breaking confidentiality is required to protect safety, discuss with the adolescent exactly what you will disclose and what you can keep confidential. Often, teens are most concerned about protecting small details (ie, which friends are involved, where they obtained substances, etc) that would have minimal impact on their immediate safety plan and can be kept confidential. Design a plan that involves the parent(s) or another responsible adult, professional counselors, and other substance abuse–related services. Schedule close follow-up to ensure student compliance and safety.

High Risk: CRAFFT-Positive. Adolescents who test positive on the CRAFFT screen, defined as having a CRAFFT score of 2 or greater, are at high risk of having a substance use disorder. The middle right side of the SBIRT algorithm shows that the adolescent with a positive CRAFFT-screen result should undergo further assessment to detect whether the alcohol and/or other drug use indicates acute danger or “red flags” for addiction and to reveal the level of conviction the adolescent has for engaging in behavior change. To look for a pattern of increasing alcohol or other drug use, ask adolescents about their drug use history, their experience with any alcohol- or other drug-associated problems or troubles, and whether they have made quit attempts and why. A well-conducted assessment that encourages an adolescent to discuss problems associated with drug use and reasons for quit attempts is consistent with motivational-interviewing or motivational-enhancement techniques for supporting positive behavior change and can be the first step of brief intervention for this level of substance use. Anticipatory guidance to avoid riding with a driver who has been drinking or using drugs is always appropriate.

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CRAFFT Part B

CRAFFT > 2 Brief Assessment

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“Tell me about your alcohol and drug use.

“What are the good things about your alcohol and drug use- reasons you want to use?”

“What are some of the downsides to drinking or using?

“Where would you like to go from here?”

No Acute Danger or Red Flag

Red Flags for Addictions

Signs of Acute Danger

An adolescent who reports experience with certain risk behaviors, such as having a drug-related hospital visit, using intravenous drugs, combining sedatives (including alcohol, benzodiazepines, barbiturates, or opioids),consuming a potentially lethal volume of alcohol (14 drinks), or driving or engaging in other potentially dangerous activity after alcohol or drug use, shows clear signs of acute danger that warrant immediate intervention (Fig 1, lower-right rectangle). If any sign of addiction is also present, the corresponding lower-middle portion of the Fig 1 algorithm will guide the medically indicated action, which is treatment referral. The next step when addiction is not yet a concern is to ask the adolescent to commit to avoiding the behavior(s) and consider using a simple written contract to document this commitment. If the adolescent is unwilling or unable to commit or seems to underestimate the significance of alcohol or other drug use, consider breaking confidentiality to protect student safety. Adolescents who choose to disclose such high-risk behaviors to a clinician might be asking for help. If breaking confidentiality is required to protect safety, discuss with the adolescent exactly what you will disclose and what you can keep confidential. Often, teens are most concerned about protecting small details (ie, which friends are involved, where they obtained substances, etc) that would have minimal impact on their immediate safety plan and can be kept confidential. Design a plan that involves the parent(s) or another responsible adult, professional counselors, and other substance abuse–related services. Schedule close follow-up to ensure student compliance and safety.

High Risk: CRAFFT-Positive. Adolescents who test positive on the CRAFFT screen, defined as having a CRAFFT score of 2 or greater, are at high risk of having a substance use disorder. The middle right side of the SBIRT algorithm shows that the adolescent with a positive CRAFFT-screen result should undergo further assessment to detect whether the alcohol and/or other drug use indicates acute danger or “red flags” for addiction and to reveal the level of conviction the adolescent has for engaging in behavior change. To look for a pattern of increasing alcohol or other drug use, ask adolescents about their drug use history, their experience with any alcohol- or other drug-associated problems or troubles, and whether they have made quit attempts and why. A well-conducted assessment that encourages an adolescent to discuss problems associated with drug use and reasons for quit attempts is consistent with motivational-interviewing or motivational-enhancement techniques for supporting positive behavior change and can be the first step of brief intervention for this level of substance use. Anticipatory guidance to avoid riding with a driver who has been drinking or using drugs is always appropriate.

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CRAFFT >2:

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No Acute Danger or Red Flag

BI: To stop or cut down

Give Brief Advice and summary
Give praise and encouragement if willing to quit.
Plan follow-up

CRAFFT >5; < 14 years; daily or near daily use; alcohol related blackouts (memory lapses)

Use BNI

Summarize
Refer to treatment (5 or 6)
Invite Parents
Plan follow-up

Red Flags - Addictions

Red Flags for Addiction

Probable substance addiction is indicated by red-flag findings, including a CRAFFT score of 2 or more in an adolescent aged 14 years or younger, daily or near-daily use of any substance, a CRAFFT score of 5 or higher, and alcohol-related blackouts (memory lapses) (Fig 1, lower-middle rectangle). Breaking confidentiality to protect student safety is, again, a key consideration. Parents should be involved in this process whenever possible, because most adolescents will not follow through with a referral on their own. In most cases, parents will already be highly suspicious or aware of their adolescent’s drug use, although they might underestimate the extent or severity. Adolescents might be willing to include their parent(s) in a discussion of recommendations, particularly if the clinician can present any concerns and recommendations in the context of positive student and family attributes, such as mentioning the adolescent’s honesty when screened or willingness to undergo further assessment. An adolescent with an addiction red flag should be referred for detailed evaluation and subspecialty treatment that is as specific to adolescents with substance use disorders as possible (see “Referral to Treatment”).

