sbirt and beyond: prevention before...

SBIRT and Beyond: Prevention before Indication

Center for Young Adult Addiction & RecoveryKennesaw State University Patrick N. Moore LPC

CYAARCenter for Young Adult Addiction and Recovery CRC Student Advisor AOD Education Peer Education Screening Brief Interventions Referrals Research Relapse Prevention CRC 101 early recovery

2(Moore, 2013)

Peer Educators

ObjectivesDefine Prevention Paradox

SBIRT Review See model powered SBIRT

Beyond SBIRT Collaboration for radical change

Examine Causal Evidence of Addiction

The Prevention Paradox (Acute) Babor et al. 201064% of Alcohol related deaths & 70% of Alcohol related hospitalizations are Light and Moderate Drinkers – Low Risk

Historic Perspective Facts & Relevance1750 to Early 1800s Sobriety “Circles” are formed within various Native American Tribes.1840 The Washingtonian Society 600,000 members in 5 years before declining1849 Introduction of the term Alcoholism by Swedish physician Magnus Huss1880s Treatment is now available by gender, ethnicity and drug type. 1901 Charles B. Towns Hospitial for Drug and Alcoholic Addictions – Detox 1907-1913 State laws passed calling for mandatory sterializaiton of “defectives” (mentally ill, developmentally disabled, alcoholics1935 Bill Wilson and Dr. Bob Meet1944 Research started Yale Center of Alcohol studies, (moved to Rutgers), National Committee for Education on Alcoholism (today

the National Council on Alcoholism and Drug Dependence. 1951 Alanon Family Groups is organized. 1960s Insurance reimburses for treatment, Armed forces build programs. 1970 Congress passed the “Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act” NIAAA 1980s Just Say No; MADD, special populations treatment, drug free workplance, War on Drugs, 1st Drug Court ; SOAR , SBIRT1990s adolescent treatement approaches2000s Expansion of SBIRT2015 Beyond SBIRT Johann Hari – Chasing the scream (connectedness)2015: 21 Intervenitons found for 18-25 yo re: Alcohol and/ or Drug www.nrepp.samhsa.gov National Registry of Evidence –based Programs and Practices. Either for indicated or evidence was frequency/quantity265 Years: Causation? Measurement? Prevention? Low Risk Intervention? Progress? Explains Prevention Paradox / Limitedmodels

www.williamwhitepapers.com/pri/additiontreatment%26RecoveryInAmerica.pdf

http://www.nrepp.samhsa.gov/

Public Health Model: Disease can be understood and treated by understanding the interaction of the Agent, Environment, and Host.

Risk Model: Hazard x Exposure = Risk

Conflation: Hazard(Alcohol) x Exposure (Environment) = Risk (Host)

Science Perspective

New Models Review How Applied

Selection Bias Model

Where to put extra armor?Collect and study evidence.

Put the armor where there is no damage. Abraham Wald (Livio, 2013)

Change by Talking Model● Combat Demoralization (Define Demoralization)● Emotionally Charged Confiding Relationship (Inform)● Rationale (Model to explain Acute & Chronic outcomes)● Rituals (Specific Directions to Change or Maintain)● Healing setting ( With Peers in Classroom)● Opportunities for new learning (Outside the Classroom)

(Frank, 1998)

Communications Model Risk Communications: A Mental Model Approach was

investigated. (2002, Morgan et al) Morgan et al with the help of several grants including grant IU19AI 38513 from The National Institute for Alcohol Abuse and Alcoholism, created a text book to generate Mental Models to deliver and measure interventions to people with limited time, energy and attention.

The focus here is on change in risk comprehension and response. The authors point out this perspective creates a common method for treating diverse problems. It is the ignorance of or mistaken beliefs about risk that is intervened on. Morgan et al defines risk communications as “communication intended to supply laypeople with the information they need to make informed independent judgments about risks to health, safety, and the environment.

Cont’D However, Morgan cautions “Better

understanding cannot guarantee changes in behavior; those depend on how people perceive benefits as well as risks, and on their resources and constraints.”

