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Virginia Summer Institute for Addiction Studies 2013. 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. Objectives. Classes of a bused drugs - PowerPoint PPT Presentation
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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