Screening, Brief Intervention & Referral to Treatment - PowerPoint Presentation

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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