Hi, I'm Derek Blevins. I'm an addiction psychiatrist and assistant professor of psychiatry at Columbia University, and this is the second part of a webinar series that is entitled Integrating Screening, Brief Intervention, and Treatment for Stimulate Use Disorder During Buprenorphine Treatment for Opioid Use Disorder in Primary Care. We'll start with some information about the Opioid Response Network, which sponsored this project. It assists states, organizations, and individuals providing education and training they need to address the opioid crisis and stimulant use, and technical assistance is available to support the evidence-based harm reduction, prevention, treatment, and recovery of opioid use disorder and stimulant use disorders. The ORN provides local experienced consultants in prevention, treatment, and recovery to communities and organizations to help address this opioid crisis and stimulant use. ORN accepts requests for education and training, and each state or territory has a designated team led by a regional coordinator who is an expert in implementing evidence-based practices. To ask questions or submit a technical assistance request, you can visit the ORN website, email ORN at AAAP.org, or call 401-270-5900. And here is a statement about the funding source from SAMHSA. And the overall mission of ORN is to provide training, education via local experts to enhance harm reduction, prevention, treatment, especially medications like buprenorphine, naltrexone, and methadone, and recovery efforts across the country addressing state and local specific needs. So the first webinar for this series, we talked about stimulant use and OUD treatment more generally, and then today we'll talk about screening, diagnosis, and brief intervention with a focus on stimulating this patient population. And then the following two webinars will focus on both behavioral and pharmacologic treatment approaches. So an overview for this talk, we'll talk about some screening tools, urine drug testing, and its role in stimulant use and stimulant use disorder, comprehensive assessments, some brief intervention strategies, and then some referral considerations. So SBIRT stands for Screening Brief Intervention and Referral to Treatment, has become a pretty standard protocol to use to screen and determine the next steps for a patient who screens positive for some sort of risky or problematic substance use. So we'll start with the screening aspect. So the purpose of screening is really for early detection of risky or problematic use to result in better outcomes in both the short and long term. Screening tools should be universal, very quick, nonjudgmental, and have a high sensitivity. So you want to make sure that you're capturing all potential people who might have a substance use or stimulant use problem. But a positive screening does not result in a substance use disorder diagnosis, but does warrant further evaluation. So a simple screen for substance use other than alcohol simply asks about any nonmedical use of medication or any illicit drug or tobacco use, or any of the substances for intoxication, use of any other substances for intoxication in the past 30 days. So a yes on any of these questions would warrant further questions, and then at least a brief intervention if not a referral to treatment. A couple of other screening tools that are pretty commonly used is the DAST, which is the Drug Abuse Screening Test, and it is a self-report measure that can be administered with other clinic paperwork with a score that equates to what they call a zone of use. So the zones are healthy, risky, harmful, or severe, and then an indicated action, which can be none, give advice, a brief intervention, or a referral to specialized treatment. The CRAFT is actually specific for patients under age 21. CRAFT stands for CAR, RELAX, ALONE, FORGET, FRIENDS, and TROUBLE, and it gives similarly a probability ranging from 30% to 100% of substance use disorder diagnosis, and it can be self-administered or clinician-administered. The NIDA quick screen is a simple question asking about alcohol, tobacco products, prescription drugs for non-medical reasons, and illegal drugs. Any positive answer would indicate that it would be necessary to follow up those questions with what is called the NIDA ASSIST. So a yes on the quick screen then necessitates asking these questions, and these questions would be asked for each substance. The result of this would also give a level of risk for each substance with a score of 0-3 being lower, 4-26 is moderate, and 27 or higher is high. This is a very comprehensive assessment, but it does take a lot of time. There is a lot of time investment. The full NIDA ASSIST is about seven pages long, and it is available online for easy access. However, NIDA has mostly recommended replacing the NIDA ASSIST with their online screening tool called the TAPS. This can be self-administered or administered by a clinician. TAPS stands for Tobacco, Alcohol, Prescription Medication, and Other Substance Use, and specifically for stimulants, it had a 60% sensitivity and a 99% specificity in identifying cocaine or methamphetamine use disorder, and this was actually in a patient population of primary care patients, about 2,000 patients. The interviewer-administered version was 57% sensitive and also 99% specific. So this is four items, the tobacco, alcohol, prescription meds, illicit substances, and it asked about in the past year, and then also has a brief assessment for the past three months. Its intention is really for primary care settings. It has, like I said, both the self-assessment or provider assessment options, so when you go to the first screen, it asks if you're the patient or the provider, and then it