Karla Ramirez, LCSW Director, Outpatient Services Laurel Ridge Treatment Center

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1 Karla Ramirez, LCSW Director, Outpatient Services Laurel Ridge Treatment Center

2 1 in 4 Americans will have an alcohol or drug problems at some point in their lives. The number of alcohol abusers and addicts holds steady at about 16 to 20 million. Half of college students binge drink and/or abuse other drugs and almost a quarter meet medical criteria for alcohol or drug dependence. In 2007, approximately 204,000 high-school seniors used marijuana on a daily basis. Substance abuse and addiction cost federal, state and local governments at least $467.7 billion in Girls and women become addicted to alcohol, nicotine and illegal and prescription drugs, and develop substancerelated diseases at lower levels of use and in shorter periods of time than their male counterparts. Alcohol is involved in as many as 73 percent of all rapes and up to 70 percent of all incidents of domestic violence

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5 To feel good. Most abused drugs produce intense feelings of pleasure. This initial sensation of euphoria is followed by other effects, which differ with the type of drug used. To feel better. Some people who suffer from social anxiety, stress-related disorders, and depression begin abusing drugs in an attempt to lessen feelings of distress. To do better. The increasing pressure that some individuals feel to chemically enhance or improve their athletic or cognitive performance can similarly play a role in initial experimentation and continued drug abuse. Curiosity and because others are doing it. In this respect adolescents are particularly vulnerable because of the strong influence of peer pressure; they are more likely, for example, to engage in thrilling and daring behaviors.

6 Nicotine Alcohol Marijuana (cannabis) Heroin/opioids Stimulants: Cocaine, Amphetamines, Methamphetamines Hallucinogens: LSD, mescaline, psilocybin Club drugs: MDMA (ecstacy) PCP Anabolic steroids Inhalants Prescription medications (opioid pain relievers, stimulants, CNS depressants/benzodiazepines)

7 Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs. Addiction is similar to other diseases, such as heart disease. Both disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, are preventable, treatable, and if left untreated, can last a lifetime.

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9 SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services For persons with substance use disorders Those who are at risk of developing these disorders Primary care, mental health, AOD and other community settings provide opportunities for intervention with at-risk substance users Before more severe consequences occur

10 Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidenced-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and drugs. Typically, this practice is conducted in medical settings, including community health centers, and has proved successful in hospitals, specialty medical practices such as HIV/STD clinics, emergency departments, and workplace wellness programs such as Employee Assistance Programs.

11 SBIRT can be easily used in primary care settings and enables healthcare professionals to systematically screen and assist people who may not be seeking help for a substance use problem, but whose drinking or drug use may cause or complicate their ability to successfully handle health, work, or family issues. SBIRT aims to prevent the unhealthy consequences of alcohol and drug use among those whose use may not have reached the diagnostic level of a substance use disorder, and to help those with the disease of addiction enter and stay with treatment.

12 Substance misuse and abuse often result in poor health outcomes and substantial healthcare costs related to illness, hospitalizations, motor vehicle injuries, and premature deaths. An Office of National Drug Control Policy study estimated that in 2011 substance use accrued a societal cost of $193 billion.

13 Screening: Very brief screening that identifies substance related problems Brief Intervention: Raises awareness of risks and motivates client toward acknowledgement of problem Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help Referral: Referral of those with more serious addictions

14 Increase access to care for persons with substance use disorders and those at risk of substance use disorders Foster a continuum of care by integrating prevention, intervention, and treatment services Improve linkages between health care services and alcohol/drug treatment services

15 There are grounds for thinking SBI may: stem progression to dependence. improve medical conditions exacerbated by substance abuse. prevent medical conditions resulting from substance abuse or dependence. reduce drug-related infections and infectious diseases. identify those at higher risk of abusing prescription drugs. identify abusers of prescription drugs or OTC drugs. have positive influence on social function.

