Screening, Brief Interventions, Referral and Treatment (SBIRT)

1. Screening, Brief Interventions,Referral and Treatment(SBIRT) Focus on Primary Care May 8, 2005

2. National Household Survey on Drug Abuse (SAMHSA) Estimates

3. National StatisticsDAWN Emergency Dept. Data-2004(of nearly 2 million drug-related ED visits) • Illicit drugs = 940,953 • Non-medical use of pharmaceuticals = 495,732 • Cocaine 383,350 • Benzodiazepines 144,385 • Heroin 162,137 • Stimulants (amphet/methamph) 102,843 • Hydrocodone & combinations 42,491 • Oxycodone & combinations 36,559 • Methadone 31,874

4. Maine Prevalence National Household Survey 2004: • Maine youth age 12-20 • 29% drink • 20% binge drink • 7.59% of people 12 and older meet the criteria for alcohol dependence or abuse • 3.17% meet the criteria for drug dependence or abuse • 14% of people 18-25 have used a prescription pain reliever non-medically

5. Maine Prevalence 2004 • Only four states have a higher drug dependence rate for people 18-25 than Maine (RI, VT, WA, OR) • Only three states have a higher drug dependence rate for people 12-17 (AZ, OK, NM) • Only Alaska and New Mexico have greater rates of past month marijuana use among 12-17 year olds

6. Maine Prevalence 2004 • Maine is one of only seven states where past month use of any illicit drug other than marijuana exceed 10% • Only VT, NM, and RI have higher use of cocaine by 18-25 year olds than Maine • Only three other states have a higher rate of teens needing but not receiving drug treatment

7. Substance Abuse Treatment Admissions by Primary Drug of Choice 1995(Maine O.S.A.)

8. Substance Abuse Treatment Admissions by Primary Drug of Choice 2005 (Maine OSA)

9. Cumberland County Admissions for Heroin Addiction 2000-2006 (Maine OSA)

10. Cumberland County Admissions for Addiction to Prescription Opiates 2000-2006 (Maine OSA)

11. Abusable Prescriptions in Cumberland County 2006 Narcotics = 198, 573 Tranquilizers = 148, 125 Stimulants = 45,544 Other = 3,203 Total = 395,445 = 20% of state total = 1.45 Rx / person (all ages) From OSA PMP Report

12. Maine Tobacco Use • 21% of those > 18years of age in Maine smoke and almost all are tobacco dependent • Seven Maine people die each day from a tobacco-related illness • One of those seven is a nonsmoker who dies because of exposure to secondhand smoke = involuntary smoking

13. Alcohol Problems • 57% of Mainer residents >18 Y.O. drink with 15% of these seeking help. • Retrospective study at John Hopkins found alcohol abuse / dependence rates on the following inpatient services: • medicine = 25% • psychiatry = 30% • Neurology = 19% • Ob-Gyn = 12.5 % • Surgery = 23% Moore RD et al Alcoholism in Hospitalized Patients JAMA 261; P403-407

14. MMC Family Medicine Outpatients Search of our EMR for patients with an active diagnosis of either alcohol or cocaine or narcotics or benzodiazepine abuse found 1127 cases out of our current population of approximately 19,000 patients = 6%. Percent not diagnosed = ?

15. Maine Drug-Related Deaths • 34 in 1997, 60 in 2000, 176 in 2005 • 90% caused by at least one pharmaceutical • Cause of death 2002-2005 (may overlap) • All narcotics (Rx and illicit) 78% • Methadone (Rx and illicit) 36% • Morphine/heroin 17% • Benzodiazepines 10% Office of Maine Medical Examiner

16. Alcohol Use and Aging Alcohol misuse rates incidence over 65 of 2 to 10 % • From 1992 - 2002 3x increase in abuse / dependence in those over 65 to 3.1% (National Household Survey on Drug Use and Health) • Binge / excessive use risen to 8.3% (National Household Survey on Drug Use and Health ) • Those seeking routine medical care have rate of 15% or greater • Most of these have not been diagnosed by providers