Education Model (Ambrose et al., 2010) Student’s prior knowledge can help or hinder learning. How students organize knowledge influences how they learn and apply what they know. Students’ motivation determines, directs and sustains what they do to learn. To develop mastery, students must acquire component skills, practice integrating them, and

know when to apply what they have learned. Goal-directed practice coupled with targeted feedback enhances the quality of students

learning. Students’ current level of development interacts with the social, emotional, and intellectual

climate of the course to impact learning. To become self-directed learners, students must learn to monitor and adjust their approaches

to learning.

No Assessment like Self Assessment

● Introduce Ambivalence – might have an issue● Increase discrepancy (remove Ambivalence) – I

have an issue● Encourage Low Risk – keep doing the right thing● Lower Resistance to Tx – where do I get help?

14

MI model: Who is the smartest person in the room?

(Miller & Sanchez, 1994)

Empowerment Model (80s) How and Why it works (Causality) Measure over time for short and long term goals Empowerment is a Host process Theoretical Orientation linking above

(Cummings, 2001)

Perception GUYS Daniel Kahneman - Affective Bias David Gardner - A baseball and bat = $1.10 Jared Diamond - What kills people in the Jungle? Low

Risk / Frequently Occurring David Ropeik - Perception Gaps , “we are not just an

amygdala and a puddle of stress hormones.” We can reduce the perception gap through conscious awareness and challenging our affective response system from time to time.

Possible to integrate the Host now – not in 200 more years

Hazard(Alcohol) x Exposure (Environment)x Host (Risk Perception) = Risk

Updated Science Perspective

Presented By:

Stephen H. O’Neil, DirectorGeorgia BASICS SBIRT Project

2 Peachtree Street, NW, Suite 22-265Atlanta, GA 30324

(404) [email protected]

19(O’Neil, 2012)

IfWe 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.

21(O’Neil, 2012)

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 advise,

and; Identification of patients who would benefit from higher levels of

care. Progressive levels of clinical interventions based on need and

motivation for change.

22

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 to a higher level of care.

Let’s Review

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 as dependence. 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.

24

The SBIRT ModelA Continuum of Substance Use

25

AbstinenceExperimental

Use

Social Use

Binge Use

AbuseDependence

(O’Neil, 2012)

26

Drinking Behavior Intervention Need

5%

20%

75%

Dependent

Low Risk orAbstinence

No Intervention or screening and Feedback

Brief Intervention and Referral for additional Services

(O’Neil, 2012)

Model Driven SBIRT Screen Use Selection Bias Brief Intervention Change by Talking Referral to Treatment Ed. and Com. models How do I know? Change by Talking

Function Model

Disease Model

Demoralization: Can’t tell right from wrong. Alcoholics Anonymous 1955

How do I know?30 day test3 Bs

Recovery Model

Alcoholics Anonymous 1955

BEYOND SBIRT Selection Bias Model: Prehab is the New Rehab Other Useful Models : Brief Interventions New Objectives: Measuring Risk

New Objectives Identify and Intervene on 20% Educate, encourage and prevent 75% Introduce Ambivalence to 5% Before Indication Before Progression Interrupt Prevention Paradox

Research & Results Hypothesis: Education increases risk perception judgment Experiment: N=457 College Freshmen / peer ed Results: There is a positive relationship

No one wants or chooses addiction or sudden tragedy.

How hard can this be to prevent?

Earthlings: Great Perceivers, Poor Interpreters

Being Careful is not a substitute for Judgment

New Models Risk Factors Motivational Assessment Prevention Program

The answers lead to a new model

What influences perception?

Risk Factors

(Ropeik 2010)

The human brain over the last 100,000 years is remarkable for Fear and Risk perception calculations. Problem: We don’t live in caves anymore…

1. Feeling (Gut), very fast, uses predetermined rules, very decisive.

Two Brain Theory: Risk Factors start here.

2. Logic (Head) very accurate, not very fast or influential. Rational

Judgment comes from Gut; Head rationalizes.

The power of Gut A ball and bat cost $1.10 together. The bat cost $1.00 more than the ball. How much does the ball cost?