just phrases the questions a little bit differently depending on if you're using it as a self-assessment or provider assessment. A positive screening of early questions, so it's adaptive, it's followed up by additional questions depending on answers to the earlier questions, and also provides this risk level from minimal to high. And I will show you just, this is the first question that it asks about stimulants in particular, so in the last three months, did you use cocaine, crack, or methamphetamine? And if someone were to answer yes to this question, this would be the next screen that would show up, which asks about in the past three months, sort of the frequency of use, and if anyone expressed any concerns about their use. If answering yes to both of those questions then, if it is the patient version, what they will see is this, thank you for taking this survey, please let your health care provider know that it's complete, and if it's, say, on a computer or an iPad, they would hand it to the health care provider. And then they click okay, and it follows up with this next screen that shows a stimulant risk level being high for stimulant use disorder. And because the font is pretty small on this screen, I pasted this text so that you can see it a little bit better, and this is the information that the clinician is actually going to see, so it's saying that a further assessment and treatment is warranted in this case, or likely warranted, and gives some very specific recommendations. So doing more assessment, asking the DSM-5 clinicians for stimulant use disorder, expressing concerns, recommending cessation, using the FRAMES components. FRAMES is feedback, responsibility, advice, menu for change, empathy, and enhancing self-efficacy, so this is a type of brief intervention. So using this and other motivational strategies to encourage engagement and treatment, making some sort of specific plan, which can include risk reduction for hepatitis C or HIV, and then providing other types of referral or treatment options. Educating on risk, advising to not use drugs and drive, and then arranging some sort of follow-up discussion. Another very brief screening tool that can be used in primary care settings in particular is the Screen of Drug Use, the SODU, and it's a very simple initial question, so I'm going to read you questions concerning information about your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months. Drug does not refer to a medication used in the manner it was prescribed or recommended. For example, include only your use of marijuana if you're using it above and beyond what was recommended by a doctor or a state-licensed physician, or if you're using it recreationally. And then questions will be related to the last 12 months, so your answers can vary from zero to 365 days. So the first question then is how many days in the past 12 months have you used drugs other than alcohol? And then if the answer is seven or more days, this is considered a positive screen for this tool, and the second question is actually not necessary because you've already met the criteria to have a positive screen. If the answer is six days or fewer, then you ask the question, how many days in the past 12 months have you used drugs more than you meant to? And the patient who responds to two or more drugs in the past 12 months, or two or more days in the past 12 months, has a positive screen. And this two-item screening tool actually has been evaluated, examined for stimulant use disorder, and shown to be about 94% sensitive and almost 90% specific. The sensitivity ranges from 67 to 100%, and specificity from 77 to 94%, and diverse subgroups of patients. With one additional follow-up question, aside from these two, the sensitivity was unchanged, and the specificity actually increased to 99% and had a lower false positive rate. Now, another tool that can be very helpful for screening for stimulant use or for any substance use disorder is urine toxicology screening. In this particular patient population where we're talking about people who are prescribed buprenorphine for opioid use disorder, it is a routine a routine procedure that is done, testing for primarily to see if buprenorphine is showing up in the urine, if there's compliance with medication, but also the effect of the buprenorphine treatment, right, if the person is reducing or continuing to use or not other opioids aside from buprenorphine. Most drug panels do include cocaine and amphetamine, and some panels also include methamphetamine specifically and MDMA. The role though of drug testing, and this is an important point, is really to improve clinical care. It's not to catch the patient, and it's certainly not to justify discontinuing buprenorphine, which would put the patient at a higher risk of opioid-related consequences, including overdose and death. Stimulant urine drug testing has advantages and limitations that I will talk about in the next couple of slides. These are the drugs that are pretty much always included on a standard urine drug screening. Urine, it can be in a cup or a dip test, and the nine to five are pretty much always included on a screen. So amphetamine, cocaine, of course the two substances that we're thinking about in this particular population, but it also includes opiates, PCP, and THC. Many other drug tests also include a number of other drugs like barbiturates, benzodiazepines, buprenorphine, MDMA or ecstasy, which is another medication that has stimulant or drug that has stimulant-like properties, methadone, oxycodone, and propoxyphene. So these are often included on a larger urine drug screen, but the original nine to five did not include these substances, these drugs. And then much rarely included on