Screening, Brief Intervention and Referral to Treatment (SBIRT) David P. Miller, MD, MS, FACP Associate Professor Internal Medicine and Public Health Sciences Sebastian G. Kaplan, PhD Psychiatry and Behavioral Medicine Wake Forest School of Medicine Winston-Salem, North Carolina

Session Overview Overview of Hazardous Substance Use The Change Process Introducing SBIRT Components of Effective Brief Interventions Implementation Challenges Working with Adolescents: Special Considerations

Mercer University SOM FM Residency Acknowledgments Funded by: Grant #1U79T1020278-01 J. Paul Seale, MD (PI) Mercer University SOM FM Residency Macon, GA Blanca Lopez, MD Mercer University IM Residency Hunter Woodall, MD AnMed Health FM Residency Anderson, SC Kristy Le, MD Wake Forest Baptist Health IM Residency Winston-Salem, NC Ann Barham, MD Wake Forest Baptist Health FM Residency Winston-Salem, NC Allen Tindol, MD Memorial University IM Residency Savannah, GA Jill Mattingly, PA-C Mercer University Chamblee, GA Ed Evans, MD Seneca Lakes FM Residency Seneca, SC Collaborator: Daniel P. Alford, MD, MPH, FACP, FASAM

Module 1: Hazardous Substance Use Review patterns of alcohol and drug misuse in the United States Recognize "at-risk" drinking and drug use Discuss the potential consequences of at-risk substance use Describe the evidence for using SBIRT 

Alcohol

Southeastern Consortium for Substance Abuse Training © 2011 Benefits of Moderate Alcohol Use Men Women DiCastelnuovo A, Castanzo S, Bagnardi V, Donati MB, Iacoviello L, de Gaetano G. Alcohol dosing and total mortality in men and women Arch Intern Med 2006;166:2437-2445 Southeastern Consortium for Substance Abuse Training © 2011 DiCastelnuovo et al, Arch Intern Med 2006.

What is moderate drinking? Most Americans overestimate what “moderate drinking” is Binge drinking negates the cardiac benefit of moderate drinking Southeastern Consortium for Substance Abuse Training © 2011

At-Risk Drinking “binge drinking” Maybe separate out epidemiology to slide AFTER audience response slide National Institute on Alcohol Abuse and Alcoholism. “Rethinking Drinking,” 2010. MMWR 2012:61:14-19.

What is a Standard Drink? 12 oz Beer 8-9 oz Malt Liquor 5 oz Wine 1.5 oz/ 1 shot liquor Beer: 12 oz = 1 16 oz = 1 1/3 22 oz = 2 40 oz = 3 1/3 Malt Liquor: 12 oz = 1 1/2 16 oz = 2 22 oz = 2 1/2 40 oz = 4 1/2 Wine: 5 oz = 1 750 ml bottle = 5 Liquor: 1.5 oz shot = 1 Mixed drink = 1 or more Pint = 8 1/2 Fifth = 17 Beware of microbrews and pints ~5% ~7 % ~12% ~40% The percent of “pure” alcohol expressed here as alcohol/volume varies by beverage. NIAAA, 2009 http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf

Drinking Patterns in the U.S. No Risk At Risk Dependent 4% 37% 24% Low Risk 35% http://pubs.niaaa.nih.gov/publications/arh29-2/79-93.htm, Grant et al, 2004; NIAAA 2009

Patterns of alcohol use among U. S Patterns of alcohol use among U.S. at-risk drinkers: 28% of population at-risk Exceed only daily limits (> 3 OR 4 drinks/day) Exceed only weekly limits (>7 or 14 drinks/wk) 16% 10% 2% Prevalence is higher in college students: 44% http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf, NIAAA 2009; http://www.collegedrinkingprevention.gov/; NESARC Wave 1 study

Alcohol Abuse: Major Cause of Morbidity and Mortality Chronic liver disease & cirrhosis Cancer Heart disease Pancreatitis Stroke Depression Injuries Homicide, suicide Family Violence Non- accidental/non- intentional poisoning The risk of Alc related cancers such as oral-pharyngeal, esophagus, liver, breast, colon and pancreas, increases with increasing amounts of alcohol, Unintentional injuries include MVAs, drowning, falls, hypothermia, burns, suicides, and homicides. Approximately 31% of those who die from unintentional, non-traffic injuries in the US have a blood alcohol concentration of .10g/dL or greater (Smith, 1999). Violence In 1997, about 40% of all crimes (violent and non-violent) were committed under the influence of alc (Bureau of Justice statistics, 19980. 2/3s of the victims of intimate partner violence reported that alc was involved in the incident (Bureau of Justice Statistics, 1998). Suicide Approximately 23% of suicide deaths are attributable to alcohol (Smith, 1999). Smith, 1999; http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5337a2.htm, CDC, 2004 12