Power of Head x + (x +1) = $1.10 2x + 1 = $1.10 2x = $.10 X = .05

Risk Factors & Heuristics TrustRisk vs. BenefitControl ChoiceNatural or Man madePain and SufferingUncertaintyCatastrophic or ChronicCan it happen to me?New or Familiar RiskRisks to ChildrenPersonificationFairnessMagnitudeProbability

Framing effectCategorizationFallacy of a Small SampleProblems with ProbabilityLoss AversionEndowment EffectAnchoring and AdjustmentAwareness/Ready Recall EffectInnumeracyOptimism BiasDiagnosis BiasValue Attribution Escalation of CommitmentAvailability

Naïve diversificationAffect heuristicEffort heuristicFluency heuristicGaze heuristicPeak-end ruleRecognition heuristicScarcity heuristicSimilarity heuristicSimulation heuristicSocial ProofTake-the-best heuristic

What influences Risk Perception? Risk Factors – usually keeps us safe – can result in Risk Perception Gaps.

(Ropeik 2010)

Risk Factor Principles Each factor can increase or decrease fear. (Breakthrough) Many factors combine in a given situation. Biases are other inputs Risk Perception Factors are universal but not the same

dependent on personal experience.

(Ropeik 2010)

The answers lead to a new model

What influences perception?Risk Factors: #1 Risk /Benefit#2 Good Bad#3 New Familiar#4 Social Proof#5 Commitment

(2012) Reyna

Risk Factors explain whyPerception is Powerful in Lifestyle Choices.

#1 RISK / BENEFIT

Low Risk

Good

If familiar or new and perception “feels” good…

Then benefits increase as risk is perceived as low.

The opposite is also true and involves fear of loss

#2 GOOD / BAD

Evolution’s answer to Google. How to sort and survive too much Info

Remember driving the first time?

#3 NEW / FAMILIAR

What’s important? Is it new?

Everything else – Habituation (off switch) Survival Mechanism

Social Proof (not peer pressure) Social proof is a type of conformity. When a person is in a situation where

they are unsure of the correct way to behave, they will often look to others for cues concerning the correct behavior. When "we conform because we believe that other's interpretation of an ambiguous situation is more accurate than ours and will help us choose an appropriate course of action,"[1] it is informational social influence. This is contrasted with normative social influence wherein a person conforms to be liked or accepted by others.

“http://en.wikipedia.org/wiki/Social_proof”

#4 SOCIAL PROOF

http://en.wikipedia.org/wiki/Conformity_(psychology)

http://en.wikipedia.org/wiki/Social_proof%23cite_note-1

http://en.wikipedia.org/wiki/Normative_Social_Influence

Social Proof

3/27/77 #5 Commitment

2015 Virgin Galactic SpaceShipTwo Pilot error; unlocked tail boom too early

Mandated Rest Periods

Hazards that carry a low risk but encountered frequently

Let’s camp here! Odds are only 1/1000 a tree falls on us tonight. 1/1000 = Certain Death in a few Years Never sleep next to dead trees = Constructive Paranoia

(Diamond, 2013)

What influences Negative Outcomes? Simple.

What Kills People in the Jungle?

Stage Physical Mental Perception Outcome

0 No tolerance issues No obsession issues Constructive ParanoiaStable Risk / Benefit

No progressionNo smoking / No drunksMature judgment

1 No tolerance issues No obsession issues New / Good Social Proof

Acute deaths & AccidentsOr to Stage 0 or 2

2 Tolerance adjustment Impulse Value AttributionGroup PolarizationEuphoric RecallEscalation/Commitment

Acute deaths & AccidentsOr to Stage 0 or 3

3 Tolerance peaks Preoccupation Familiar / Good Confirmatory BiasOptimistic

Addiction progression Or to Stage 0 or 4

4 Withdrawal Obsession Desperate for change -Cling to familiar Pain & Suffering Loss Acceptance

Can’t stop, can’t quit Recovery (abstinence) or Jails, Institutions, Death

* Copyright 2013, Patrick Moore MA LPC

New Model Needs a New Assessment.

● What stage were you at?

● What Stage are you at?

● What Stage will you be at?

(Moore, 2013) * Copyright 2013, Patrick Moore MA LPC

Repeated Measures

0 1 0Velocity of Risk


Direction of Risk

OperationalizeINTERVENTION MAINTENANCE PREVENTION

Any decrease after intervention and 0 or 1

No change and 0 or 1 from last two columns.

