1. 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

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

3. Mercer University SOM FM Residency
Acknowledgments
Funded by: Grant #1U79T
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

4. 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 

5. Alcohol

6. 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:
Southeastern Consortium for Substance Abuse Training © 2011
DiCastelnuovo et al, Arch Intern Med 2006.

7. 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

8. 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.

9. 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

10. Drinking Patterns in the U.S.
No Risk
At Risk
Dependent 4%
37%
24%
Low Risk
35%
Grant et al, 2004; NIAAA 2009

11. 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%
NIAAA 2009; NESARC Wave 1 study

12. 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,
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;
CDC, 2004 12

13. 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

14. 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
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

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

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

17. http://www. sheandheplanweddings

18. Drunk Texting and Calling

19. 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;
Exact figure is 11.9%
Southeastern Consortium for Substance Abuse Training © 2011

20. Consequences of Alcohol-Impaired Driving (2013)
Over 10,000 deaths/year
$51 billion in total costs/year
Flowers et al, 2008
Southeastern Consortium for Substance Abuse Training © 2011

21. 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)
Southeastern Consortium for Substance Abuse Training © 2011

22. Drug Use

23. Past Month Use

24. Past Month by Age

25. Marijuana

26. Marijuana legalization

27. NIDA DrugFacts, SAMHSA 2014. DAWN 2011
Epidemiology of use
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 year olds
Male: female ratio >3:1
NIDA Info-facts, NSDUH 2010
NIDA DrugFacts, SAMHSA DAWN 2011

28. 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 ***
Johnston, 2014

29. 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)

30. 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

31. Prescription Pain Killers

32. 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

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

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

35. Overdose Deaths by State
Prescription Drug
Overdose Deaths by State
MMWR 2011;60:

36. Stimulants

37. 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

38. 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

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

40. 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.

41. 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
Show this video of crack dance
Physical signs of sympathetic stimulation

42. Cocaine causes most ED visits

43. SBIRT
Q: Who has heard of SBIRT?

44. 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.

45. 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.