1 Integrated Substance Abuse Programs Department of Psychiatry amp Biobehavioral Sciences David Geffen School of Medicine at UCLA Pacific Southwest Addiction Technology Transfer Center wwwuclaisaporg ID: 370659
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Slide1
Screening, Brief Intervention & Referral to Treatment
1
Integrated Substance Abuse Programs
Department of Psychiatry & Biobehavioral Sciences
David Geffen School of Medicine at UCLA
Pacific
Southwest Addiction Technology Transfer Center
www.uclaisap.org
www.psattc.orgSlide2
Monitoring the Future 2013
Elicit and
PrescriptionSlide3
Co-Occurring MH and SUD
Adolescents with SED are five times more likely to have an alcohol
problem
than those without
43% of youth receiving mental health (MH) treatment services have a COD Among young adults ages 18-25 with a serious mental illness, 48% report past-year illicit substance use
, and 36% meet criteria for a SUD 36% of all adults with COD are ages 18-25 years
3
5x
>1/3Slide4
Normal Dopamine TransmissionSlide5
0
50
100
150
200
0
60
120
180
Time (min)
% of Basal DA Output
NAc shell
Empty
Box
Feeding
Source: Di Chiara et al.
FOOD
100
150
200
DA Concentration (% Baseline)
Mounts
Intromissions
Ejaculations
15
0
5
10
Copulation Frequency
Sample
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Scr
Scr
Bas
Female 1 Present
Scr
Female 2 Present
Scr
Source: Fiorino and Phillips
SEX
Natural Rewards Elevate
Dopamine LevelsSlide6
Methamphetamine
and DopamineSlide7
DA D2 Receptor Availability
control
addicted
Cocaine
Alcohol
Reward Circuits
DA
DA
DA
DA
DA
DA
Drug Abuser
DA
DA
DA
DA
DA
DA
DA
Reward Circuits
DA
DA
DA
DA
DA
Non-Drug Abuser
Heroin
Meth
Dopamine D2 Receptors are Lower in AddictionSlide8
Control
> MA
4
3
2
0
1Slide9
MA >
Control
5
4
2
0
1
3Slide10
What does this mean for the
adolescent?Slide11
Continuing Brain Development
Early in development, synapses are rapidly created and then pruned back. Children’s brains have twice as many synapses as the brains of adults.
SOURCE: Shore
,
1997.
11Slide12
Information taken from NIDA’s
Science of Addiction
http://www.drugabuse.gov/ScienceofAddiction/
SOURCE:
Gagtay
,
et al., 2004.
Brain Development
Ages 5-20 years
MRI scans of healthy children and teens compressing
15 years of brain development (ages 5–20).
Red indicates more gray matter, blue less gray matter.
Neural connections are pruned
back-to-front.
The prefrontal cortex ("executive" functions), is last to mature.
12Slide13
The Interaction between the Developing Nervous System and Substances of Abuse Leads to:
Difficulty in decision making
Difficulty understanding the
consequences of
behavior
Increased vulnerability to
memory
and attention
problems
This can lead to:
Increased experimentation
Alcohol and drug addiction
SOURCE: Fiellin, 2008.
13Slide14
Young Brains are Different
from Older Brains
Alcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains
Adolescent rats are
more sensitive to the memory and learning problems
than adultsConversely, they are
less susceptible to intoxication (motor impairment and sedation) from alcohol
These factors may lead to higher rates of dependence in these groups
SOURCE:
Hiller-
Sturmhöfel
&
Swartzwelder
,
2004/2005
.
14Slide15
Marijuana
15Slide16
35.6%
26.6%
19.5%
Monitoring the Future 2013
26.0%
34.9%
36.4%
Using
Perceived Harm
1993
2003
2013
MARIJUANA: AS PERCEIVED HARM DROPS,
USE GOES UPSlide17
Neurologic Impact of Marijuana
When cannabis users were asked to rate the effects of their own cannabis use as positive, neutral, or negative, they gave overwhelmingly negative ratings of the effects that cannabis had had on their
social
life (70%):
physical health (81%) : mental health (60
%) : cognition (91%) : memory (91%)
: career (79%) :
Gruber AJ, et al., (2003).
Psychol
Med.
33(8):1415-22.Slide18
Neurologic Impact of Marijuana in Adults
Administered neuropsychological tests to 63 current heavy cannabis users
who had smoked cannabis at least 5,000 times in their lives and to
72 control subjects who had smoked no more than 50 times in their lives.
Differences between the groups after 7 days of supervised abstinence were reported. However, no deficits were found after 28 days abstinence, after adjusting for various potentially confounding variables.
Suggests that cognitive deficits associated with long-term cannabis use are reversible and related to recent cannabis exposure.
Pope HG, et al. (2001). Arch Gen Psychiatry. 2001 Oct; 58(10):909-15.Slide19
Marijuana and the Adolescent Brain
Human studies suggest early onset (prior to 16-18 yo) associated with more severe cognitive consequences.
Poorer attention
(Ehrenriech
et al., 1999)Executive functioning (sustained attention, cognitive inhibition, abstract reasoning)
(Fontes et al., 2011)
(Lisdahl
and Price.,
2011)Slide20
Marijuana and the Adolescent Brain
Longitudinal research demonstrates that early onset marijuana use associated with lower IQ
Drop from childhood “average” to adult low “average”
Never achieved predicted adult IQ trajectory even with sustained abstinence in adulthood
(Meier et at., 2012)Overall studies suggest that regular
adolescent MJ use may cause brain structural changes associated with poor neuronal efficiency
poorer cognitive functioning (psychomotor speed, executive functioning, emotional control, and learning and
memory)
(
Lisdahl
et al., 2013)
This may indelicate a large proportion of youth are experiencing cognitive difficulties that may negatively impact their performance, leading to increased school difficulty and reduced grades
(Medina et al., 2007)Slide21
Why Screening and
Brief Intervention?