Any score ending in an increase or 2.


Are we doing any good?

N=457 Results

INTERVENTION

TAV Frequency Freqency % Cumulative Fr. Cumulative Fr % % Sample010 27 29% 92 100% 20.13%110 10 11% 65 71%121 8 9% 55 60%210 7 8% 47 51%020 6 7% 40 43%021 5 5% 34 37%320 4 4% 29 32%221 3 3% 25 27%331 2 2% 22 24%120 2 2% 20 22%220 2 2% 18 20%

01.50 2 2% 16 17%01.51 1 1% 14 15%340 1 1% 13 14%34.5 1 1% 12 13%330 1 1% 11 12%321 1 1% 10 11%11.5 1 1% 9 10%440 1 1% 8 9%310 1 1% 7 8%230 1 1% 6 7%030 1 1% 5 5%031 1 1% 4 4%040 1 1% 3 3%231 1 1% 2 2%410 1 1% 1 1%

Total 92


59

MAPP Stage Intervention Need

5%

20%

75%

Dependent

HazardousHarmfulSymptomatic

Low Risk orAbstinence

Lower Codependence; Encourage LR

Identify & Intervene BEFORE Indication

Lower Resistance NOW

(O’Neil, 2012)

Intervention SR Maintenance LR Prevention HR

20% 74% 6%


20% 75% 5%Target

Results

Was Is Will be eCHUG WHO TAV

High Risk 1% 1% 0% 2% 5% 6%

Some Risk 13% 14% 5% 18% 20% 20%

Low Risk 86% 85% 94% 80% 75% 74%

N=457 Fall 2014


Collaboration SBIRT and EDBIRT = End of Prevention Paradox

Sim

ilar b

ut d

iffer

ent

SBIRT MAPP

Intervene HR progression (risk reduction) Intervene on LR progression (Directional Intervention)

Screen Sort

Behavioral Perception

Chronic Acute

Target 25% Some Risk & High Risk Target 100% Some Risk & Low Risk & High Risk

Model None / DM is BI Model DM and RF

Continuum Stage

Postive Negative Measure direction before and after intervention

65

Low Risk Intervention High Risk Intervention

5%

20%

75%(Patrick N. Moore 2015)

66

Low Risk Intervention High Risk Intervention

0%

5%

95%(Patrick N. Moore 2015)

Perception Gaps: Nomothetic Causation?

The variables must be correlated The cause takes place before the effect The variables are nonspurious

Since no “complete cause” in Social Resarch… Necessary cause must be present Sufficient cause must be present

Babbie, 2004

There’s More Previous Interventions

Repeated Measures

2 1 0Intervention

Intervention Maintenance Prevention Total TST

Preintervention 3% 9% 1% 13%

Prerisk 13% 8% 3% 23%

High risk 2% 0% 2% 4%

Low risk 3% 57% 0% 60%


Intervention Maintenance Prevention Total TST Change Locus Total Change Locus

Pre-intervention 3% 9% 1% 13% Low Risk base 57%

Pre-risk 13% 8% 3% 23% EDBIRT/MAPP 20%

High risk 2% 0% 2% 4%Prior to EDBIRT/MAPP 17%

Low risk 3% 57% 0% 60% High Risk 6%

100%

17% of interventions prior to eBIRT: Another 20% after eBIRT . High Risk 6% is all that is left. Of these 26 students, only six selected above stage 2 going forward.

Time Matters in a Progressive Model. Waiting for Indication is too late

96% of 457 freshmen responded to MAPP by selecting stage 0 or stage 1 going forward.

The smallest category has the most Pre High Risk. Of the 26 students in the Prevention High Risk Category only 6 chose above stage 2 going forward.