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CRAFFT >2:

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Signs of Acute Danger: Drug-related hospital visit; use of IV drugs; combining alcohol use with benzodiazepines’ barbiturates or opiates; consuming potentially lethal volume of alcohol (14 or more drinks); driving after substance use

Use BNI

Make an immediate intervention

Contract for safety

Discuss confidentiality and possibly contacting parents

Plan follow-up

An adolescent who reports experience with certain risk behaviors, such as having a drug-related hospital visit, using intravenous drugs, combining sedatives (including alcohol, benzodiazepines, barbiturates, or opioids),consuming a potentially lethal volume of alcohol (_14 drinks), or driving or engaging in other potentially dangerous activity after alcohol or drug use, shows clear signs of acute danger that warrant immediate intervention (Fig 1, lower-right rectangle). If any sign of addiction is also present, the corresponding lower-middle portion of the Fig 1 algorithm will guide the medically indicated action, which is treatment referral. The next step when addiction is not yet a concern is to ask the adolescent to commit to avoiding the behavior(s) and consider using a simple written contract to document this commitment. If the adolescent is unwilling or unable to commit or seems to underestimate the significance of alcohol or other drug use, consider breaking confidentiality to protect student safety. Adolescents who choose to disclose such high-risk behaviors to a clinician might be asking for help. If breaking confidentiality is required to protect safety, discuss with the adolescent exactly what you will disclose and what you can keep confidential. Often, teens are most concerned about protecting small details (ie, which friends are involved, where they obtained substances, etc) that would have minimal impact on their immediate safety plan and can be kept confidential. Design a plan that involves the parent(s) or another responsible adult, professional counselors, and other substance abuse–related services. Schedule close follow-up to ensure student compliance and safety.

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Let’s Review

Screening does not provide a diagnosis.
Screening does provide immediate rule-out of no risk/low risk users.
Screening does provide immediate identification of level of risk.
There are 2 levels of screening:

Universal.
Targeted.

There are 4 types of intervention:

Feedback.
Brief Intervention.
Extended Brief Intervention or Brief Treatment.
Referral for further assessment.

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3 Statements…

A 41-year-old woman says: “Last night Joe really got high and he came home late and we had a big fight. He yelled at me and I yelled back and then he hit me really hard! He broke a window and the TV set, too! It was like he was crazy. I just don’t know what to do!”

Write here what you would say next:

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3 Statements…

A 36-year-old man says: “My neighbor really makes me mad. He’s always over here bothering us or borrowing things that he never returns. Sometimes he calls us late at night after we’ve gone to bed and I really feel like telling him to get lost.”

Write here what you would say next:

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3 Statements…

A 15-year-old girl says: “I’m really mixed up. A lot of my friends, they stay out real late and do things their parents don’t know about. They always want me to come along and I don’t want them to think I’m weird or something, but I don’t know what would happen if I went along either.”

Write here what you would say next:

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What do people find helpful?

When an individual is faced with a dilemma, what do they find helpful?

As a group let’s come up with as many things as possible.

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What do people find helpful?

Being listened to.

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If we aren’t listening what are other things we may be doing?

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Roadblocks

Telling/Ordering
Warning/Threatening
Disagreeing
Judging
Giving advice/solutions
Moralizing
Labeling
Interpreting/Analyzing
Reassuring
Pitying
Self-disclosing

Telling/Ordering “You need to..” – Provokes resistance, discord, rebellion. No one like being told what to do & this often results in resentment. People rarely engage in conversations to be told what to do. Patients will often feel like their needs aren’t being taken into consideration.

Warning/Threatening “If you don’t start right now..” – these kinds of responses bring the threat of power. They invite the patient to do exactly what they are being warned not to do. They produce resentment, anger, rebellion

Persuading – This implies we believe the patient hasn’t adequately reasoned through the problem and needs help in doing so.

Giving advice/solutions “It would be best if you” “have you tried?”

It’s often true that people don’t want advice. Just because a patient comes to get an appointments doesn’t mean they are ready to follow through with what we think is the best solution. It also implies that we are superior & limits autonomy support. Before we give advice, we must develop partnership, understand what the patient wants, and what they know/have tried.

Moralizing “The right things to do…” – Some vague authority is brought into the picture again. This can make them feel guilty or inadequate.

Analyzing “What’s wrong with decision is..” playing patients therapist isn’t helpful. Being right can leave them feeling vulnerable and exposed & being wrong can cause resistance and discord

Self-disclosing “ I’ve dealt with something similar..” – minimizes their lived experience, causes them to feel detached

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Understanding Change

Change is a universal phenomenon. We all experience it and go through change processes.

At the core of an individual struggling to make healthy decisions or chance is unresolved ambivalence or inadequate closure

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MI and Principles of Change

People want to be their best self
People already have within themselves what they need to be their best self
My job is to evoke it

What are the implications

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Implication for statement 1

Asks us to trust and hold in our hearts an unshakable belief that people are making decisions they believe are in their best interest.

