SBIRT: What It Is and How to Start Doing It

1. Virginia Summer Institute for Addiction Studies 2013 SBIRT:What It Is andHow to Start Doing It Michael Weaver, MD Division of General Medicine and Division of Addiction Psychiatry Virginia Commonwealth University School of Medicine

2. Objectives Classes of abused drugs Models of addiction Vulnerable populations Screening Brief intervention Addiction treatment Cases for Discussion

3. Drug Classes • Sedative-hypnotics • Opioids • Stimulants • Hallucinogens • Inhalants • Marijuana • Nicotine

4. Sedative-Hypnotics • Alcohol, benzodiazepines, barbiturates • CNS depressants • Disinhibition: depress inhibitions first • Reduce anxiety (fun at parties) • Sedation, anxiolytic • Oversedation, ataxia, respiratory depression

5. Other Sleeping Pills • Bind to BZ receptor subtypes • Zolpidem (Ambien) • Zalaplon (Sonata) • Eszopiclone (Lunesta) • Behavioral pharmacological profile similar to benzodiazepines • Drug liking, good effects, monetary street value • Recommended for short-term use, many taken long-term • May cause hazardous confusion & falls

6. Opioids • Morphine, heroin, OxyContin, methadone • Analgesics: disconnect from pain • Euphoria, disconnection, sedation • Nausea, constipation, itching • Oversedation, respiratory depression

7. Prescription opioid misuse/abuse • Use pain med to sleep, relax, soften negative affect • Short-acting are the most easily & widely available • Defeat extended-release mechanism • Problems • Sedation, confusion • Respiratory depression

8. Stimulants • Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine • Enhanced concentration, alertness • Edginess, paranoia, hypervigilance, psychosis • Hypertension, hyperthermia, vasoconstriction • Heart attack, stroke

9. Prescription Stimulant Abuse • Abused for euphoria, energy, alertness • Abused by • Students • Long-distance drivers • Polysubstance abusers • Problems • Vasoconstriction • Agitation, psychosis

10. Caffeine • Not just coffee, tea, soda • Energy drinks • Leads to • Anxiety • Tachycardia, palpitations • Disrupted sleep

11. “Bath Salts” • Synthetic derivatives of cathinone (khat) • Designer drugs • Methylenedioxy-pyrovalerone • Methcathinone • Methalone • Potent stimulants and hallucinogens • Labeled “not for human consumption” • Smoke, snort • Psychotic reactions

12. Hallucinogens • LSD, mescaline, psilocybin • Perceptual distortions • Hallucinations • Visual effects • “Bad trip” • Death most often due to perceptual and judgment errors

13. Volatile Inhalants • Common & legal • Use & abuse difficult to characterize • Examples • airplane glue (epoxies) • Freon (“freebies”) • carbon tetrachloride • amyl & butyl nitrite • nitrous oxide • propellant (spraypaint)

14. Marijuana • Pot, dope, Mary Jane • Widely popular, easily available, not illegal in certain states • Active ingredient: THC • relaxation, hallucination • short-term memory impairment, anterograde amnesia • panic attacks

15. K2 and Spice • Synthetic cannabinoids • More potent than THC • Solution sprayed on other plant material • Sold as incense • Smoked by users • Serious reactions with intoxication • Psychosis

16. “Ecstasy” Methylenedioxy-methamphetamine Stimulant Hallucinogen Entactogen “Special K,” “kitty” Ketamine Hallucinogen Anesthetic Used by teens at dance clubs (“raves”) Relatively new drugs Erroneously presumed safe Many drugs may be substituted (not “as advertised”) Have arrived in Central Virginia Club Drugs

17. Nicotine • ~ 400,000 deaths each year from health consequences of tobacco • Lung disease • Heart disease • Cancer • Cigarettes, cigars, pipes • Smokeless • “snuff,” “chew,” snus • Electronic cigarettes

18. Models of addiction • Disease • Genetic • Self-medication • Moral/volitional

19. Disease Model • Biologic basis • Chronic course • Relapses and remissions • No cure • Like other chronic diseases • Treatable • Individualize therapy • Medications may help improve outcomes

20. Picking your parents “Your DNA test shows you’re predisposed to sue doctors.” • Liability for Substance Use Disorders (SUD) aggregates in families • Twin studies • Adoption studies • Genetic factors • Genetic factors play an important role in alcohol and illicit drug use

21. Self-medication • Use of mood-altering substance is to ameliorate underlying negative psychiatric symptoms • Stimulants for depression • Alcohol or heroin for anxiety

22. Moral/Volitional Model • Personal choice • Weak willpower • Moral failing • Research doesn’t support this model

23. Vulnerable Populations • Adolescents • Elderly • Psychiatric Co-Morbidity

24. Addiction is an equal opportunity disease • Erroneous stereotypes • All social strata • All races • different susceptibilities • All age groups • 10% of population have problems due to substance abuse