Some Risk is estimated at 20% to 22.7% by WHO and SAMHSA

The Athletic Sample is 12.57%Substance Abuse 101 is 40.95%

MAINTENANCE

TAV Frequency Freqency % Cumulative Fr. Cumulative Fr % % Sample

000 211 62% 339 100% 74.18%

111 40 12% 128 38%

011 30 9% 88 26%

100 17 5% 58 17%

211 9 3% 41 12%

200 7 2% 32 9%

001 5 1% 25 7%

300 4 1% 20 6%

01.5 4 1% 16 5%

00.5 3 1% 12 4%

400 2 1% 9 3%

.5.5.5 2 1% 7 2%

311 2 1% 5 1%

0.5.5 1 0% 3 1%

-101 1 0% 2 1%

411 1 0% 1 0%

Totals 339


PREVENTION

TAV Frequency Freqency % Cumulative Fr. Cumulative Fr % % Sample

022 5 19% 26 100% 5.69%

222 4 15% 21 81%

122 3 12% 17 65%

322 3 12% 14 54%

333 1 4% 11 42%

223 1 4% 10 38%

444 1 4% 9 35%

2.52.52.5 1 4% 8 31%

022.5 1 4% 7 27%

023 1 4% 6 23%

12.52.5 1 4% 5 19%

233 1 4% 4 15%

132 1 4% 3 12%

032 1 4% 2 8%

332 1 4% 1 4%

Totals 26

457


The Educator was great and very strong to stand and give a testimony

This has been an eye opener as far as my issues w/alcohol. I have been aware of my issues and problems w/drinking, but this has been very revealing as to some the reasons.

I drink and use amphetamines on a weekly basis. I don't find it a necessity but definitely a very strong want. I want to slow down eventually.

The 4 stages really helped me realize that I may have a bigger problem than I thought + I could really relate to a lot of the mental processes described in the addiction cycle.

This presentation opened my eyes. I like the speaker's use of personal experience.

While the presentation is helpful and does encourage thoughtful decision making, it only seems like it'll reach stages 0-2 because 3&4 probably will deny having a problem & be dismissive.

smiley face

High Risk Comments

I feel that is something that is important for all college students to know. Educator knew what he was talking about very well. I would make it on an easier level so people don't get as bored and pay more attention.

Thank you for being so informative, I'm going to change some of my habits.

The 70% of death being low risk is scary. I had so many drinks that other night my room mate turned me on my side B4 threw up & probably saved my life. Thank you.

It's interesting to know that most people who are harmed by alcohol are those that are not necessarily addicted

I am a member of a fraternity and drinking is synonymous with Greek life so it's hard to be a member and not get hammered every weekend.

This helped me open my eyes to see the truth about alcohol and drug used / abuse. Thank you so much for taking the time to teach me, and help me become aware of the effects and the future effects this usage withholds. Heart shape.

You helped me understand me ten times better and the risks I am at. Thank you for helping me out.

I have had a family member at stage 4 and this presentation helped me better understand what he is/was going through

Stages most helpful. Good presentation. I learned a lot of new things.

Good presentation. Made me think more about what I do.

Very interesting - enjoyed learning more into this concept. Better understanding on my part. I like to think I am responsibleThis was a nice presentation.

Some Risk Comments

This was fantastic, thank youvery good presentationI enjoyed learning about the processes of addiction on a deeper level .

The examples and explanations were helpful and created a better and unique understanding.This was a very informal talk. I enjoyed the information shared

Great for freshman, allowing them to be aware of the consequences of having "fun" without limits.

Lecture was helpful on understanding the evolutionary reason behind addiction. How the brain works.

Lecture was informative and helpful in understanding how our brains work and the process of addiction.

It was helpful to see the concept of how people become addicted and risk factors of addiction.

I wasn't a smoker until I came to campus, made some friends, and picked up the habit. I know its bad, yet I still do it. Over all the presentation was well constructed and the speaker did a phenomenal job. Very good presentation. I hope that all learning communities see this presentation.All freshmen must know this information about addictions.

Low Risk Comments

Results:

● Increase Risk Perception● Decrease Negative Outcomes● Reduce addiction● Reduce Codependence● Accelerate Recovery● The beginning of the end of addiction

MAPP*● Motivational ● Assessment ● Prevention ● Program

80

Motivational Interviewing in a box

(Moore, 2013) * Copyright 2013, Patrick Moore MA LPC

20 million High School students will enter College this fall

4 million Prehab opportunities.

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