Allowing clients to make mistakes

Never expressing judgment

Learning how to disagree in a non-confrontational manner

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Implication for statement 2

If people already have what they need within themselves, it means there is nothing I need to give or do for someone on their behalf.

Strong need for partnership

People need to feel safe to explore what is important to them, their values, and self-confidence

No need to fix a person’s problem

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Implication for statement 3

If my job is to evoke from a client their best self it means my responsibility is not to fix a problem for a client or

Strong need for partnership

People need to feel safe to explore what is important to them, their values, and self-confidence

No need to fix a person’s problem

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Key Takeaways

Understanding what people find helpful and unhelpful is important as providers.

Reflecting on and thinking through the 3 principles of change can enhance our ability to be helpful.

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A member of the patient shares,

“My furnace broke the other day, and I can’t afford to get it fixed. I went down to the shop to see if I could get the part to fix it myself but I’m afraid I won’t be able to get it fixed.”

You really shouldn’t try to fix it yourself. You could get seriously hurt.�
Who did you call to get it fixed. Maybe you need to shop around more to find a price you can afford.�
That’s really overwhelming. How do you think you’re going to move forward?

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Brief Intervention (BI) Motivational Interviewing and

4 BI Options��Module Three

Re-designing How We Treat Substance Use Problems

This module will go over the screening process and specifically address using the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test – 10 (DAST – 10).

Module 2: Re-defining the Identification of Substance Use Problems

Objectives:

• Understand the information screening does and does not provide.

• Recognize the 2 levels of screening.

• Recognize the 4 interventions based on screening results.

• Become familiar with the AUDT C, AUDIT, and DAST-10 screening tools.

• Encourage active participation.

Instructional Methods (IM):

Didactic – the instructor explains the content knowledge.

Collaborative – the instructor asks the learners to process the content knowledge through facilitated

discussion.

Role play – participants will practice screening role plays.

Practice:

Direct delivery – there are multiple roles plays for participants to practice with the AUDIT and the DAST.

Animated Slides: Yes

Video: Yes

Materials: Copies of slides; copies of standard drink chart, copy of AUDT -C, AUDIT, and DAST-10.

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SBIRT Decision Tree

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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What is Brief Intervention (BI)?

A Brief Intervention is a time limited, individual counseling session.

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What are the Goals of BI?

The general goal of a BI is to:

Educate the patient on safe levels of substance use.
Increase the patient's awareness of the consequences of substance use.
Motivate the patient towards changing substance use behavior.
Assist the patient in making choices that reduce their risk of substance use problems.

The goals of a BI are fluid and are dependent on a variety of factors including:

Screening score.
Readiness to change.
The patients' specific needs.

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What is Your Role?

Provide a safe and supportive environment.
Offer information on low-risk substance use, the link between substance use and other lifestyle or healthcare related problems.
Understand the client’s viewpoint regarding their substance use.
Explore a menu of options for change.
Assist the patient in making new decisions regarding their substance use.
Support the patient in making changes in their substance use behavior.
Give advice if requested.

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Ask Yourself

Who has the best idea in the room?

The Patient

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Where Do I Start?

What you do depends on where the patient is in the process of changing.

The first step is to be able to identify where the patient is coming from.

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Stages of Change:�Primary Tasks

1. Precontemplation

Definition:

Not yet considering change or

is unwilling or unable to change.

Primary Task:

Raising Awareness

2. Contemplation

Definition:

Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:

Resolving ambivalence/

Helping to choose change

3. Preparation

Definition:

Committed to changing.

Still considering what to do.

Primary Task:

Help identify appropriate

change strategies

4. Action

Definition:

Taking steps toward change but

hasn’t stabilized in the process.

Primary Task:

Help implement change strategies

and learn to eliminate

potential relapses

5. Maintenance

Definition:

Has achieved the goals and is

working to maintain change.

Primary Task:

Develop new skills for

maintaining recovery

6. Recurrence

Definition:

Experienced a recurrence

of the symptoms.

Primary Task:

Cope with consequences and

determine what to do next

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

The Stages of Change is a theoretical perspective that we can use to understand where a person is coming from in terms of their substance use. At the top in blue is the first stage called precontemplation. At this stage people do not see a problem with their use and are not considering change.

Use the pointer so participants can follow along on screen.

The stages that follow are contemplation, preparation, action, maintenance, and recurrence.

Contemplation is a stage that we strive to move clients to if they are at risk for substance use related problems. Clients in the contemplation stage can see the possibility of change, but they are ambivalent about changing.

The preparation stage is where we begin to identify strategies for change.

Action is where changes are taking place.

Maintenance is where patients have achieved their goal and are working to maintain their new behaviors.