17. GI bleeding Hypertension Arrhythmias and cardiomyopathy Depression / anxiety Insomnia Hepatitis / Pancreatitis Reduced nutritional absorption Cognitive impairments Osteoporosis Reduced immunity GI Cancer risk Bone marrow function Proximal muscle strength loss Peripheral neuropathy Etc. Medical Problems caused by / worsened by EtOH

18. Alcohol Use and Hypertension • Drinking 3 - 4 drinks a day associated with a 50% greater risk of hypertension compared to non-drinkers • Women having 2 - 3 drinks a day had a 40% increase in rates of hypertension Ref # 6

19. Anger Avoidance Discouragement Fatalism Frustration Futility Helplessness Judgmental Prevalent Negative AttitudesTowards the Substance Abuser

20. Factors Contributing to Negative Attitudes Limited positive work/professional experiences • Prior experiences with difficult patients w/o positive mentoring or role models • Overexposure to chronic, relapsing patients • Lack of adequate treatment resources • Lack of positive training, educational settings • Narrow view of professional responsibility • Only managing w/d, OD, med complications

21. Factors Contributing to Negative Attitudes Negative societal attitudes and stereotypes • “Alcoholics and addicts are the dregs of society.” • “They cause incredible harm to their families and society. Why should we help them?” • “They deserve the self destructiveness they get.” • “Why bother? Treatment doesn’t work. They don’t want to get better.” • Criminalizing addictive disease vs. resultant behaviors

22. Consequences of Negative Attitudes and Behaviors • At-risk persons not recognized & screened • Affected persons not diagnosed & treated • Family’s / Significant others not helped • Denial of existence of SA problems • Under / Over treatment with controlled Rx

23. Consequences of Negative Attitudes and Behaviors • Enabling hi-risk behavior (prescriptions, social support rather than treatment, etc.) • Punitive management • Patronizing • Nagging approach to treatment

24. Primary Care Role • Assessment • Active education / intervention • Referral when needed • Monitor maintenance process • Engage significant others in treatment

25. What is Safe Alcohol Use? • Two standard drinks per day for males and one per day for females associated with physical and mental health benefits in younger population • Seniors likely to be similarly helped by 1 std drink/day for males and perhaps less for females. • Problematic if more than this or > 4 std drinks on any given day

26. And what is a standard drink? • 12 grams pure alcohol = • 12 oz beer • 5 oz wine • 1&1/4 oz (one shot) 80 proof distilled liquor • Estimate is by how long a bottle lasts (750 ml wine = 5 std drinks) • Drinks at bars / restaurants may be larger

27. Levels of Use • Abstinence = none in the previous year (was there a prior problem?) • Low Risk Use = use within guidelines and no problems from use (Rx interactions?) • At Risk Use = use above the safe limits => evaluate / educate / monitor • Problem Use / Abuse = currently occurring adverse results from use at whatever level of use => intervene • Dependence = Loss of control / use despite problems from use / preoccupation with use / physiologic changes => possible detoxification / specialty treatment ?

28. Other Substance Misuse • Rising rate of illicit drug use from 2002 to 2005 for all ages per prior pie charts. One factor: • Age 50 to 55 increase from 3.4% to 5.2 % • Age 55 to 59 increase from 1.9% to 3.4% • Most have been using for many years => an emerging cohort effect (National Household Survey on Drug Use and Health)

29. Don’t Forget … • Nicotine • Caffeine

30. SBIRTScreening, Brief Interventions, Referral and Treatment • Multiple studies show this to be an effective primary care / hospital strategy to significantly reduce use at all age levels • Reduced levels of use is associated with improved health / physical functioning / role functioning / mental health / social functioning

31. Brief Screening • Part of annual evaluation or • Adding new possibly interactive medications or • Appearance of potentially related medical / social / mental problems

32. Assessment Tools • Validated screening questionnaires • Lab tests • Collateral Information • Review of prior medical / emotional problems • Assessment of current medical and mental health problems

33. Brief Screening • Have you ever had problems due to _____ use? • CAGE - Any one (+) should prompt further inquiry • Two or more (+) highly suggestive of problems with use • Designed as screen for those who are alcohol dependent • TACE - More specific for women with similar interpretation

