Transcript SBIRT: What It Is and How to Start Doing It

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
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Classes of abused drugs
Models of addiction
Vulnerable populations
Screening
Brief intervention
Addiction treatment
Cases for Discussion
Drug Classes
• Sedativehypnotics
• 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 shortterm use, many taken longterm
• 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
– Methylenedioxypyrovalerone
– 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
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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”
– Methylenedioxymethamphetamine
• 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
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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
• 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
“Your DNA test shows you’re
predisposed to sue doctors.”
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
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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
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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 patients
for 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 for
Alcohol Abuse
• CAGE Questions
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Cut down
Annoyed
Guilty
Eye-opener
• Affirmative response to
2 or more is positive
test
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
APA 2000
Drinking Guidelines
• Men:
– 2 standard drinks/day
– No more than 14
drinks per week
– No more than 5 drinks
on any one occasion
• Women:
NIAAA 2005
– 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
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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
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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
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
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
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Stages of Change
The 5 “A’s”
Elements of Brief Intervention
Practice Cases
Stages of Change
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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”
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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
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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 selfconfidence
Motivating patients
not yet ready to quit:
The 4 “R’s”
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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
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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