Recurrence is when patients may relapse or go back to their old behaviors. Recurrence is part of the process of changing.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Stages of Change: Intervention Matching Guide

Offer factual information Explore the meaning of events that brought the person to treatment Explore results of previous efforts Explore pros and cons of targeted behaviors	Explore the person’s sense of self-efficacy Explore expectations regarding what the change will entail Summarize self-motivational statements Continue exploration of pros and cons	Offer a menu of options for change Help identify pros and cons of various change options Identify and lower barriers to change Help person enlist social support Encourage person to publicly announce plans to change

Support a realistic view of change through small steps Help identify high-risk situations and develop coping strategies Assist in finding new reinforcers of positive change Help access family and social support	Help identify and try alternative behaviors (drug-free sources of pleasure) Maintain supportive contact Help develop escape plan Work to set new short and long term goals	Frame recurrence as a learning opportunity Help to develop alternative coping strategies Explain Stages of Change & encourage person to stay in the process Maintain supportive contact

1. Pre-�contemplation

2.Contemplation

�3.Preparation

4.Action

5.Maintenance

�6.Recurrence

This chart shows what strategies we can employ with patients at the different stages of readiness to change. If we look at the first two stages—which are most relevant for people engaging in at-risk levels of substance use—we can see that our goals are just to offer information or feedback, explore the meaning of events, explore pros and cons of substance use, and build self-efficacy.

Patients may not be ready to make a change at the time of this brief intervention. However, they may be willing to explore the pros and cons of their use, or track levels of use to see if they may have a more significant problem than they realized. By linking the interventions to where they are in the stages of change, we can help to move them forward in the stages and increase the likelihood that they will take action.

If we get ahead of them (ask them to take action before they have identified that they even have a problem), we are likely to stimulate resistance.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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“People are better persuaded by the �reasons they themselves discovered than �those that come into the minds of others”�Blaise Pascal�

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Motivational Interviewing�(MI)

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�Motivational Interviewing�

Motivational Interviewing is a person-centered, evidence-based, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence with the individual.

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Patient-centered refers to a fundamental collaborative approach to the practitioner/Patient relationship. Patient-centered specifically refers to Carl Rogers (1946) reflective listening which is a central skill for a Motivational Interviewing practitioner. The practitioner follows the patient’s thoughts, feelings and perceptions and responds with reflective statements. Reflective statements include degrees of complexity such as possible meaning behind the patient’s statement and reflection of possible patient feelings.

Evidence-based includes practices that are shown to be successful through research. Models that have shown the greatest levels of effectiveness have the ability to replicate successful outcome with different populations, over time.

Person-centered: Person-centered is a transition of the term patient-centered. It is advocated for use by those who believe it is less clinical, less role defining, more equalizing and more personable than the term patient-centered. The term person-centered also serves to broaden MI’s relevance beyond the clinical setting.

Directive: MI is both patient-centered meaning it follows the patient’s thoughts, feelings and perceptions, and directive. Directive refers to the use of specific strategies and interventions that may facilitate the patient’s movement toward exploration, change talk, problem recognition (resolving ambivalence) or the decision to change. The practitioner guides the discussion towards the possibility of change.

Intrinsic Motivation: The motivation that comes from the patient. It’s in there somewhere, and it’s the practitioner’s job to find out what it is and amplify it, reflect it back.

Ambivalence: This refers to the patient’s experience of conflicting thoughts and feelings about a particular behavior or change – advantages and disadvantages. The MI practitioner listens for and evokes the Patient’s reasons for concern and arguments for change (change talk), while also accepting and reflecting perceived disadvantages of change (sustain talk). The practitioner reflects both sides, sometimes in the form of a double sided reflection. The recognition of ambivalence may add clarity where the patient has not been ready to move forward or reach a decision. The MI practitioner listens for and evokes the patient’s own arguments for change and assists the patient to keep moving in the direction of change.

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Why Motivation

Research has shown that motivation-enhancing approaches are associated with greater participation in treatment and positive treatment outcomes.

(Landry, 1996)

(Miller, et al., 1995)�

A positive attitude and commitment to change are also associated with positive outcomes.

(Miller & Tonigan, 1996)

(Prochaska & DiClemente, 1992)

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Ask the participants to think about something they want to change. After a few moments elicit a response to this question: “How long have you thought about changing the thing you are thinking about”? Responses will range from days, to weeks, to months, to years…..This exercise demonstrates how difficult change really is even when you want to change.

Sources:

Landry, M.J. (1996). Overview of addiction treatment effectiveness. Substance Abuse and Mental Health Services Administration, SMA96-3081.

Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.F., Montgomery, H.A., Hester, R.K., & Tonigan, J.S. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R.K. Hester & W.R. Miller (eds.), Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd ed. NJ: Allyn and Bacon, p. 12-44.

Miller, W.R., & Tonigan, J.S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10, 81-89.

Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. The American Psychologist, 47(9), 1102-14.

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Motivation

Motivation is not something one has but is something one does.
Motivation is a key to change.
Motivation is dynamic and fluctuates.
Motivation can be influenced.
Motivation can be modified.
The clinician can elicit and enhance motivation.

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Motivational Interviewing

Creates therapeutic partnerships:

Motivational Interviewing encourages an active partnership where the client and counselor work together to establish treatment goals and develop strategies.

Uses empathy not authority:

Research indicates that positive outcomes are related to empathy and warm and supportive listening.

Focuses on less intensive treatment:

Motivational Interviewing places an emphasis on less intensive, but equally effective care, especially for those whose use is problematic or risky but not yet serious.

