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
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
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
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
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