TIPS & TOPICS
Volume 6, No.1
April 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

This month’s TIPS and TOPICS (TNT) marks the start of our sixth year of sending our free monthly e- newsletter. That means there are five years of material on the website that you can read, download and share. The time is getting closer when you will be able to search all that material; there are consultants revamping the website as we write

SAVVY

There has been a lot of attention lately on Screening and Brief Intervention (SBI) for alcohol and other drug use problems. Here is why screening is important plus some developments and resources:

Tip 1

• The vast majority of people who need addiction treatment never even reach out for help.

The 2006 National Survey on Drug Use and Health (NSDUH) found that 21.1 million needed (but did not receive) treatment for illicit drug or alcohol use. In the year prior to the survey, they found the following—-

Of those aged 12 or older who needed treatment for illicit drug or alcohol use, but who did not receive treatment:
–> 95.5% Did not feel they needed treatment
–> 3.0% Felt they needed treatment and did not make an effort to get treatment
–> 1.5% Felt they needed treatment and did make an effort to get treatment

You can see that there is a vast population of people who could benefit from SBI and referral to treatment.

Reference:
National Survey on Drug Use and Health (NSDUH): National Findings and Results From the 2006 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (SAMHSA). Published September, 2007. (http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Res ults.pdf).

Tip 2

• Physicians can now be paid for SBI.

Let your primary care physician or medical personnel know that not only is it the right thing to do to screen for substance use problems, but now they can be paid for identifying and intervening. Societal discrimination and lack of training will still mean they will need your support to help patients and clients get into appropriate treatment. But this is a great start to legitimizing better assessment and intervention.

** American Medical Association created codes 99408 (15-30 minutes) and 99409 (over 30 minutes interaction) for alcohol and/or substance use structured screening and brief intervention services.

** Center for Medicare & Medicaid Services created codes H0049 and H0050 for alcohol/and other drug screening and brief intervention.

** Centers for Medicare & Medicaid Services created codes G0396 and G0397 for reporting comparable services for Medicare fee-for-service schedule (FFS) patients.

Tip 3

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is developing standards for screening and brief intervention for alcohol and other drugs.

To further expand the continuum of healthcare to include SBI, the Joint Commission is seeking input from healthcare professionals, providers, measurement experts, consumers, government agencies and employers. Last year the Joint Commission implemented a WikiHealthCareTM application to make it easier for healthcare professionals to collaborate in the development of standards and quality improvement solutions. To collaborate with the Joint Commission on the development of SBI standards using this application, you will need to follow the steps below:

STEP #1: Register at the Joint Commission’s website at the following link:
http://wikihealthcare.jointcommission.org/twiki/bin/ view/TWiki.TWikiRegistration

STEP #2: To add comments to the SBIRT Wiki process, click on or paste the link below in your browser:
http://wikihealthcare.jointcommission.org/twiki/bin/ view/Perform/ScreeningAndBriefIntervention . Once you are there you will need to enter your username and password.

STEP #3: Once you have entered the SBIRT Wiki process, you should add to the content or modify existing content.

For more tidbits on the Screening and Brief Intervention, refer to a previous edition: April 2005 edition: in Savvy & Skills

SKILLS

By definition, screening and brief intervention needs to be brief, feasible, valid and user-friendly for both the practitioner and the patient and client. Here are some tips and resources from the National Institute on Alcohol Abuse and Alcoholism (NIAAA):

1. For alcohol, the NIAAA one question is a good start: How many times in the past year have you had 5 or more drinks in a day (men); 4 or more drinks in a day (women)?

• One standard drink – 12 ounces beer; 5 ounces of wine; 1.5 ounces of 80-proof spirits.
• Drinking limits: for healthy men to age 65 – no more than 4 drinks in a day AND no more than 14 drinks in a week.
• For healthy women and men over 65 – no more than 3 drinks in a day AND no more than 7 drinks in a week.
• Recommend lower limits or abstinence as medically indicated e.g., for patients taking medications that interact with alcohol; have a health condition exacerbated by alcohol; or pregnant (advise abstinence).
• Express openness to talking about alcohol use and any concerns it may raise.
• Re-screen at every opportunity.

2. Test your clinical skills in Screening and Brief Intervention online.

Just this month, NIAAA unveiled an online video program that trains clinicians to help people who drink too much. This “new, interactive video-training program demonstrates quick and effective strategies for screening patients for heavy drinking and helping them to cut down or quit.”