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Motivational Interviewing

Assumes motivation is fluid and can be influenced.
Motivation is influenced in the context of a relationship – developed in the context of a patient encounter.
Principle tasks – to work with ambivalence and resistance.
Goal – to influence change in the direction of health.

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Goal of MI

To create and amplify discrepancy between present behavior and broader goals.

How?

Create cognitive dissonance between where one is and where one wants to be.

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The MI Shift

From feeling responsible for changing patients’ behavior to supporting them in thinking & talking about their own reasons and means for behavior change.

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Video of a practitioner who is not using Motivational Interviewing

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http://youtu.be/_VlvanBFkvI

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Rate the BI

How would you rate this providers Motivational Interviewing skills?
Imagine you are the patient….How do you feel?
Is this approach:

Helpful?
Harmful?
Neutral?

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How willing do you think this patient will be to change her use or decrease her risk as a result of this intervention?

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1 2 3 4 5 6 7 8 9 10

Not Willing

Very Willing

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MI Tools

DARN CAT
OARS
EARS

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Types of Change Talk

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Desire: I want to…. I’d really like to….I wish….
Ability: I would….I can….I am able to....I could….
Reason: There are good reasons to….This is important….
Need: I really need to….
Commitment: I intend to….I will….I plan to….
Activation: I’m doing this today….
Taking Steps: I went to my first group….

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Eliciting Change Talk

Attending Skills
Open-ended Questions
Affirmation
Reflective Listening
Summary
Eliciting Change Talk

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Responding to Change Talk: EARS

Elaborations: directive statements that ask the client to share more about what they just expressed.

- “In what way…?” � - “What else?”

- “Tell me more about…”

Affirmations: reflective statements that highlight a person’s strengths and positive characteristics.

- “You’re a person who can make changes when needed”

- “That took a lot of strength to…”�

Reflections: statements that evoke from the client more change talk.

- “This is the most important thing to you right now”

Summaries: statements that evoke from the client more change talk.

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“I grew up always being told I was a failure. It’s not my fault I can’t get it done.”

Respond with E.A.R.S.

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“At the end of the day I’m responsible for the choices I make so what’s it matter to other people what I do. It’s my choice.”

Respond with E.A.R.S.

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“It’s always been hard for me to make change. I can never seem to get it right for a long enough period.”

Respond with E.A.R.S.

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“I’m really proud of myself. I’ve been able to take some positive steps. I’m worried I’ll fall back, but I don’t want to lose hope.”

Respond with E.A.R.S.

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Importance

Confidence

Readiness

The Keys to Readiness

Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New York, NY: Guilford Press.

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Importance Ruler

On a scale of 1-10 how important is it for you to change your drinking, drug use, substance use?
Why not a lower number?
What would it take to move to a higher number?

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IMPORTANCE

1 2 3 4 5 6 7 8 9 10

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Readiness Ruler

On a scale of 1-10 how ready are you to make a change in your drinking, drug use, substance use?
Why not a lower number?
What would it take to move it to a higher number?

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READINESS

1 2 3 4 5 6 7 8 9 10

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Confidence Ruler

On a scale of 1-10 how confident are you that you could change your drinking, drug use, substance use?
Why not a lower number?
What would it take to move it to a higher number?

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CONFIDENCE

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Video of a practitioner who is using Motivational Interviewing

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http://youtu.be/67I6g1I7Zao

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Rate the BI

How would you rate this providers Motivational Interviewing skills?
Imagine you are the patient….How do you feel?
Is this approach:

Helpful?
Harmful?
Neutral?

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How willing do you think this patient will be to change her use or decrease her risk as a result of this intervention?

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Not Wiling

Very Willing

1 2 3 4 5 6 7 8 9 10

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Zingers

Push back, Resistance, Denial, Excuses:

Look, I don’t have a drinking problem.
My dad was an alcoholic; I’m not like him.
I can quit anytime I want to.
I just like the taste.
That’s all there is to do in (my town)!!!!

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Handling Zingers

I’m not going to push you to change anything you don’t want to change.
I’m not here to convince you that you have a problem/are an alcoholic.
I’d just like to give you some information.
I’d really like to hear your thoughts about….
What you decide to do is up to you.

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Let’s Review

A brief intervention/brief negotiated interview is a time limited, individual counseling session.
The goals of a BI are fluid depending on a variety of factors.
The patient has the best idea in the room.
Use MI tools.
Always listen for change talk.
Be prepared for zingers.
Always end on a positive note.

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Brief Interventions �for Patients at Risk for �Substance Use Problems

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Four BI Model Options

FLO (Feedback, Listen and understand, Options explored)
4 Steps of the BNI (Raise the Subject; Provide Feedback; Enhance Motivation; Negotiate and Advise)
Brief Negotiated Interview (BNI) Algorithm (Build Rapport; Pros and Cons; Information and Feedback; Readiness Ruler; Action Plan)
FRAMES (Feedback; Responsibility; Advice; Menu of options; Empathy; Self efficacy)

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The 4 Steps of a Brief Negotiated Interview

1) Raise The Subject

2) Provide Feedback

3) Enhance Motivation

4) Negotiate And Advise

D'Onogrio, G., Pantalon, M.V., Degutis, L.C., O'Connor, P.G., Fiellin, D., Owens, P., & Martel-Regan, S. (2008). Screening, brief intervention, and referral to treatment (SBIRT) training manual for alcohol and other drug problems. Retrieved from http://medicine.yale.edu/sbirt/curriculum/manuals/SBIRT%20training%20manual_2012_tcm508-100719_tcm508-284-32.pdf

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Step 1: Raise the Subject

Key Components

Be respectful
Ask permission to discuss use
Avoid arguing or being confrontational

Key Objectives

Establish rapport
Raise the subject�

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Step 2: Provide Feedback

What you need to cover.

