SBIRT: What It Is and How to Start Doing It

SBIRT:What It Is and

How to Start Doing It

Michael Weaver, MDDivision of General Medicine andDivision of Addiction Psychiatry

Virginia Commonwealth UniversitySchool of Medicine

Virginia Summer Institute for Addiction Studies 2013

Objectives

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

Drug Classes

• Sedative-hypnotics• Opioids• Stimulants• Hallucinogens• Inhalants• Marijuana• Nicotine

Sedative-Hypnotics• Alcohol, benzodiazepines,

barbiturates• CNS depressants• Disinhibition: depress

inhibitions first– Reduce anxiety (fun at

parties)• Sedation, anxiolytic• Oversedation, ataxia,

respiratory depression

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

Opioids• Morphine, heroin,

OxyContin, methadone• Analgesics: disconnect from

pain• Euphoria, disconnection,

sedation• Nausea, constipation,

itching• Oversedation, respiratory

depression

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

Stimulants• Cocaine, amphetamine,

methylphenidate, MDMA (Ecstasy), caffeine

• Enhanced concentration, alertness

• Edginess, paranoia, hypervigilance, psychosis

• Hypertension, hyperthermia, vasoconstriction– Heart attack, stroke

Prescription Stimulant Abuse• Abused for euphoria,

energy, alertness• Abused by

– Students– Long-distance drivers– Polysubstance abusers

• Problems– Vasoconstriction– Agitation, psychosis

Caffeine

• Not just coffee, tea, soda

• Energy drinks• Leads to– Anxiety– Tachycardia,

palpitations– Disrupted sleep

“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

Hallucinogens• LSD, mescaline,

psilocybin• Perceptual distortions– Hallucinations– Visual effects

• “Bad trip”• Death most often due

to perceptual and judgment errors

Volatile Inhalants• Common & legal• Use & abuse difficult to

characterize• Examples– airplane glue (epoxies)– Freon (“freebies”)– carbon tetrachloride– amyl & butyl nitrite– nitrous oxide– propellant (spraypaint)

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

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

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

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

Models of addiction

• Disease• Genetic• Self-medication• Moral/volitional

Disease Model

• Biologic basis• Chronic course– Relapses and remissions– No cure– Like other chronic diseases

• Treatable– Individualize therapy– Medications may help improve outcomes

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

Self-medication

• Use of mood-altering substance is to ameliorate underlying negative psychiatric symptoms– Stimulants for

depression– Alcohol or heroin for

anxiety

Moral/Volitional Model

• Personal choice• Weak willpower• Moral failing• Research doesn’t

support this model

Vulnerable Populations

• Adolescents• Elderly• Psychiatric Co-Morbidity

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

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

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

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

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

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

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

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

Why screen patientsfor addiction?

• Medical problems– Cardiovascular disease– Stroke– Cancer

• Mental health– Depression– Anxiety– Sleep problems

• Financial difficulties• Legal problems• Interpersonal problems– Family issues

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

Screening Tool forAlcohol Abuse

• CAGE Questions– Cut down– Annoyed– Guilty– Eye-opener

• Affirmative response to 2 or more is positive test

APA 2000

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

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

Types of treatment

• Detoxification• 12-Step groups• Outpatient

counseling• Intensive outpatient• Inpatient• Residential

12-Step Groups

• A.A., N.A., C.A.• Group format• Anonymous• No cost• No affiliations or

endorsement• Different groups have

different characteristics

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

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

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

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

Patient Behavior

• Ambivalence– Attracted to problem

behavior (substance use)• Denial– Unable to admit

problem to themselves– Actively conceal

• Common to many chronic conditions

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

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

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

Questions?

Cases for Group Discussion

Objectives

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

Stages of Change

• Precontemplation• Contemplation• Preparation• Action• Maintenance

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

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.)

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

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

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

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

The 5 “A’s”

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

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?

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

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

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?"

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

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

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

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

Elements of Brief Intervention

• FRAMES– Feedback–Responsibility–Advice–Menu– Empathy– Self-efficacy

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

Responsibility

• Client has the ultimate responsibility for change

• Practitioner can’t force client to change

• Client chooses goals, not practitioner– Should be realistic– Clarify client’s goals– Develop discrepancy

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

Empathy

• Listen carefully• Clarify client’s

meaning• Don’t impose

practitioner’s values on client

Self-efficacy

• Build up client’s belief in ability to succeed

• Be optimistic• Simple goals early– Success breeds

success– Increases self-

confidence

Motivating patientsnot yet ready to quit:

The 4 “R’s”

• RELEVANCE to that patient• RISKS of continuing to use• REWARDS of quitting• REPETITION at each encounter

Questions?

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 A’s

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

Practice Cases

• Stage of change of patient• What FRAMES elements were used?• Which of the 5 A’s were used?• What felt awkward?– Clinician– Patient

• What seemed more natural?– Clinician– Patient