Based on the NIAAA Clinicians Guide, the online program features four 10–minute video case scenarios, each led by an expert clinician who offers insights and engages viewers in considering different strategies for treatment and follow-up.
The video scenarios take place in several different settings to show that clinicians in primary care, mental health, and other specialties are all in a prime position to make a difference.
The tutorial and case studies require about an hour to complete.

You can download the Clinician’s Guide and try the video program from the reference below.

Reference:
“Helping Patients Who Drink Too Much” – A Clinician’s Guide. Updated 2005 Edition.. National Institute on Alcohol Abuse and Alcoholism.

(Online Video Program Trains Clinicians to Help Patients Who Drink Too Much. Download at: http://www.niaaa.nih.gov/Publications/EducationTrainin gMaterials/guide.htm#slides)

3. Recognizing a problem is just the first step in helping a person actually make some changes.

Some people you work with may recognize they have a problem, but may not be all that concerned about it. Or if they are concerned, they may not intend to do anything about it. Or even if they really want to do something about it, they may be demoralized and have no self-efficacy – i.e. meaning that they have no confidence and optimism that change is possible for them. Based on their previous failures, it may not seem worth it to them to even make the effort to try to change.

So here are some ways to explore where your client is really at.

Sample Questions To Evoke Self-Motivational Statements

Problem Recognition
–> What things make you think that this is a problem?
–> What difficulties have you had in relation to your drug use or emotions and behavior?
–> In what ways do you think you or other people have been harmed by your drinking or behavior?
–> In what ways has this been a problem for?
–> How has your use of tranquilizers or your behavior or emotions stopped you from doing what you want to do?

Concern
–> What is there about your drinking or emotions and behavior that you or other people might see as reasons for concern?
–> What worries you about your drug use or emotions and behavior? What can you imagine happening to you?
–> How much does this concern you?
–> In what ways does this concern you?
–> What do you think will happen if you don’t make a change?

Intention to Change
–> The fact that you’re here indicates that at least part of you thinks it’s time to do something.
–> What are the reasons you see for making a change?
–> What makes you think that you may need to make a change?
–> If you were 100% successful and things worked out exactly as you would like, what would be different?
–> What things make you think you should keep on drinking, behaving or feeling the way you have been? And what about the other side? What makes you think it’s time for a change?
–> I can see that you’re feeling stuck at the moment. What’s going to have to change?

Optimism
–> What makes you think that if you decide to make a change, you could do it?
–> What encourages you that you can change if you want to?
–> What do you think would work for you, if you needed to change?

Source: Miller and Rollnick, 1991 Modified to include dual diagnosis.

Reference:
Table above is modified from Figure 3-5 p.54, Treatment Improvement Protocol Series No. 35 (1999) “Enhancing Motivation for Change in Substance Abuse Treatment”, Consensus Panel Chair: William R. Miller, Ph.D. The Center for Substance Abuse Treatment.

SOUL

A lot of comedians make jokes about racial and ethnic stereotypes. The mean-spirited comedians are a turn- off and if they are on TV, I literally turn them off. But it was fortunate that at a live performance of Russell Peters- a comedian of Indian ethnicity, raised in Canada – there was no reason to turn him off. That would have been difficult sitting in the second front row six feet from him in a small comedy club in Sacramento, California. He was funny, insightful and good-natured in poking fun at the mostly Asians, Indians and a variety of others in the audience.

Russell made a good point that there is a big difference between your ethnicity and your culture. He was humorously relating how he was so proud to be an Indian, getting ready to bond with his Indian people until he actually arrived in India. As soon as the airplane door opened, he was confronted with sights, sounds and smells that screamed to him that he was much more Canadian than Indian.

In the heat of the US Presidential marathon, race, culture, gender, class, age, color, creed and religion have already tested our national fault lines. It’s too easy to reduce people to man, woman, old, young, black, white, elitist, populist, liberal, conservative and the ongoing list of politically correct categories.

And in the behavioral health world, it’s also easy to reduce people to alcoholics, addicts, schizophrenics, borderlines, sociopaths, manic-depressives and narcissists. In clinical work and in choosing a President, it’s going to be important to increasingly resist reducing people to a label.

If you think you know Chinese people, you don’t know me, because I’m a banana – yellow on the outside, but white on the inside – mostly anyway. I still like using chopsticks.

Until Next Time

Thanks for joining us as we start year six. See you in late May.

David