1. Ask permission; explain how the screen is scored

2. Range of scores and context

3. Screening results

4. Interpretation of results (e.g., risk level)

5. Substance use norms in population

6. Patient feedback about results

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Click to animate in Item 1

Once you have permission, you start by helping the patient understand the scoring for the instrument.

Click to animate in Item 2

At minimum, provide the range of scores and some context for understanding them.

Click to animate in Item 3

Then, give the score

Click to animate in Item 4

and explain what the score means in terms of their relative level of risk.

Click to animate in Item 5

Next, relate the patient’s substance use (drinking or drug use) to the norms in the larger population. Normative information can be powerful because many people, particularly college students, believe that everyone in college drinks a lot when in fact many students do not drink or use drugs. Sharing information about norms can help patients get an accurate picture of social norms and realize that their level of use may be above average.

Click to animate in Item 6

Finally, ask the patient for her reaction to the score and any feedback.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Feedback

Handling Resistance

Look, I don’t have a drug problem.
My dad was an alcoholic; I’m not like him.
I can quit using anytime I want to.
I just like the taste.
Everybody drinks.

What would you say?

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Feedback

Easy Ways to Let Go

I’m not going to push you to change anything you don’t want to change.
I’m not here to convince you that you have a problem/are an alcoholic.
I’d just like to give you some information.
I’d really like to hear your thoughts about…
What you decide to do is up to you.

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Feedback

Finding a Hook

Ask the patient about their concerns
Provide non-judgmental feedback/information
Watch for signs of discomfort with status quo or interest or ability to change
Always ask this question: “What role, if any, do you think alcohol played in your (getting injured)?
Let the patient decide.
Just asking the question is helpful.

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

When we elicit feedback about the screening results, we want to listen intently for a hook or a piece of information that we can use to leverage “change talk.”

Ways that we can find the hook include asking the patient about his or her concerns and watching for signs of discomfort with the status quo. For example, a college student may share that partying and drinking a lot is expected when you belong to a fraternity or sorority. The student may have some concerns about keeping up with his or her brothers or sisters because the partying can interfere with studying.

Always ask the question, “What role, if any, do you think alcohol or drugs played in your getting injured or depressed or sanctioned? You can fill in the last part of the question with the specific situation of your patient.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Form Dyads/Triads

Practitioner
Patient/Client

Practice Session:

Providing Feedback

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Role Play

Lets practice Feedback:

Give Feedback Using Completed Screening Tools
Establish rapport
Raise the subject
Give feedback results
Express concern
Substance use norms in population
Elicit patient feedback about the feedback

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Now we are going to practice giving Feedback using the sample AUDIT that is in your folder. The patient is named Chris and can be a man or a woman. The AUDIT has been filled out for you and you will see the score (13) at the top. The completed AUDIT is in the resource section. “How much is too much (What counts as a drink?)” in the resource section can also be helpful here. Please take a minute to review the “Tools and Resources” section of the appendix and select a tool or tools (like the AUDIT Scores and Zones) that will help you give feedback. Form pairs. One person should play the clinician or counselor and one the patient. We’ll stay in these roles through a few activities and I’ll let you know later when it’s time to switch.

Check to see that everyone has a copy of the AUDIT.

SBIRT Role Play Scenarios

Chris Sanchez- The Man

You are a 40 year old divorced father of 2 boys, age 9 and 7. You have your own catering business, which is struggling. You have high blood pressure, feel stressed and have bouts of depression from time to time. You are mostly a beer drinker, but occasionally add hard liquor to the mix. You find that drinking is both a social activity and a stress reducer. However, it has had some negative effects on your work and your relationship with your sons and your ex-wife. You have driven after drinking on more than one occasion but have never been arrested for DUI. Your doctor is concerned about your stress and how it is affecting your blood pressure, so he recommended some counseling to address your stress and depression.

Chris Sanchez- The Woman

You are a 38 year old married mother of 3 children between the ages of 7 and 11. You have a part-time job as a waitress, working 24 hours a week. Your husband drives a bus for the local transit authority and works a variety of shifts. You have a lot of stress balancing the needs of your family with your work, and you experience occasional bouts of depression. You drink mostly wine at home to relax but enjoy a “night out with the girls” when you get the chance. You often find it difficult to get up in the morning to get your kids off to school. Your husband has sometimes complained about your drinking, which makes you angry, since he drinks too. Your doctor recently diagnosed you with early stage type 2 diabetes. He recommended that you get some counseling to help you deal better with your stress and depression.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Step 3: Enhancing Motivation

Critical components:

Develop discrepancy
Reflective listening
Open-ended questions
Assess readiness to change

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Enhancing Motivation

Ambivalence is Normal

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Enhance Motivation

Importance/Confidence/Readiness

On a scale of 1–10…

How important is it for you to change your drinking?
How confident are you that you can change your drinking?
How ready are you to change your drinking?