Binge Drinking: A GREATER cause of harm/death Other substance use Alcohol use disorders Liver disease Impaired physical health Impaired mental health Impaired cognition/ADL’s Obesity/overweight DUI’s Injuries (intentional & unintentional) School problems Unsafe sex/STD’s Unintended pregnancy Sexual victimization

High Risk Population: College Students 44% of college students binge drink 23% of college students are frequent binge drinkers (3 times in past 2 weeks) Total: 6.6 million college binge drinkers http://www.collegedrinkingpreventi on.gov/ How much is binge drinking a problem on the ASU campus? Need to appreciate the challenge that many students you teach will be binge drinkers Southeastern Consortium for Substance Abuse Training © 2011

ASU Student Body Survey (Fall 2015) 21% reported binge drinking Response Rate = 7%

Terms used: Hazardous drinking, at-risk drinking, healthy alcohol limits, binge drinking, etc. Alcoholic

http://www. sheandheplanweddings http://www.sheandheplanweddings.com/wp-content/uploads/2010/05/toilet-drunk.jpg http://www.blogoncherry.com/wp-content/uploads/2011/08/drunk_people_42.jpg http://www.whileiwasdrunk.org/image/drunk/1106/-drunk-1307417472.jpg http://www.blogoncherry.com/wp-content/uploads/2011/08/drunk_people_42.jpg http://www.extremefunnyhumor.com/pics/drunk_people_7.jpg

Drunk Texting and Calling

Binge Drinking Increases DUI Risk Over 10% of binge drinkers report driving within 2 hours of their most recent binge Almost half of alcohol-impaired driving involves persons who are not heavy drinkers, based on average daily consumption 1 in 3 college binge drinkers (2.1 million students) report driving under the influence Naimi et al 2009; Flowers et al, 2008; http://www.collegedrinkingprevention.gov/ Exact figure is 11.9% Southeastern Consortium for Substance Abuse Training © 2011

Consequences of Alcohol-Impaired Driving (2013) Over 10,000 deaths/year $51 billion in total costs/year http://www-nrd.nhtsa.dot.gov/Pubs/812102.pdf Flowers et al, 2008 Southeastern Consortium for Substance Abuse Training © 2011

Other Risks of Exceeding Daily Drinking Limits (College Students) Unsafe sex: 400,000 had unprotected sex (1:15); 100,000 too drunk to give consent Sexual abuse: 70,000 victims of sexual assault Academic problems: 25% of college binge drinkers report negative academic consequences (1:4) http://www.collegedrinkingprevention.gov/ Southeastern Consortium for Substance Abuse Training © 2011

Drug Use

Past Month Use

Past Month by Age

Marijuana

Marijuana legalization

NIDA DrugFacts, SAMHSA 2014. DAWN 2011 Epidemiology of use http://buelahman.wordpress.com/2009/08/02/marijuana-doesnt-affect-brain-function-and-gets-rid-of-cancer-vile-weed/ Most commonly abused illicit drug in US – lifetime use 44% males, 35% females 456,000 drug-related ED visits, involving MJ (2011) 21% increase from 2009 Highest use in 18-24 year olds Male: female ratio >3:1 NIDA Info-facts, NSDUH 2010 NIDA DrugFacts, SAMHSA 2014. DAWN 2011

Epidemiology Use in past 30 days (NSDUH 2014) 19.8 million Americans age 12 & older Stable use among teens in recent years, but perception of risk decreased in youth over past 5-8 years *** http://www.thefix.com/content/is-marijuana-good-your-health7100 http://www.nme.com/news/snoop-dogg/61332 Johnston, 2014

Harmful Effects of Marijuana Occasional panic/anxiety reactions Potential to precipitate psychoses Impaired coordination Decreases in learning and memory Lung damage and infections Increased risk of heart attack (older adults)

