SCREENING AND BRIEF

INTERVENTION

CLARA HIDALGO-FUDERANAN,MD, FPCAM, FPCPsych, FPSMS

Psychiatrist/Addiction Specialist
Medical Specialist II
DOH-Dangerous Drugs Abuse Prevention and Treatment
Program
 DDB Board Regulation No. 7
Series of 2019
• Section 5. Screening and Assessment of
Person Who Used Drugs (PWUDs) and
Determination of Appropriate Intervention
Prior to the administration of standard screening tools,
an intake interview shall be conducted by the trained
paramedical which shall give primary importance on
establishing rapport and on determining the PWUD’s
risk factors for substance abuse disorder and identify
other areas of risks in relation to his/her drug abuse.

❑ Establish Rapport
❑ Intake Interview
❑ AFFIDAVIT OF UNDERTAKING AND WAIVER
under oath allowing the conduct of
screening/assessment
❑ Screen
❑ Brief Intervention
❑ Referral to Treatment
 BUILD RAPPORT—RAISE THE
SUBJECT

❑ Begin with a general

conversation.

❑ Ask permission to
talk about alcohol
or drugs.
Prior to the administration of standard screening tools,
an intake interview shall be conducted by the trained
paramedical which shall give primary importance on
establishing rapport and on determining the PWUD’s
risk factors for substance abuse disorder and identify
other areas of risks in relation to his/her drug abuse.

❑ Establish Rapport
❑ Intake Interview
❑ AFFIDAVIT OF UNDERTAKING AND WAIVER
under oath allowing the conduct of
screening/assessment
❑ Screen
❑ Brief Intervention
❑ Referral to Treatment
• Screening (ASSIST) and Brief
Intervention aim

➢ to identify current or potential

problems with substance use and
➢ motivate those at risk to change
their substance use behavior by
creating a connection, for the client,
between their current pattern of use
and the associated risks and harms
 SCREENING
• Done by : any trained paramedical (Healthcare Worker,
trained rehabilitation center personnel, qualified allied
professional, board certified psychiatrist and registered
psychologist, among others, and even to a DOH-
Accredited Physician
• Done where: RHU/health Center or facility, hospital,
school, workplace, community, etc.
• Screen for what: risk for drug dependency and co-
occurring disorders
• Screening Tools: ASSIST and SRQ and other evidenced-
based and internationally accepted screening tools
 SURRENDERERS/PWUDS WHO ARE CHILDREN (BELOW 18 YEARS
OLD) SHALL BE REFERRED TO A LICENSED SOCIAL WORKER THAT
WILL HANDLE THEM IN ACCORDANCE WITH BOARD
RESOLUTION NO. 4 SERIES OF 2019: ADOPTING THE PROTOCOL
WHEN HANDLING CHILDREN ALLEGEDLY INVOLVED IN
DANGEROUS DRUGS.

• Adolescent Screening, Brief Intervention,

and Referral to Treatment….
What does it look like?
 UNIVERSAL
PRESCREENING
• 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?
Best imbedded into a health and wellness survey.
 FULL
SCREENING
 SRQ
❑If the PWUD is found to be at risk for co-occurring
psychiatric/medical comorbidity during the screening and
interview, he/she shall be referred to the appropriate mental
health/medical professional who shall manage the mental issue
simultaneously with the drug use.

❑[Risk for severe medical comorbidity and/or risk for severe mental
comorbidity as defined by SRQ scores of:
➢ For question 1 to 20 (depression and anxiety) – positive score
is 5 or more; and
➢ For question 21 to 25 (psychosis) – 1 or more.]

❑Once the mental health problem is addressed and upon the

discretion of the mental health professional, he/she can be
referred back to the process flow. A clearance may be
requested from the mental health professional.
 ALCOHOL, SMOKING,
SUBSTANCE INVOLVEMENT
SCREENING TOOL (ASSIST)
 ASSIST
Screening shall yield the following results:

❑Low Risk for Drug Abuse and

Dependence (for ASSIST score of 0 to 3)
❑Moderate Risk for Drug Abuse and
Dependence (for ASSIST score of 4 to
26)
❑High Risk for Drug Abuse and
Dependence (for ASSIST score of 27
and above)
 ASSIST FEEDBACK REPORT
CARD
➢The risk scores are recorded on the
ASSIST feedback report card which is
used to give personalized feedback to
clients by presenting them with the
scores that they have obtained, and the
associated health problems related to
their level of risk.
 ASSIST-LINKED BRIEF
INTERVENTION
Results of the screening shall be discussed with the
PWUD by the trained paramedical who provided the
screening services.
PWUDs shall be provided with Brief Intervention. The
ASSIST-Linked Brief Intervention can be utilized for
feedback, information, and motivation to the PWUDs.
 STEP 1