screening is methylphenidate, which is another one of the prescription stimulants, and cathinones or bath salts. These often require some sort of send-out test. So for cocaine specifically, the enzyme immunoassay screen is highly sensitive and specific for benzoyl echinine. This is one of the major metabolites of cocaine when it's broken down in the body and is what most or all tests that screen for cocaine are actually testing for is benzoyl echinine. And there's very little cross-reactivity with benzoyl echinine. So that means that a positive screen almost certainly indicates some type of ingestion. Now, if a patient were to deny using cocaine use and had a positive screen, you know, you might suggest that they were exposed to cocaine if they were denying that they had actually used it, and ask about any situations that came up that might have increased their risk of exposure. Are they out drinking with friends, smoking marijuana, or using some other substance that cocaine might have been in? But a positive screen, again, almost certainly or certainly indicates ingestion by that person. GC-MS or gas chromatography mass spectrometry is used to confirm the cocaine and can also show new or changing use by showing the levels of benzoyl echinine in the urine. Cocaine is typically positive for two to three days. It can be up to 14 days with chronic heavy use, but it most often will just be positive for a few days after use, even in people that are using more regularly. Now, this story is very different for other stimulants. The enzyme immunoassay includes a lot of false positives for other stimulants like methamphetamine, amphetamine, antihistamines, pseudoephedrine, a lot of different antidepressants and antipsychotic medications can result in false positives on the screening test. So this is where the GC-MS confirmatory test can be much more helpful to show the specific drug and again can show drug levels, so new or increasing or decreasing use. There's a lot of cross-reactivity between amphetamine, methamphetamine, and MDMA, and I included some of the chemical structures on this slide because you can see they look pretty similar, so you would understand why they might cross-react. This benzene ring and the amine group result in a lot of that cross-reactivity. Methylphenidate, you can see, looks quite a bit different than the other substances, so there often is less cross-reactivity with methylphenidate. Methylphenidate is also rarely included on screening panels, but it can be ordered for a confirmation by GC-MS. Like cocaine, most amphetamines are going to show up for two to three days, can be longer, maybe longer than seven days with regular use, but typically will not stay positive in the urine for very long on a screening test. And urine acidification can actually increase the elimination of amphetamines. So far we've talked about some ways to do sort of fast screening or screening that fits into a standard treatment protocol for a patient that's coming in for buprenorphine for opioid use disorder, and now I'm going to talk a little bit more about a more comprehensive assessment and thinking about diagnosis of a stimulant use disorder as well as some of the other things that we want to have in mind as we're thinking about an intervention or a referral to treatment. So first we'll talk about the DSM diagnosis, some about patterns of use, the impacts of use on physical and mental health, and their treatment history. These can all be very helpful to understand sort of the next steps. So this is just a reminder of the DSM criteria. This list is exactly the same as for opioid use disorder. There are no differences. There also were no changes in the criteria from the DSM-5 to the DSM-5-TR. And I just want to point out that there may be a lot of overlap between screening questions and the DSM criteria. Often it's not 100%, and it is important to assess for a diagnosis before documenting that someone has a substance use disorder, in this case a stimulant use disorder. It's also important to note that someone doesn't have to have a diagnosis of a disorder to have risky or problematic use, that this can still be, you know, part of the problem list, but they may not meet the full diagnostic criteria. It's easiest to remember the criteria by these kind of four major categories, so impaired control, social issues related to use of this substance, physical or psychological consequences, and then what we call the physiological criteria, which are withdrawal or tolerance. And of note there, like an opioid use disorder, if the person is prescribed opioids, they need one more criterion if it's a prescription medication that they're taking. So they would need to meet one of these other criteria, one through nine, in addition to tolerance and withdrawal, which we would expect if they're taking a medication as prescribed. So that might be the case, for example, with a prescription amphetamine. And then here are some additional questions that may be helpful after a positive screen or after you've asked the diagnostic questions to better understand the patient's substance use. Answering these questions will guide some of the aspects of the physical and mental health assessment and will help with your brief intervention or consideration of referral options. And just an example, if a person is using multiple substances, asking about the drug of choice might indicate that they should go to cocaine anonymous versus crystal meth anonymous, or N.A. And the amount and route administration may encourage you to further investigate particular body systems on exam or with lab work. And in addition to thinking about the type, the way that someone is using a substance and how much they're using, I think it's