21Slide22
Brief Intervention Effect
Brief interventions trigger change
A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min
Research is less extensive for illicit drugs, but promising
Cocaine/heroin users seen in primary care: 50% higher odds of abstinence at follow-up after receiving BI than those who didn’t get BI
22Slide23
The Key to
Successful Interventions
Brief interventions are most successful when clinicians relate patients’
risky substance use
to improvement in their overall health
and well-being
23Slide24
2.5M people (1%) receiving treatment*
21M people (8%) have problems
needing treatment, but not receiving it*
≈ 60-80M people (≈19-25%)
using at risky levels
US Population:
316,148,990
US Census Bureau, Population Division
July
2013
estimate
*NSUDH, 2012 results
24Slide25
In treatment
(4
Million)
Diagnosable problem with substance use
Referred to treatment by:*
*Los Angeles County Data
Self/Family 37%
Criminal Justice 25% Other SUD Program 8%
County Assessment Center 19% Healthcare 3%
Other 8%
Healthcare 3%
25Slide26
In need of treatment (
23
Million)
Reported problems associated with use
Not in treatment currently
1.7%
Made an effort to get treatment
3.7% Felt they needed treatment, but made no effort to get it.
94.6%
Did not feel that they needed treatment
Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are
unaware of the problem
or do not feel they need help.
26
SOURCE: SAMHSA, NSDUH, 2012 results.Slide27
Using at risky levels (60-80 Million)
Do not meet diagnostic criteria
Level of use indicates risk of developing a
problem.
Some examples…
Drinks 3-4 glasses of wine a few times per week
Pregnant woman occasionally has a shot of vodka to relieve stress
Adolescent smokes marijuana with his friends on weekends
Occasionally takes one or two extra
Vicodin
to help with pain
These
people may
need services,
but will
never enter
the treatment system
27Slide28
Distribution of Alcohol
(or Drug) Problems
28
Specialized
Treatment
Brief
Intervention
PreventionSlide29
Screening
to Identify Patients At Risk for
Substance Use Problems
29Slide30
What is a Standard Drink?Slide31
Men
: No more than 4 drinks on any day and
14
drinks per week
Women: No more than 3 drinks on any day and
7 drinks per weekMen and Women >65: No more than 3
drinks on any day and 7 drinks per week
NIAAA, 2011
Drinking Guidelines
Beer Wine
Fortified Wine
Liquor
12 oz 5 oz
3.5
oz
1.5
ozSlide32
It’s Not About the Nail
32Slide33
Accident
SUD
Pain
Family
Medical Issues
MH
SUD
33Slide34
How Does It All Fit Together?
34
Feedback
Setting the stage and getting buy in
Tell screening results
Listen & understand
Explore pros & cons
Explain importance
Assess readiness to change
Options explored
Discuss change options
Follow upSlide35
Why SBIRT for Adolescence?
Substance use starts in adolescents.Mental health issues increase vulnerability to SUDSubstance use increases vulnerability to MHDCatching
use early
we can change the life trajectory and outcomes for these people
35Slide36
Strategies for Implementation
Study and Learn
Study the SBIRT models and guidelines
Consider how to apply best in your setting
Determine availability of behavioral health services for referral and treatment
36
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider Conference, August 7, 2012Slide37
Strategies for Implementation
Decide
Choose the best screening method for you
Annually
What screening tool to use
Who will administer
Indications for screening (everyone, age groups, certain diagnoses)37
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider Conference, August 7, 2012Slide38
Strategies for Implementation
Prepare
Select a “champion” for the effort
Train clinicians and staff on their specific responsibilities
Put copies of screener, guidelines, etc. in exam rooms
Determine a record-keeping system (EHR’s?)
38Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider Conference, August 7, 2012Slide39
Strategies for Implementation
Reinforce
Remind staff regularly
Collect success stories to encourage ongoing implementation/support
Accept feedback from staff and patients and adapt as you go
39
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider Conference, August 7, 2012Slide40
For Assistance on Implementation
SAMHSA TAP (Technical Assistance Publication Series) #33: Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT)Available for download at:
http://store.samhsa.gov/product/TAP-33-Systems-Level-Implementation-of-Screening-Brief-Intervention-and-Referral-to-Treatment-SBIRT-/SMA13-4741
40Slide41
Oregon SBIRT in Primary Care Video Clips
http://www.sbirtoregon.org/videos.php
41Slide42
Excellent example of step-by-step SBIRT procedure:
A Nurse-Delivered Brief Motivational Intervention for Women Who Screen Positive for Tobacco, Alcohol, or Drug Use Available for download at: http://www.mirecc.va.gov/apps/activities/products/productDetail.asp?id=146
42Slide43
Thank You!
Thomas E. Freese, PhDtfreese@mednet.ucla.edu
For additional information on SBIRT or other training topics, visit:
www.attcnetwork.org
www.worldofsbirt.wordpress.comhttp://www.attcelearn.org/
(“Foundations of SBIRT”)43