34. AUDIT-C • 1) How often did you have an alcohol containing drink in the last year?(Monthly or less / 2-4 times a month / 2-3 times a week / 4 or more times a week) • 2) How many drinks did you have on a typical day when you were drinking in the past year?(1or 2 / 3 or 4/ 5 or 6 / 7 to 9 / 10 or more) • 3) How often did you have 6 or more drinks on one occasion in the past year?(Never / less than monthly / monthly / weekly / almost daily) • Score from 0 to 4 for each and add up • score greater than 4-7 (males) or 3-7 (females) => Preventive Advice or Brief Intervention • Score > 7 => Full Assessment or referral

35. AUDITAlcohol Use Disorders Identification Test • 10 questions based on amounts used and impact => screen for hazardous drinking • Validated cross-culturally • Not studied in those over 65 • http.libdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf

36. Other Screens • Drug Abuse Screening Test (DAST-10) • Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) • AC-OK Screen for Co-Occurring Disorders (Mental Health, Trauma related Mental Health Issues & Substance Abuse) • CRAFFT screening test specifically for adolescents

37. There does not have to be … • Overt withdrawal • Obvious tolerance • Legal Issues • Complaints by others

38. Substance Use Screening Labs • BAL • Elevated MCV and low BUN • GGTP elevation • Ethylglucuronase level (Mayo Lab #91696) • Drugs of Abuse Screen (Mayo Lab #81410)

39. New onset / variable Sx of: Anxiety / depression / mood swings Memory loss / episodic disorientation New problems in decision making Poor hygiene Falls / bruises / burns Family conflict / social isolation Idiopathic seizures Financial problems Sleep problems Headaches Incontinence Poor nutrition Signs / Symptoms of Alcohol Use

40. Common Alcohol Related Health Problems • Anemia or other reduced marrow function • Distal neuropathy • Proximal muscular weakness • Arrhythmia / cardiomyopathy • Dementia • Incontinence • Hypertension • Reduced glucose control • Osteoporosis • Hepatitis • Pancreatitis • Malignancies of upper GI tract / esophageal varices • Trauma / fractures

41. Prescription Monitoring Program (PMP) • System that tracks all Schedule II to IV prescriptions filled in the State of Maine over the past several years. • Physicians and designated PA / nursing staff can obtain on-line real-time listings of medications obtained by a given patient. • Register at www.ghsinc.com

42. Intervention Spectrum • Prevention / Education • Brief Advice • Brief Intervention • Formal Specialized Treatments

43. Motivational Interviewing • Contemplation = helping the patient understand the connection between their substance use and the secondary problems Stages of Change (Miller and Rollick) • Pre-contemplation • Contemplation • Decision • Action • Maintenance Slips ?

44. Prevention / Education • What are their perceptions of use? • Both positives and negatives (four box chart) • Comparisons of their use with established risk levels for EtOH / risks with any illicit use. • Current / potential medical consequences • Do they want to change? • Barriers to changing use patterns?

45. Alcohol Prevention • Advise patient to stay below guidelines: • Men = No more than 14 standard drinks per week or 4 drinks on any one occasion • Women = No more than 7 standard drinks per week or 3 drinks on any occasion • If they cannot then consider if problems are greater than perceived.

46. Brief Intervention • Research shows that people who are abusing but not addicted will cut down use when a physician / PA / NP points out: • what is normal / safe use verses • Express concern about the patient’s use • what is harmful use and how it is harmful to them. • Offer concrete advice to stay below the recommended limits

47. Brief Advice • State medical associated problems • “Common problem” & avoid shame based comments • Change takes a little effort but is likely to improve several areas of functioning • “How can I help?”

48. Brief Interventions • Disease model => less shame but still accountable for choices • Change is possible • You are concerned about their use • You are here to help and not to judge • Resources available if they cannot change on their own

49. Treatment Plan • Clearly defined goals • Limitation of use / harm avoidance / warm turkey / abstinence from use ? • Health problems to be treated ? • Mental health needs / treatment ? • Need for specialized treatment ?

50. Integrated Treatment Options • Studies have show integrated services using nurse /social worker can effectively deliver screenings and interventions / telephone follow-ups (Olsin DW, Psychosom. Med 2003 & Psychiatr. Serv. 206) • Avoid confrontational approaches