important to note that we don't, in medical school, often learn some of the sort of street terms that can be used for different drugs. And this can be helpful in having conversations with patients and allowing them to open up more, but also getting correct and accurate information. So I've included here some of the different names for cocaine and methamphetamine that are used, that are used on the street. The cost for cocaine is about $200 per gram compared to methamphetamine, about $100 per gram. Of course, this will vary by location and purity of the drug. And when people mention quantities, if they say an eight ball, that's three and a half grams of cocaine. An intranasal dose is around 30 to 70 milligrams. So that means that if someone is describing their use as using a bump of cocaine, that there might be about 20 bumps of cocaine in a gram. Cocaine is often used intranasally, it can be used IV or smoked, and it can also be used orally or rectally, but intranasal IV or smoked are more common routes of administration. For methamphetamine, a gram is about four hits of a smoked methamphetamine and used in similar ways as cocaine. Okay, so we've talked about screening aspects of the screening aspects, so now we'll talk some about brief intervention. So broadly speaking, the major elements of a brief intervention are engagement, motivation, and planning. There are three similar methods of providing a brief intervention. So motivational interviewing focuses on engaging, focus, invoking, planning. These are sort of the phases of motivational interviewing. A brief negotiated interview talks about raising the subject, providing feedback, enhancing motivation, negotiating a plan. And then the five A's from NIAAA are ask, advise, assess, assist, and arrange. So these all sound very familiar, they're different sort of strategies for providing a brief intervention. Other commonalities that are brief, so five to 10 minute interventions, nonjudgmental in terms of the way it's approached and the language that's used. You can provide education. You really want to appeal to the patient's goals and values, allow for the patient contribution, which also includes disagreement. So you don't have to be the all-knowing expert giving sort of ultimatums. This attitude can also increase patient resistance if they do encounter that. So allowing for disagreement can really be helpful, encouraging the patient to problem solve and reflecting their commitment to change. So in motivational interviewing, the first step, as I mentioned, is engage. And these are some of the approaches and strategies that can be used. So you want to develop a comfortable way to introduce the topic, establish rapport and ask permission to discuss especially sensitive topics, frame the discussion within the context of medicine, emphasize any medical consequences of substance use, and really consider the language that you're using, like describing it as drug use instead of drug abuse, normalizing the questions, like saying that you routinely ask all of your patients, and really integrating it into preventative care or into the opioid use disorder treatment. ORS is a very common and helpful acronym when thinking about this strategy of motivational interviewing or this conversational style of motivational interviewing. ORS stands for open-ended questions, affirmations, reflections, and summaries. So the idea of open-ended questions is to not lead the patient and not to ask yes or no questions. So something like, can you tell me a little bit more about your cocaine use, for example. Affirmations are showing appreciation and understanding of their experience. And these affirmations should be genuine and can be as simple as saying wow, or that's really difficult. Reflections demonstrate an understanding of what they're saying and clarify any misunderstandings. Like, so while you don't really like using cocaine, it provides you with some energy when you're feeling down, would be an example of a reflection. That may be something that they would say to you that you would reflect back with slightly different language. And then summaries is taking time to periodically review the discussion up to that point and offering to discuss anything missed or anything that needs clarification. So taking time every once in a while to provide these summaries. In this engagement process, again, you really want to understand and give credence to patient perceptions, emphasize their values and goals, think about the impacts of substance use on those goals, develop discrepancy between substance use and achieving their goals, and elicit the need and perceived ability to change. And then when we move sort of to the second phase of motivational interviewing, which is motivation, at this point, you want to provide very clear, specific, personalized feedback, talk about risk and consequences of use, express your concern, recommend any explicit changes that you might suggest, support their self-determination and autonomy, emphasize your confidence in their ability to change, assure your continued support throughout the process, emphasize any strengths and past successes that they've had, and validate frustrations while remaining optimistic. And again, this is also a time to reflect a lot and summarize at different intervals during the discussion, and then really prepare the patient for taking the next steps. And then the final sort of phase of this discussion or conversation is planning. So more concrete, making goals aligned with the patient's goals. Those goals should be attainable, measurable, and timely. You want to help anticipate any challenges they might have, be flexible with the strategies, avoid any arguments and defensiveness, which again, just may