1. SBIRT Introduction and Relevance to DGIM Jason Satterfield, PhD SBIRT Collaborative Education Project Funded by SAMHSA/CSAT Grant 1U79TI020295-01

2. Outline/Roadmap n SBIRT defined n Substance use epidemiology and significance in primary care n SBIRT research support n How this will fit into clinical practice at DGIM

3. What is 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. QUIZ: Your Clinic Panel? n What percentage of your current clinic patients would be classified with alcohol abuse or dependence? n What percentage would be classified as “at risk” drinkers? n What percentage of your current clinic patients have used illicit drugs in the past month?

5. QUIZ: Demographics n How did your answers compare to statistics for the general population? u Percent with alcohol abuse or dependence F 7% or about 1 in 14 u Percent “at risk” drinkers F 23% or nearly 1 in 4! u Percent using illicit drug F 8% or about 1 in 12 SAMHSA, National Survey on Drug Use and Health, 2008 Ages 12+ in the United States

6. Continuum of Substance Use 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 Only Abuse and Dependence are considered “Substance Use Disorders” (SUD) n Your initial job as a primary care provider is to assess use, classify appropriately, and screen for possible co- morbidities. n Tips for screening, intervening, and medical management come in subsequent modules.

7. Substance Use Issues are Highly Prevalent in Americans SAMHSA, National Survey on Drug Use and Health, 2008 Ages 12+ in the United States Risky Drinking*23% Illicit Drug Use8% Substance Abuse or Dependence9% Alcohol7% Illicit Drugs3% *Defined in later slides.

8. Health Impact – Alcohol/Drugs n Trauma, disability n Hypertension, dyslipidemia, heart disease n Liver disease, gastritis, pancreatitis n Depression, anxiety, sleep dysfunction n Sexual and menstrual dysfunction n Risk for breast, colon, esophageal, head and neck cancers n HIV/AIDS, other STIs, and other infectious diseases

9. Psychosocial Aspects of Substance Use Disorders Violence/Crime:  Alcohol is involved in one-half to two-thirds of all homicides and at least one-half of serious assaults (Martin, 1992).  Opioids predispose patients to trauma (Stolbach, 2009).  Adolescents who used cannabis committed more crimes compared to those who never used cannabis. These relationships declined with age but remained significant (Fergusson).

10. Evidence for SBIRT n A recent meta-analysis suggests an overall reduction of 56% in number of drinks. n The effect size for a brief motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months Burke et. al., 2003

11. Evidence for SBIRT n Research has shown brief interventions can reduce alcohol use for at least 12 months in patients who are not alcohol dependent. n 10-30 % of patients can be expected to change their drinking behaviors as a result of a brief intervention. Babor & Higgins-Biddle, 2000; Fleming and Manwell, 1999.

12. Brief Intervention (BI) Effectiveness n 32 controlled studies found brief interventions often as effective as more extensive treatments. n Reduction in the following as a result of brief intervention: u Alcohol and other substance consumption/use. u Harmful physical consequences. u Social consequences. u Sick days, missed work. u Hospitalization. u Trauma/accidents/injuries. Fleming & Manwell, 1999

13. Results for SBIRT Alcohol* n Primary care - $950 net savings in 1 year continuing out to at least 4 years; ROI >$4 per $1 spent n ER/trauma centers - 47% reduction in recurrent alcohol- related injury; nearly $4 ROI per $1 spent n WA Medicaid disabled - $185 decrease in health care costs per recipient per month x 12 months * *References on final slide

14. SBIRT Prospective Cohort Study n 6 clinical sites n 459,599 pts screened n At 6-month follow up  Drug use 67.7% ↓  Alcohol use 38.6% ↓  Self reported improvement in general health, mental health, employment, housing and criminal behavior Madras et al, Drug and Alcohol Dependence, 2009

15. Relevance to DGIM Clinic: Screening n Given the evidence supporting SBIRT in primary care, DGIM has made a commitment to screen every patient once per year for alcohol, tobacco, illicit drugs, and prescription drug abuse. n Starting in Fall 2010, you will see a screening sheet attached to the front every patient chart. n See Module 2 for more information and Tips on Screening.

16. Relevance to DGIM: Referrals and Interventions n All patients who are classified as “at risk” or “substance abusers” or “substance dependent” should receive a 3-5 minute motivational intervention. n Patients who meet criteria for abuse or dependence should be referred for specialty care if they agree to accept the referral (see Module 3). n Patients who meet criteria for dependence may be candidates for addiction pharmacotherapy (see Module 4).

17. Relevance to DGIM: Precepting n All UCPC R2/R3’s will receive SBIRT training. They will be required to screen all patients and intervene when appropriate. n Be sure to reinforce screening skills and discuss brief, structured interventions. n Residents will also be trained in addiction pharmacotherapy and may need your guidance in initiating an Rx.

18. Relevance to DGIM: Expert Backup n Addiction Psychiatrists and Psychologists are available to answer your clinical questions. Please contact Kathleen McCartney 476-5235 to set up a consultation. n As always, you are welcome to contact Jason Satterfield for assistance with referrals and mental health/behavior change issues.