25. Epidemiology in Adolescents • Youthful experimentation is common • Experimental: use <6 times • Most teens use drugs or alcohol occasionally without consequences • 80% of high school students have used alcohol • Problem behavior • 55% of youth have tried an illegal drug by 12th grade • 35% of 12th graders binge drink at least once a month • 4% of adolescents drink daily • 13% of adolescents smoke ½ pack/day

26. The Age Wave is cresting • First ‘Baby Boomers’ just turned 65 • This generation used illicit drugs in youth • Continue to use their drugs into older adulthood • Different from previous generations

27. Sensitivity to alcohol with age • Older adults more sensitive to alcohol • Reduced total body water • Higher concentrations • Reduced metabolism in GI tract • Amount with little effect in youth causes intoxication in older adults

28. Psychiatric Co-Morbidity • Higher risk for substance use among those with psychiatric disorders • Depression or anxiety disorders • Other psychiatric comorbidities • Personality disorders • May present with complex clinical histories and symptoms • Diagnosis challenging • Intoxication and withdrawal symptoms may be mistaken for other psychiatric or medical symptoms • Cognitive-behavioral counseling more challenging

29. Dual Diagnosis • Best success with treatment of both conditions simultaneously • Contact with health care system is opportunity to intervene • Earlier detection and intervention prevents problems

30. Clinicians often have difficulty identifying addicted patients • Don’t think/don’t ask about it • May not be obvious from a single visit • Patients may be unable to admit the problem to themselves • Patients may try to conceal it

31. Impact on Healthcare Providers • Medication misuse causes adverse health consequences for patient • Worsens prognosis of coexisting medical and/or psychiatric conditions • Significant proportion of practice is dealing with consequences of unrecognized/untreated addiction • Leads to practitioner frustration

32. Why screen patientsfor addiction? • Medical problems • Cardiovascular disease • Stroke • Cancer • Mental health • Depression • Anxiety • Sleep problems • Financial difficulties • Legal problems • Interpersonal problems • Family issues

33. Screening makes a difference • Patients reduce alcohol and tobacco use when this is addressed by a physician • Research shows benefits from screening and brief intervention for illicit and prescription drug abuse

34. Screening Tool forAlcohol Abuse CAGE Questions Cut down Annoyed Guilty Eye-opener Affirmative response to 2 or more is positive test

35. Diagnosis ofAlcohol Abuse/Dependence Continued substance use despite adverse consequences Use in larger amounts or for longer periods than intended Preoccupation with acquiring or using Inability to cut down, stop, or stay stopped, resulting in a relapse Use of multiple substances of abuse APA 2000

36. Drinking Guidelines Men: 2standard drinks/day No more than 14 drinks per week No more than 5 drinks on any one occasion Women: 1 standard drink/day No more than 7drinks per week No more than 5 drinks on any one occasion NIAAA 2005

37. Types of treatment Detoxification 12-Step groups Outpatient counseling Intensive outpatient Inpatient Residential

38. 12-Step Groups • A.A., N.A., C.A. • Group format • Anonymous • No cost • No affiliations or endorsement • Different groups have different characteristics

39. Success with 12-Step • More groups=more abstinence • No threshold, but at least 2 meetings/week best • Not affected by • Gender • Religion • Psychiatric diagnosis • Novice

40. Addiction Counseling • Motivational Interviewing • Network therapy • Family therapy • Supportive psychotherapy • Building Social Networks • Twelve-Step facilitation • Perceptual Adjustment Therapy • Rational Recovery • Medication Management • Brief Intervention

41. Treatment Matching • Engage patients with addiction by matching to optimal setting and modalities for most effective and least restrictive level of care • Base matching on • Intoxication and withdrawal • Medical complications, psychiatric factors • Treatment acceptance/resistance • Relapse potential, recovery environment

42. Treatment works Sustained remission rates of up to 60% Better success than treatment of hypertension, diabetes Every $1 spent on treatment saves $7 in costs to society Lots of new research

43. Patient Behavior • Ambivalence • Attracted to problem behavior (substance use) • Denial • Unable to admit problem to themselves • Actively conceal • Common to many chronic conditions

44. Motivation • Probability of certain behaviors • State of readiness to change • May fluctuate from one situation to another • Clinician’s goal is to increase the patient’s intrinsic motivation • change arises from within rather than being imposed from without

45. Brief Intervention Motivate patients to change problem behavior Multiple brief sessions Bridge to treatment or sufficient itself Same impact as more extensive counseling Most cost effective Weaver & Cotter 1998

46. Summary 10% of population has problems of addiction Different classes of drugs have different effects, from type of euphoria to side effects to withdrawal syndromes Addiction is a complex chronic disease with genetic and environmental factors Patients reduce substance abuse when this is addressed by a physician Recognition, diagnosis, and referral for treatment improves patient outcomes Screen for substance abuse in all patients, avoid stereotyping Addiction treatment is effective and cost-effective Brief intervention techniques help motivate patients to make healthier lifestyle changes

47. Questions?

48. Cases for Group Discussion

49. Objectives • Stages of Change • The 5 “A’s” • Elements of Brief Intervention • Practice Cases

50. Stages of Change • Precontemplation • Contemplation • Preparation • Action • Maintenance