For each ask:

Why didn’t you give it a lower number?
What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Another tool is the importance, confidence or readiness ruler. This is really just a number line from 1 to 10. You can preprint one or simply draw one on a piece of paper. To use the ruler, you need to pick the issue that the patient is most concerned about.

The ruler can be use to determine how ready the person is to make a change, how important making a change is to them or how confident they are that they will be able to make the change. In our example below we will use readiness.

Show the patient the ruler and ask him or her, “On a scale of 1 to 10, with 1 being not at all ready and 10 very ready, how ready are you to… change your drinking/work on your relationship/try another strategy for your pain, whatever you think the issue is they want to talk about. Only focus on one issue in the intervention.

More than likely, people will not choose 1, but will aim a little higher. If they choose 1, it is not an issue that they are willing to talk about at all which probably means that you are not focusing on the issue that is most important to them. Refocus and try another issue.

After the patient responds, you counter by asking why they didn’t chose a lower number, e.g., “Why not 2?” You want them to defend the higher number. Their responses will be very informative and will likely contain some change talk.

You should never go more than two points below the number they originally select. This ensures that you do not minimize too dramatically the number they select, or make them feel as if they need to make huge changes to reach a new number. You can also ask them to explain why they have not chosen a number that is 2 above the number they selected, as this can provide relevant information as well.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Enhance Motivation

Strategies for Weighing the Pros and Cons
What do you like about drinking?
What do you see as the downside of drinking?
What else?
Summarize Both Pros and Cons
“On the one hand you said..,
and on the other you said….”

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

We want the patient to discuss the pros and cons of using alcohol and/or drugs. This is unusual for many of us because as health providers and educators, we tend to only talk about the negative aspects of alcohol and drugs. If we can appreciate the good things about using, we can understand the underlying need of using (feeling less depressed, increased social interactions). This can help point the way to solutions once we get to that point. Discussing the positive effects of use can also help to build rapport.

Ask the participants:

Who here likes chocolate chip cookies? What do you like about them?

Reflect their feelings in order to demonstrate understanding.

What else is good?

You want to push the limits of the conversation.

Are there any downsides?

When you hear ambivalence in their remarks, reflect it using a double sided-reflection.

To do a double-sided reflection, use this formula.

Click to advance the animation

On the one hand you like…; on the other hand… You want to reflect both sides of the statement to highlight

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Dig for Change Talk

I’d like to hear your opinions about…
What might you enjoy about…
If you decided to ____ how would you do it?
What are some things that bother you about using?
What role do you think ____ played in your ______?
How would you like your drinking/using to be 5 years from now?
What do you need to do in order to_____?

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Listen to Understand Dilemma. Don't Give Advice.

Ask:
Why do you want to make this change?
What abilities do you have that make it possible to make this change if you decided to do so?
Why do you think you should make this change?
What are the 3 best reasons for you to do it?
Give short summary/reflection of speaker’s motivation for change
Then ask: “So what do you think you’ll do?”

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Form Dyads/Triads

Practitioner
Patient/Client

Practice Session:

Enhancing Motivation

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Role Play

Let’s practice Enhance Motivation:
Using Completed Screening Tool
Importance/Confidence/Readiness Scales
Pros and Cons
Develop Discrepancy
Dig for Change Talk
Summarize

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Now we are going to role play Enhance Motivation. You want to pick up where you left off with the Feedback step and start exploring the reasons why a patient might want to make risk-reducing changes. Ask the patient what they think they will do, offer advice if relevant, and summarize patient’s views.

Allow 5 min. for the role play. Walk around the room to observe and assist. Again, each participant should be in the same pair and playing the same role (clinician/counselor or patient) as before. Ask participants to report how the exercise went. Ask for feedback from the people playing the clinician and then the patients. Reflect back what the participants describe and provide encouragement.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Critical components:
Negotiate a plan on how to cut back and/or reduce harm
Direct advice
Provide patient health information
Follow-up

Step 4: Negotiate and Advise

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

The Advice Sandwich

Ask Permission

Give Advice

Ask for Response

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

What now?
What do you think you will do?
What changes are you thinking about making?
What do you see as your options?
Where do we go from here?
What happens next?

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

You can also explore previous strengths, resources, and successes
Have you stopped drinking/using drugs before?
What personal strengths allowed you to do it?
Who helped you and what did you do?
Have you made other kinds of changes successfully in the past?
How did you accomplish these things

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

Offer a Menu of Options
Manage drinking/use (cut down to low-risk limits)
Eliminate your drinking/drug use (quit)
Never drink and drive (reduce harm)
Utterly nothing (no change)
Seek help (refer to treatment)

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

The goal here is for the patient to generate acceptable options toward change and then to select one that they are willing to try. You can offer menu options if the patient has difficulty coming up with their own ideas.