16 Severe Problem Drinkers SBIRT Hazardous & Harmful Drinkers SBIRT Non-Drinkers or Low Risk Drinkers

17 Substance Abuse Challenges: 19.7 Million Americans Are Current* Users of Illicit Drugs Any Illicit Drug Marijuana Any Illicit Drug, not marijuana Psychotherapeutics (non-medical use) Cocaine Crack Ecstasy Meth Inhalants Heroin LSD (in millions) *past month users Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

18 Conclusion: Increase in non-medical use of prescription drugs among year olds since Substance Abuse Challenge: Non-Medical Use of Psychotherapeutics

19 Sources of Opioid Pain Relievers Used Non-Medically (Accounts for 73% of prescription drug abuse) Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006

20 Multiple studies have shown that investing in SBIRT can result in healthcare cost savings that range from $3.81 to $5.60 for each $1.00 spent. People who received screening and brief intervention in an emergency department, hospital or primary care office experienced 20% fewer emergency department visits, 33% fewer nonfatal injuries, 37% fewer hospitalizations, 46% fewer arrests and 50% fewer motor vehicle crashes.

21 In 2002, researchers analyzed more than 360 controlled trials on alcohol use treatments and found that screening and brief intervention was the single most effective treatment method of the more than 40 treatment approaches studied, particularly among groups of people not actively seeking treatment. Additional studies and reports have produced similar results showing that substance use screening and intervention help people recognize and change unhealthy patterns of use.

22 Periodically and routinely screen all patients for substance use disorders. Ask questions about substance abuse in the context of other lifestyle questions. Use the Alcohol Use Disorders Identification Test (AUDIT) to screen for alcohol problems among English-speaking, literate patients, or use the first three quantity/frequency questions from the AUDIT, supplemented by the CAGE questionnaire. Use the CAGE-AID (Cage Adapted to Include Drugs) to screen for drug use among patients. Ask "Have you used street drugs more than five times in your life?" A positive answer suggests further screening and possibly assessment. Ask high-risk patients about alcohol and other drug use in combination.

23 Use the TWEAK to screen pregnant women for alcohol use. Ask pregnant women "Do you use street drugs?" If the answer is yes, advise abstinence. Use the CAGE, the AUDIT, or the Michigan Alcoholism Screening Test -- Geriatric Version (MAST-G) to screen patients over 60. Screen adolescents for substance abuse every time they seek medical services. When recording screening results, indicate that a positive screen is not a diagnosis. Present results of a positive screen (and conduct all discussions about substance use) in a nonjudgmental manner.

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29 Perform a brief intervention with patients whose substance abuse problems are less severe. Include in the brief intervention feedback about screening results and risks of use, information about safe consumption limits and advice about change, assessment of patient's readiness to change, negotiated goals and strategies for change, and arrangements for followup visits.

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34 Refer high-risk patients to a specialist, if possible, for in-depth assessment. Become familiar with available assessment and treatment resources. Keep encouraging reluctant patients with substance use disorders to accept treatment of some kind.

35 Visits to primary care clinicians provide unparalleled opportunities to intervene with substance abuse problems at a relatively early stage in disease progression. Office or clinic visits also give clinicians an opening to discuss substance abuse prevention with patients and in many cases, forestall problems from ever developing. As one primary care physician observed, "With respect to substance abuse, our charge is straightforward: first we must ask something, then we must do something."

36 Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. By any measure, effectively treating a primary care patient's substance abuse problem is addressing a significant "personal health care need." Alcoholrelated disorders, for example, occur in up to 26 percent of general medical clinic patients, a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes.

37 In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol- or other drug-related service. Basic skills in identifying and diagnosing patients who are chemically dependent will become essential.

38 Clinicians in areas with limited substance abuse resources may be responsible for assessments, while those trained in addiction medicine may be providing a range of treatment services. Regardless of how extensively involved clinicians become, those who are familiar with the medical complications of substance abuse and are able to relate them to other comorbid illnesses will be better equipped to deliver adequate care.

39 Substance use disorders share many characteristics with other chronic medical conditions like hypertension. Among the similarities between the two are late onset of symptoms, unpredictable course, complex etiologies, behaviorally oriented treatment, and favorable prognosis for recovery.

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