1. SBIRT Module 2: Screening for Substance Use Problems in Primary Care UCSF SBIRT Collaborative Education Project Janice Tsoh, PhD

2. Outline n Basic screening for alcohol and drugs n DSM-IV assessment for substance use disorders n Relevance to clinical practice at DGIM

3. SBIRT n Screening: quickly assess use and severity of alcohol, illicit drugs, and prescription drug abuse. n Brief Intervention: a 3-5 minute motivational and awareness-raising intervention given to risky or problematic substance users. n Referral to Treatment: referrals to specialty care for pts with substance use disorders.

4. Substance Use Continuum n In Module 1, you learned about the continuum of substance use ranging from: u abstinence u moderate use u “at risk” use u Abuse u Dependence n Your initial job as a primary care provider is to assess use, classify appropriately, and screen for possible co- morbidities. “Substance Use Disorders” (SUD)

5. Screening Strategy n Use of most efficient yet psychometrically sound screening questions. u The NIAAA Single Screener u The Single Question Drug Screener n If you get a positive screen, you’ll have to ask further assessment questions.

6. Screening for alcohol use n Start with “Prescreen” u Do you sometimes drink beer, wine, or other alcoholic beverages?  If no, alcohol screening is complete n If yes, proceed to NIAAA Single Screener u How many times in the past year have you had 5 (men) or 4 (women or pts over 65yo) drinks or more in a day?

7. What’s a Standard Drink? In the U.S., a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons).

8. NIAAA Alcohol Screener “How many times in the past year have you had X or more drinks in a day?” X = 5 (for men); 4 (for women or pts >65 y.o.) 1 or more times “NONE” Not an “at risk” binge drinker but may exceed recommended limits. Continue to assess At-risk binge drinker, inquire further u Sensitivity/ specificity: 82%/ 79% Source: Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test. J Gen Intern Med 2009;24(7):783-8.

9. Alcohol Screen (cont’d)  Determine the average drinks per day and average drinks per week, ask:  On average, how many days a week do you have an alcoholic drink?  On a typical drinking day, how many drinks do you have? (Daily average)  Weekly average = days X drinks Recommended Limits Men: 2 per day/ 14 per week Women / any 65+: 1 per day or 7 drinks per week > regular limits = At Risk Drinker

10. A Positive Alcohol Screen = At Risk Drinker Binge drink? (  5 for men or  5 for women /any 65+) Exceeds regular limits? (Men: 2/per or 14/week Women/any 65+: 1/day or 7/week) Pt is at risk. Assess for alcohol use disorders maladaptive pattern of use clinically significant impairment Pt is not at risk. Move to drug screen YESNO

11. SUD: DSM-IV Criteria for Substance Abuse Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 or more of the following in the past 12 mo u Failure to fulfill obligations at work, school or home u Recurrent substance use in situations where it would be hazardous u Recurrent substance related legal problems u Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by effects of the substance Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), American Psychiatric Association, 2000.

12. SUD: DSM-IV Criteria for Substance Dependence Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following in the past 12 mo n Taking the substance often in larger amounts or over a longer period than was intended. n A persistent desire or unsuccessful efforts to cut down or control substance use. n Tolerance, as defined by: u Need for markedly increased amounts of substance to achieve intoxication or desired effect u Markedly diminished effect with continued use of the same amount of substance n Withdrawal, as manifested by: u Characteristic withdrawal syndrome for the substance u The same substance is taken to relieve/avoid withdrawal symptoms n Continuing the substance use with the knowledge that it is causing or exacerbating a persistent or recurrent physical or psychological problem. n Spending a great deal of time in activities necessary to obtain or use the substance or to recover from its effects n Giving up social, occupational, or recreational activities because of substance abuse. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), American Psychiatric Association, 2000.

13. “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” (…for instance because of the feeling it caused or experiences you have…) any number or suspicious clues “NONE” Screening is complete Inquire further Screening for Drugs u Sensitivity/ specificity: 100%/ 74% Source: Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med 2010; 170(13):1155-60.

14. A Positive Drug Screen n Ask which drugs the patient has been using, such as: u Cocaine, meth, heroin, ecstasy, pot, vicodin, valium, etc. n Determine frequency and quantity. n Ask about negative impacts. Note: Any positive on the drug screen question puts the pt in an “at risk” category. The follow-up questions are to assess impact and whether or not use is serious enough to warrant a substance use disorder diagnosis.

15. Relevance to DGIM n Every DGIM patient will be screened at once per year for alcohol, tobacco, illicit drugs and Rx abuse. n In Fall 2010, you will see screening forms attached to the front of each patient chart. n Patient fill out screening questions on the top of the form. n If you see positive answers, you should continue the assessment – i.e. determine if the pt is at risk, abusing, or dependent for each substance.

16. Take Home Points for Screening  Screen every patient  Screen both alcohol and drug use including Rx abuse and tobacco  Explore each substance; many patients use more than one  Follow up positives or "red flags" by assessing details and consequences of use  Show nonjudgmental, empathic verbal and non-verbal behaviors during screening