Anthony 1994, Lopez-Quintero 2011, NSDUH 2010 Addictive potential Identified by the 4C’s: compulsive use, loss of control, craving, continued use despite adverse consequences Estimated 1 out of 11 users become addicted 1 out of 9-- if start use as teen 25-50% of daily users Total=4.5 million people with marijuana or hashish dependence or abuse Marijuana was the illicit drug with the highest rate of past year dependence or abuse in 2010, followed by pain relievers and cocaine. Of the 7.1 million persons aged 12 or older classified with illicit drug dependence or abuse in 2010, 4.5 million had marijuana or hashish dependence or abuse (representing 1.8 percent of the total population aged 12 or older, and 63.0 percent of all those classified with illicit drug dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and 1.0 million persons had cocaine dependence or abuse (Figures 7.2 and 7.3). NSDUH 2010 p. 70 Anthony 1994, Lopez-Quintero 2011, NSDUH 2010

Prescription Pain Killers

Opioid-Related Consequences Addiction: 980,000 opioid addicts Opioid-related visits to Emergency Rooms: 305,885 Opioid-related fatalities: 16,651 deaths Costs: $72.5 billion annually in direct healthcare costs MMWR June 18, 2010; MMWR August 20, 2010, JAMA February 20, 2013, CDC November 2011

Opioid Pain Reliever (OPR) Sales and Complications, 1999 – 2010 MMWR Morb Mortal Wkly Rep 2011; 60:1487-1492 (89)

outnumber cocaine + heroin Overdose deaths from prescription opioids outnumber cocaine + heroin MMWR 2012;61:10-13.

Overdose Deaths by State Prescription Drug Overdose Deaths by State MMWR 2011;60:1487-92.

Stimulants

Cocaine Epidemiology Over 14 million world wide: .03% world population North America 6.4 million: 2.2% Central/South America 2.2 million: 6.8% Minimal use: Africa, Asia, East Europe, Oceana Urban men 15 to 35

History: Methamphetamine 1893 methamphetamine first synthesized in Japan as decongestant. Used by German, English, American, and Japanese military in WWII for performance enhancement. First epidemic occurred in Japan when the military dumped large quantities into the civilian market Popular among truckers and west coast bikers in 1970s DESOXYN to treat ADHD and obesity Speed, Crystal, Crank, Ice, Meth, Tina Methamphetamine Super labs – Primarily Mexico and California Local clandestine labs - 1 pound of MA creates 6 pounds of toxic waste Holton WC.  Unlawful lab leftovers. Environ Health Perspect. 2001;109:A576 Lineberry 2006

Steady Increases in Stimulant Prescriptions Dispensed by U. S Steady Increases in Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies 1991-2011 Source: Weiss, Susan. The Science of Drug Addiction: Implications for Treatment. Addiction Medicine: Improving Clinical, Teaching, and Research Skills. May 2012.

Prescription stimulants DO promote wakefulness DO NOT enhance learning or thinking ability when taken by people who do not actually have ADHD. Students who abuse prescription stimulants actually have lower GPAs in high school and college NO difference in later substance use for children with ADHD who received treatment and those that did not. This suggests treatment with ADHD medication appears not to affect (either negatively or positively) an individual’s risk for developing a substance use disorder.

Acute Toxicity Hypertension Energy, alertness, euphoria Rapid heart rate Heart arrhythmias Blood vessel constriction Increased temperature Agitation Muscle breakdown Seizure Acute Psychosis Energy, alertness, euphoria Increased dose  dysphoria Paranoia impaired judgment Tremor Stereotyped behaviors http://www.youtube.com/watch?v=FI_8jc6VaSU Show this video of crack dance Physical signs of sympathetic stimulation

Cocaine causes most ED visits

SBIRT Q: Who has heard of SBIRT?

What is SBIRT? Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.

SBIRT Works! 23 randomized controlled trials for alcohol 12% fewer patients report no risky drinking episodes at 1 year follow-up Reduces average weekly consumption from 23 to 19 drinks Reduces frequency of college-age heavy drinking days by one per month at 6-month follow-up 6 state study of over 450,000 primary care patients Rates of drug use were 68% LOWER after 6 months Improved general health, mental health, employment, housing status, and less criminal behavior There have been over 100 studies showing it works and is cost-effective USPSTF now recommends it for all primary care practices Moyer, Annals 2013; USPSTF 2013. Madras, Drug Alcohol Depend 2009.