Try to provide concrete examples of things they can do to reduce their risk of harm, e.g., not drinking and driving and cutting back on the number of drinks per day. For patients in the high risk range, seeking professional help from a specialist is an option that should be discussed. Remember that patients have a choice. Of course, doing nothing is also an option. But in addition to doing nothing, you can suggest to the patient that you monitor how things are going. Are there any questions about this?

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

Giving Advice Without Telling Someone What to Do
Provide Clear Information (Advice or Feedback )
What happens to some people is that…
My recommendation would be that…
Elicit their reaction
What do you think?
What are your thoughts?

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Negotiate and Advise

Closing the Conversation (“SEW”)
Summarize patients views (especially the pro)
Encourage them to share their views
What agreement was reached (repeat it)

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Video of a practitioner conducting BI for alcohol use (ambivalent client)

135

https://www.youtube.com/watch?v=25kE7p0-V0M

SBIRT Colorado. [Video files]. Retrieved from http://improvinghealthcolorado.org.

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Form Dyads/Triads

Practitioner
Patient/Client

Practice Session:

Negotiate and Advise

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Role Play

Let’s practice Negotiate and Advise
Ask about next steps, offer menu of options
Offer advice
Summarize patient’s views
Repeat what patient agrees to do

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Now we are going to role play Negotiate and Advise. You want to pick up where you left off with Enhance Motivation and start exploring options. Ask about next steps, offer advice if relevant, and summarize patient’s views. Finally, end by repeating what the patient agreed to do. Make sure the steps the patient agrees to take are realistic and that the patient shows a commitment to taking them. Writing the plan down can be a useful exercise. Let’s take 5 minutes.

Allow 5 min. for the role play. Walk around the room to observe and assist. Again, each participant should be in the same pair and playing the same role (clinician/counselor or patient) as before. Ask participants to report how the exercise went. Ask for feedback from the people playing the clinician and then the patients. Reflect back what the participants describe and provide encouragement.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Role play: Putting It All Together

Raise The Subject

Establish rapport
Raise the subject

Provide Feedback

Provide screening results

Relate to norms

Get their reaction

Enhance Motivation

Assess readiness
Develop discrepancy
Dig for Change

Negotiate and Advise

Menu of Options
Offer advise

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

Now we are going to role play the 4 Steps, but we are going to switch roles with our partners. The person playing the patient will now be the clinician or counselor. Start again with the AUDIT score and go through the feedback, listen and understand, and options explored. Let’s take 10 to 15 minutes to run through this.

Allow 10-15 minutes for the full role play. Walk around the room to see how people are doing how. Take another 5 minutes to debrief with the audience at the conclusion of the role play, asking for feedback from the people playing the clinician and then the patients. Reflect back what the participants describe and validate their experiences or concerns.

Source: Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Extended �Brief Intervention��Module Four��

A Brief Treatment Model

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Extended BI/Brief Treatment

An extended BI/Brief Treatment consists of ongoing individual counseling sessions with patients scoring in AUDIT Zone III or DAST Level Moderate/High Risk.
Generally, extended BI/BT consist of 4 to 6 sessions, up to 1 hour in duration.
Additional tools and exercises can be used to enhance and support readiness to change.

140

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Extended BI/Brief Treatment

Who is most appropriate for EBI/BT?
Who will provide EBI/BT?
What are the goals of EBI/BT?
When will the interventions take place? Frequency?
Where is the most appropriate setting?
Why is EBI/BT indicated?
How will you know when EBI/BT is completed?

Anything else?

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Extended BI/Brief Treatment

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AUDIT Scores and Zones

Score	Risk Level	Intervention
0-7	Zone 1: Low Risk Use	Alcohol education to support low-risk use – provide brief advice
8-15	Zone 2: At Risk Use	Brief Intervention (BI), provide advice focused on reducing hazardous drinking
16-19	Zone 3: High Risk Use	BI/EBI – Brief Intervention and/or Extended Brief Intervention with possible referral to treatment
20-40	Zone 4: Very High Risk, Probable Substance Use Disorder	Refer to specialist for diagnostic evaluation and treatment

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Extended BI/Brief Treatment

The type of provider may be dependent on:

Scope
Competence
Availability
Reimbursement

143

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Referral to Treatment for Patients at Risk for Substance Dependence��Module Five

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Referral to Treatment

Approximately 5% of patients screened will require referral to substance use evaluation and treatment.
A patient may be appropriate for referral when:

Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use.�

These high risk patients will receive a brief intervention followed by referral.

Addiction Technology Transfer Center Network. (2011). SBIRT curriculum. Retrieved from http://attcnetwork.org/home/.

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Referral to Treatment

AUDIT Scores and Zones

Score	Risk Level	Intervention
0-7	Zone 1: Low Risk Use	Alcohol education to support low-risk use – provide brief advice
8-15	Zone 2: At Risk Use	Brief Intervention (BI), provide advice focused on reducing hazardous drinking
16-19	Zone 3: High Risk Use	BI/EBI – Brief Intervention and/or Extended Brief Intervention with possible referral to treatment
20-40	Zone 4: Very High Risk, Probable Substance Use Disorder	Refer to specialist for diagnostic evaluation and treatment

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