➢ Ask the client if they are interested

in seeing their scores
◦ “Are you interested in seeing how
you scored on the questionnaire
you just completed?”
➢ Asking clients if they are interested in viewing
their scores allows the health worker to
commence a discussion (brief intervention) with
the client in a non-confrontational way, and has
been found to be a successful way of getting
clients at moderate risk, in particular, to change
their substance use
 STEP 2
➢ Provide personalized feedback to
clients about their scores using the
ASSIST Feedback Report Card

◦ Explain to the patient the definition of moderate risk

and high risk and high risk
◦ Explain the risk associated with each substance
used
◦ Link substance use behaviors to any known consequences.
 HARMS RELATED TO HAZARDOUS
ALCOHOL AND SUBSTANCE USE

Increased risk for—

• Injury/trauma

• Criminal justice involvement

• Social problems

• Mental health consequences (e.g., anxiety, depression)

• Increased absenteeism and accidents in the workplace

 STEP 3

➢ Give advise about how to reduce risk

associated with substance use
◦ “ The best way you can reduce your risk of these
things (harms) happening to you is to either cut
down or stop using drug”
 STEP 4
➢ Allow patients to take ultimate responsibility
for their choices
◦ Maintaining personal control is an important
motivating factor in achieving change
 “What you do with this information about your
drug use is up to you….I’m just letting you know
the kinds of harms associated with your current
pattern of use”
•There is something in human nature that
resists being coerced and told what to do.
Ironically, it is acknowledging their
freedom to choose and not change that
sometimes makes change possible
 STEP 5

➢ Ask clients how concerned they are

about their scores
◦ Use open ended questions
 “How concerned are you by your score for drug?”

• Verbalizing concern in supportive context

leads to change in beliefs and behaviour.
 STEP 6 AND 7
• Weighing up good things and less good things about using
the substance
• “What are the good things and less good things for you about
using the drug?”
• Health – physical and mental
• Social – relationship with family friends work colleagues
• Legal – accidents, contact with law enforcement, driving under
the influence of a drug
• Financial – impact on personal budget
• Occupational – difficulty with work, study
• Spiritual – feelings of self worth, guilt, wholeness
 STEP 8
• Summarize and reflect the client’s statements about his
substance use with emphasis on the less good things
Ex. - “ So you like the effect of the drug which makes you
feel talkative and confident… but you don’t like when you’re
taking the drug because you usually get into arguments saying
or doing things that you regret the next day”
 STEP 9

• Ask client how concerned he is by

the less good things
• “Do the less good things concern
you? How?”
 BUILD READINESS TO
CHANGE
Could we talk for a few minutes about your interest in
making a change?
On a scale from 1 to 10, 1 being not ready at all and 10
being completely ready, how ready are you to make any
changes in your substance use?
 NEGOTIATE A PLAN FOR
CHANGE

❑ A plan for reducing

use to low-risk levels
OR
❑ An agreement to
follow up with
specialty treatment
services
 STEP 10

• Give client take home materials to bolster the brief

intervention,
• ASSIST Feedback Report Card,
• General Information pamphlets of illegal
drugs/substances of abuse
 BRIEF INTERVENTION
AND STAGES OF CHANGE
• Prochaska and DiClemente and their
“Stages of Change” Model help
clinicians tailor brief interventions to
clients’ need to prevent treatment
resistance and non-compliance
 BRIEF INTERVENTION
AND STAGES OF CHANGE
 BRIEF INTERVENTION
AND STAGES OF CHANGE

• Pre-contemplation: Not considering any change. BI

must raise their awareness
Contemplation: Considering behavior change. To
resolve ambivalence, BI must help clients to choose
positive change over their current circumstances
Preparation: Preparing for acting on the behavior
change. BI must help client in identifying potential
change strategies and choosing the appropriate ones.
Action: BI must help client to carry out and comply
with the change strategies
Maintenance: BI can help client continue his behavior
change
• Relapse: earn from the experience;build confidence to
try again
 SUMMARY:

• Brief intervention can help initiate

change, continue it, accelerate it
and prevent the client from
regressing to previous behaviors
The way in which you talk with
people can substantially
influence their personal
motivation for behavior change.
 FRAMES: 6 ELEMENTS TO BI
(HESTER AND MILLER)

• Feedback: about risk or impairment of current level of use.

