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

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

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Drug Classes Sedative- hypnotics Opioids Stimulants Hallucinogens Inhalants Marijuana Nicotine

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

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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

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

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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

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

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

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

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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

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

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

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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

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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

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Club Drugs 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

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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

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Models of addiction Disease Genetic Self-medication Moral/volitional

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

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Picking your parents Your DNA test shows youre 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

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

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Moral/Volitional Model Personal choice Weak willpower Moral failing Research doesnt support this model

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Vulnerable Populations Adolescents Elderly Psychiatric Co-Morbidity

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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

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Epidemiology in Adolescents Youthful experimentation is common Experimental: use

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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

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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

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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

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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

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Clinicians often have difficulty identifying addicted patients Dont think/dont 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

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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

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Why screen patients for addiction? Medical problems Cardiovascular disease Stroke Cancer Mental health Depression Anxiety Sleep problems Financial difficulties Legal problems Interpersonal problems Family issues

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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

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

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APA 2000 Diagnosis of Alcohol 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

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NIAAA 2005 Drinking Guidelines Men : 2 standard 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 7 drinks per week No more than 5 drinks on any one occasion

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

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

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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

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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

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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

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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

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

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Motivation Probability of certain behaviors State of readiness to change May fluctuate from one situation to another Clinicians goal is to increase the patients intrinsic motivation change arises from within rather than being imposed from without

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Weaver & Cotter 1998 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

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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

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Questions?

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Cases for Group Discussion

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Objectives Stages of Change The 5 As Elements of Brief Intervention Practice Cases

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Stages of Change Precontemplation Contemplation Preparation Action Maintenance

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Precontemplation No intention to change behavior for the foreseeable future (at least in the next 6 months) Unaware that they have a problem Resistance to recognizing or modifying a problem

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Contemplation Aware that a problem exists seriously thinking about overcoming problem not yet made a commitment to take action Seriously considering changing the behavior in the next 6 months Weighing of the pros and cons of the problem and the solution to the problem Facilitation Provide feedback (history, problems, labs, etc.)

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Preparation Planning to change behavior intending to take action in the next month have unsuccessfully taken action in the past year May have made some reductions in problem behavior Not yet reached a criterion for effective action Not yet abstinent from illicit drugs Looking for advice Provide menu of choices

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Action Modifying behavior, experiences, or environment to overcome problems considerable commitment of time and energy successfully altered behavior for 1 day to 6 months Facilitation Provide encouragement Assist to identify barriers and solutions

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Maintenance Working to prevent relapse and consolidate gains attained during Action stage Extends from 6 months to an indeterminate period past the initial action, including a lifetime Hallmarks stabilizing behavior change avoiding relapse

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Recycling Most people taking action to modify their behavior do not successfully maintain their gains on the first attempt Recycle through the Stages of Change several times before termination of the problem behavior During relapse, individuals regress to an earlier stage, but not usually all the way back to where they began Number of successes continues to increase gradually over time

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The 5 As ASK about alcohol and drug use ADVISE all patients to quit ASSESS willingness to change ASSIST patients in quitting ARRANGE for follow-up

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ASK about alcohol and drug use Have you ever used Tobacco products Caffeinated beverages Alcohol OTC drugs of abuse Prescription drugs of abuse Illicit drugs When did it begin? How often? How much? When was the last use?

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ADVISE all patients to quit A strong recommendation to change substance use is essential "Based on the screening results, you are at high risk of having or developing a substance use disorder. It is medically in your best interest to stop your use of [insert specific drugs here]. Recommend quitting before problems (or more problems) develop Give specific medical reasons Medically supervised detoxification may be necessary

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ADVISE Many ways to change substance use behavior Community treatment programs, self-help groups, medications, etc. Treatment is often on an outpatient basis Programs are often accommodating of concerns Maintaining employment, insurance reimbursement, child care, etc. Whether to attend treatment will be the patient's decision

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ASSESS willingness to change Have a conversation about whether the patient is ready to quit. You might say something like, "Given what we've talked about, do you want to change your drug use?"

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ASSESS If the patient is unwilling to quit, raise awareness about drugs as a health problem Revisit the issue at future visits Have resources available when he/she decides to pursue making a change

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ASSIST patients in quitting Help set concrete (and reasonable) goals for making a change For patients not interested in a change plan, encourage them to set a few brief goals cutting back try a self-help group

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ARRANGE for follow-up Refer high-risk patients for a full assessment If nearby treatment resources are not available, provide support group contact information self-change materials counseling resources Clergy Mental health referrals

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ARRANGE For patients who attended referral and/or treatment Obtain records of assessment and/or treatment Discuss ways to help support recommendations For patients who did not attend the referral Offer additional brief intervention Make additional referrals

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Elements of Brief Intervention FRAMES Feedback Responsibility Advice Menu Empathy Self-efficacy

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Feedback Present information to client Based on history, exam, labs, etc. Increase awareness of adverse consequences Help make the case for change in drinking, med use, or illicit substances

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Responsibility Client has the ultimate responsibility for change Practitioner cant force client to change Client chooses goals, not practitioner Should be realistic Clarify clients goals Develop discrepancy

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Advice and Menu Give clear, concrete advice to change Give choices (menu) 3 is ideal Making a choice is first step to making a change in behavior

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Empathy Listen carefully Clarify clients meaning Dont impose practitioners values on client

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Self-efficacy Build up clients belief in ability to succeed Be optimistic Simple goals early Success breeds success Increases self- confidence

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Motivating patients not yet ready to quit: The 4 Rs RELEVANCE to that patient RISKS of continuing to use REWARDS of quitting REPETITION at each encounter

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Questions?

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Practice Cases Interviewing style Non-judgmental attitude Open-ended questions Identify stage of change Brief Intervention format Use of some of the FRAMES elements Use of some of the 5 As

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Practice Cases Roles to play Clinician Patient Observers (2) Groups of 4 people Decide role for each person Read page for your role Clinician and Patient do role play Observers give constructive feedback afterward

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Practice Cases Stage of change of patient What FRAMES elements were used? Which of the 5 As were used? What felt awkward? Clinician Patient What seemed more natural? Clinician Patient