SBIRT..What should I know? Michelle Bauer MD Addiction Psychiatry .Addiction Medicine Medical Director Substance Use Disorder Service VAMC

Screening,BrIef Intervention and Referral to Treatment Evidence base approach supported by SAMHSA since 2003 for use in primary care setting and some other settings. Goal is to reduce frequency and severity of alcohol use. Promote early involvement of primary care providers in prevention and treatment of substance use disorder

Substance use and related disorders are among the leading causes of preventable injuries and illnesses 21.5million americans 12 or older had substance use disorder in 2014

Where ever you go….. Medicine……..liver cirrhosis, HIV Cardiology……myocardial infarction ,arrhythmia Neurology……neuropathy, Parkinson, Korsakoff Pulmonary……small cell Ca,pulmonary edema Obstetrics…….abruptio placenta Surgery………..trauma,fractures Pediatrics……..FAS,NAS,asthma

Alcohol use disorder Most people drink with moderation . 87.6% adult over 18 reported they drank alcohol at some point in their life Lifetime prevalence Alcohol Use Disorder is 29.1% However of those 176.6 million alcohol users,an estimated 17million have alcohol use disorder 1.5million received treatment for AUD (8.9% of adult who need treatment)

Tobacco use disorder In 2014, 66.9 million Americans aged 12 or older were current users of a tobacco product. Young adults aged 18 to 25 had the highest rate of current use of a tobacco product (35%), followed by adults aged 26 or older (25.8%), and by youths aged 12 to 17 (7%). Tobacco 66.9

Cannabis use disorder Marijuana is the most-used drug after alcohol and tobacco in the United States. In 2014, about 22.2 million people ages 12 and up reported using marijuana during the past month.

Stimulant use disorder In 2014, an estimated 913.000 people ages 12 and older had a stimulant use disorder because of cocaine use. 476.000 people had a stimulant use disorder as a result of using other stimulants besides methamphetamine. In 2014, almost 569.000 people in the United States ages 12 and up reported using methamphetamine in the past month.

Opioid use disorder In 2014 an estimated 1,9 million people had an opioid use disorder related to prescription pain relievers and 586 000 had opioid use disorder related to heroin Overdose death from opioids have nearly quadruple since 1999 (increase 265% in man and 400% in women ) 28 000 people died from opioid OD in 2014 (more than 1/2 related to prescription drugs ) Approximately 3 out of 4 new heroin users abused prescription opioids before switching to heroin In 2014 an estimated1,9 millions people had an opioid use disorder related to prescription pain relievers and 586 000 had an opioid use disorder related to heroin Overdose death from opioids,have nearly quadruple since1999. Overdose involving opioids killed more than 28000 people in2014. Over half of these deaths were from prescription opioids.

Perspective High blood pressure…………75 million /410 000 Tobacco use disorder……….66.9 million /88 000 Diabetes…………………….29.1 million / 75 578 Cannabis use disorder……..22.2 million Asthma……………………….17.7 millions /3630 Alcohol use disorder………..17 million /88 000 Opioid use disorder……1.9 million +586 K /18 930+10 574

“I am right there in the room and no one even acknowledges me“

WHY ?

Same disease ..complex illness . Addiction is a brain disease

Pharmacology

Substance use Disorder Alcohol use disorder. Disulfiram 1950. Naltrexone PO and IM Acamprosate Tobacco use disorder Nicotine gum 1984. Bupropion 1997. Varenicline Opioids use disorder Methadone. Buprenorphine

Diabetes 28 different drugs…. 9 insulin ,rapid,short intermediate long acting 14 sulfonylurea-3rd generation, 4 DPP-4 inhibitor (Sitagliptin ,Alogliptin ), 3 bile sequestrates (Cholestyramine ) 1 biguanide (Metformin), 3 meglitinides(Repaglinide), 2 thiazolidinediones ,( Pioglitazone ) 2 alpha glucosidase inhibitor(Acarbose,Miglitol)

Hypertension 63 FDA approved medication 6 diuretics 3 potassium sparing diuretics 1 loop diuretic 13 beta blockers 10 ACE inhibitors 6ARB 8 calcium channel blocker 3 alpha blockers 1 alpha2 receptor agonist 4 central agonist 3 peripheral adrenergic inhibitor 2 vasodilators 2 combined alpha and beta blockers

Asthma 23 FDA approved medication . 9 corticosteroids, 5 long acting beta blockers, Cromolyn sodium, 2 leukotriene modifiers (Zabirlukast), 1 5lipoxygenase inhibitor (Zileuton ) Short acting beta 2 agonist

Patient Interview

Language is source of misunderstandings Antoine de Saint Exupery

Many physicians admit they are not confident about how to prescribe opioids safely,how to detect abuse or emerging addiction or even how to discuss these issues with their patients Nora Volkow

Whoa! way too much information!

“You should relax less..”

“You said you need to relax. Let’s talk about it “

References Substance Abuse and Mental Health Administration. www.samhsa.gov National Institute on Drug Abuse. www.drugbuse.gov SBIRT:Public health training for primary care . R.Taylor MD ,American Journal Public Health ,August 2012 ,vol 102,No 8 Neurobiologic advances from the Brain Disease model of Addiction . Nora Volkow MD,George Koob,PHD Thomas McLellanPHD:N England J Medicine 374:4,January 28 2016 The Future of Public Health Thomas Frieden MD,MPH :N England J Medicine 373;18 ,October 29 2015 Drug dependence,a chronic medical illness . Thomas McLellan ,JAMA Vol 284,No13;October 4 2016