Responsibility: emphasis on personal responsibility for change;
reinforce that decision to change (or not) lies with service
user/client
Advice: offer advise to change behavior but respecting their right
to choose what is right for them
Menu: alternative options for changing and the person setting
their own goals
Empathy: listening reflectively without cajoling or confronting;
exploring the person’s reasons for change as they see their
situation; non-judgmental
Self-efficacy: an interviewing style which enhances peoples’
belief in their ability to change.
 LESSONS LEARNED
• SBIRT is a brief and highly adaptive evidence-
based practice with demonstrated results.
• SBIRT has been successfully implemented in
diverse sites across the life span.
• Patients are open to talking with trusted
helpers about substance use.
• SBIRT makes good clinical and financial sense.
 CASE MANAGEMENT
❑begins at the screening phase and provided seamlessly
throughout at all levels of care to all clients. The main
purpose of case management is to link clients to the
range of services that suit their individual needs.
❑Case managers work with the client, other members of
the treatment team, and other services or organization
in selecting the mix of interventions and support.
❑The appropriate mix of interventions and services is
based on research evidence.
❑ Questions could include: how appropriate a method is
to the client’s individual situation, how acceptable it is to
the client, whether trained staff are available, and
whether it is culturally appropriate, doable or accessible.
 Confidence to change is equally
important as the importance to
change.
If the person is not confident they run
the risk of talking themselves out of
change.
THANK YOU FOR YOUR
KIND ATTENTION!
QUESTIONS?
 WHAT IS SBIRT?
❑Screening, Brief Intervention and Referral to Treatment
(SBIRT) is a public health approach to the delivery of early
intervention and treatment services for individuals at risk of
developing substance use disorders (SUDs) and those who have
already developed these disorders
❑SBIRT focuses on the large numbers of people who may
use alcohol or drugs in unhealthy ways but who do not
have a substance use disorder (i.e., abuse,
dependence).
 SBIRT COMPONENTS
• Screening (S) identifies unhealthy use. 75-85% of patients will
screen negative.
For those who screen positive, further assessment is needed to
determine level of risk.
• Brief Intervention (BI) provides feedback about unhealthy
substance use. It also focuses on
education, increasing patient insight and awareness about
risks related to unhealthy substance use,
and enhances motivation toward healthy behavioral change.
• Referral to Treatment (RT) helps facilitate access to addiction
assessment and treatment. A referral
is usually indicated for only about 5% of people screened.
 WHY IS SBIRT IMPORTANT?

• Unhealthy and unsafe alcohol and drug use are

major preventable public health problems resulting
in more than 100,000 deaths each year.
• The costs to society are more than $600 billion
annually.
• Effects of unhealthy and unsafe alcohol and drug use
have far-reaching implications for the individual,
family, workplace, community, and the health care
system.
 WHY IS SBIRT IMPORTANT FOR
PHYSICIANS, CLINICIANS AND
OTHER PRIMARY CARE
PRACTITIONERS?
 WHY?
• Primary care and other settings such
as schools are convenient points of
contact for substance issues.
• SBIRT supports an overall emphasis
on health and wellness.
• SBIRT can decrease the incidence
and severity of alcohol and Drug use.
• It helps to change how substance
use is viewed.
 HOW MUCH TIME IS
NEEDED?
❑ Most patients (75-85%) will screen negative.
Completing 3-4 simple questions will take 1-2
minutes.
❑ For the remaining 15-25% of patients, the full screen
and brief intervention will take
between 5 - 20 minutes to complete.
 SBIRT IS A HIGHLY FLEXIBLE
INTERVENTION
SBIRT has been adapted for use in hospital emergency settings, primary care centers,
office- and clinic-based practices, and other community settings, providing opportunities
for early intervention with at-risk substance users before more severe consequences occur.

SBIRT Settings

Workplace Primary Care Clinic

Community /barangayHealth Center Psychiatric Clinic
Community Mental Health Center School-Based/ Student Health
Drug Abuse / Addiction Services Trauma Centers/Trauma Units
Emergency Room Urgent Care
Hospital Veterans Hospital
Homeless Facility Other Agency Sites
 PATIENTS ARE OPEN TO DISCUSSING THEIR
SUBSTANCE USE TO HELP THEIR HEALTH

Survey on Patient Attitudes

Agree/Strongly Agree
“ If my doctor asked me how much I drink, I would give an
92%
honest answer.”

“ If my drinking is affecting my health, my doctor should

96%
advise me to cut down on alc ohol.”

“ As part of my medical care, my doctor should feel free to

93%
ask me how much alcohol I drink.”
Disagree/Strongly Disagree
“ I would be annoyed if my doctor asked me how much
86%
alcohol I drink.”
“ I would be embarrassed if my doctor asked me how much
78%
alcohol I drink.”
Source: Miller, P. M., et al. (2006). Alcohol & Alcoholism .
Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum( www.sbirtoregon.org)
 SBIRT REDUCES SHORT- AND
LONG- TERM HEALTH CARE
COSTS
• Multiple cost benefit analyses have
demonstrated its cost savings.
• Late-stage intervention and substance abuse
treatment is expensive, and the patient has
often developed comorbid health conditions.
 STRONG RESEARCH AND
SUBSTANTIAL EXPERIENTIAL
EVIDENCE SUPPORTS THE
MODEL
• There is substantial evidence for the
effectiveness of brief interventions for harmful
drinking. There is a growing body of literature
showing the effectiveness of SBIRT for risky
drug use.
SAMHSA Whitepaper, 2011 (http://www.samhsa.gov/prevention/sbirt/SBIRTwhitepaper.pdf)
 LESSONS LEARNED
• SBIRT is a brief and highly adaptive evidence-
based practice with demonstrated results.
• SBIRT has been successfully implemented in
diverse sites across the life span.
• Patients are open to talking with trusted
helpers about substance use.
• SBIRT makes good clinical and financial sense.