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

2. Screening,BrIef Intervention and Referral to Treatment
Evidence base approach supported by SAMHSA since 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

3. 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

4. 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

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

7. 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

8. 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.

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

10. Opioid use disorder
In 2014 an estimated 1,9 million people had an opioid use disorder related to prescription pain relievers and had opioid use disorder related to heroin
Overdose death from opioids have nearly quadruple since (increase 265% in man and 400% in women )
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 had an opioid use disorder related to heroin
Overdose death from opioids,have nearly quadruple since1999.
Overdose involving opioids killed more than people in2014.
Over half of these deaths were from prescription opioids.

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

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

14. WHY ?

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

19. Pharmacology

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

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

22. Hypertension
63 FDA approved medication diuretics potassium sparing diuretics loop diuretic beta blockers ACE inhibitors ARB calcium channel blocker alpha blockers alpha2 receptor agonist central agonist peripheral adrenergic inhibitor vasodilators combined alpha and beta blockers

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

24. Patient Interview

25. Language is source of misunderstandings Antoine de Saint Exupery

26. 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

27. Whoa! way too much information!

28. “You should relax less..”

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

30. References
Substance Abuse and Mental Health Administration.
National Institute on Drug Abuse.
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
The Future of Public Health Thomas Frieden MD,MPH :N England J Medicine 373;18 ,October
Drug dependence,a chronic medical illness . Thomas McLellan ,JAMA Vol 284,No13;October