increase their resistance to change, recommend the ideal, but accept less than that, if that's what they're able to do or willing to do, reinforce, reassess, and update the plan at different intervals as time goes on in their treatment, acknowledge their efforts and experiences, offer again, your continued support despite any progress or lack of progress, and give self-help and guidance for social support. So in the process of SBIRT, after the screening, and if a brief intervention is warranted because of risky or problematic use, then the next steps might be a referral to treatment, especially if the patient meets criteria for a substance use disorder, or if their risk is greater than a brief intervention is appropriate for. So when we talk about referral to treatment, it is important to understand the continuum of care. Most people of course are gonna benefit from lower levels of care, that is the goal is to have the person in the lowest level of care, lowest least restrictive level of care possible. And these are the levels of care that are recommended by the ASAM criteria. So as you go up the pyramid, the level of intensity and treatment increases, and fewer people should require that higher intensity. There is an exception for inpatient treatment. If there's high psychiatric or medical comorbidity for stimulant use disorder in particular, though often if medical treatment is needed first, the substance use disorder treatment is usually delayed, and the patient is then stepped down to residential treatment. So for most cases for a stimulant use disorder, because there isn't a necessity for detox or for medical detox, most people fit in this range from residential treatment to outpatient treatment. And just to note that harm reduction should be considered and integrated at all levels of the continuum of care model. And I'm gonna talk a little bit about harm reduction before going back to the levels of care. So what is harm reduction? So it's a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction is also a movement for social justice built on the belief in and respect for the rights of people who use drugs. And a very important point is that harm reduction is for those who are and aren't ready to change their use. This point of risk set and setting is important when thinking about different harm reduction strategies. So risk is the risk itself related to an activity for cocaine or stimulants. It may be overdose, seizure, or cardiac event. Set is the mindset. So the thoughts, mood, or expectations that someone has at the time of use, and then setting is the physical or social environment of use. Some examples of harm reduction. So sterile syringes or straws, and straws meaning for snorting a powder substance. Avoiding mixing with other drugs or alcohol. Having naloxone, which is the opioid overdose reversal medication in the event that cocaine or another stimulant may be adulterated with an opioid. Drug testing kits. And a good example is the DanSafe kits, which have been around for a long time. You can actually order those kits online. They have some different reagents to test. A multitude of different drugs that are often used illicitly. And then fentanyl or xylazine test strips. And I've included an example of one of those here. They're very available from harm reduction agencies, and often you can get them at the same time as the naloxone or Narcan spray. And this can be used to test cocaine powder or other powder substances in particular. So one of the reasons that we want to talk about harm reduction for stimulants is the many adulterants that show up in the drug supply. Levamisol in particular. There are some studies that show that 70 to 80% of the cocaine supply is adulterated with levamisol. Levamisol is a veterinary anti-helminthic drug. It is very similar in appearance to cocaine. So it often can't be distinguished from it. So they use it to cut the cocaine so that people that are buying it can't really tell the difference. It can cause agranulocytosis, neutropenia, and vasculitis. Some other adulterants that may show up in cocaine or other stimulants. Fentanyl certainly is a highly concerning one. There are a lot of questions about whether fentanyl adulteration in the stimulant supply is accidental or intentional because people who are buying stimulants don't necessarily have tolerance to opioids. So a one-time use of adulterated cocaine with fentanyl could result in an overdose death. It does also show up in pressed pills. So drugs that are sold as Adderall illicitly have been tested and shown to be positive for fentanyl. And again, there's this importance of low opioid tolerance especially if the person is not on MLUD. So in this population where we're talking about people on buprenorphine, the risk is at least lower. But if people are not on a medication treatment then this is of a great concern if people are using cocaine that has fentanyl. Xylosine is also a potential adulterant. Certainly it's much more well-known to be adulterating the heroin or opioid drug supply. It's often combined with fentanyl, sold as heroin or sold as fentanyl that has xylosine in it. It is a veterinary anesthetic drug. It's an alpha-2, very strong alpha-2 agonist which is the same mechanism as clonidine, but much stronger. Sometimes referred to as Trank on the street and can result in skin ulceration or necrosis. And then other stimulants. So methamphetamine can sometimes be sold as Adderall or Ritalin pills. So going back now, switching a little bit from thinking about harm reduction to the ASAM criteria and guidance for placement. So these criteria are used mostly by insurance companies to figure out the best place for treatment. It's across these six dimensions of assessment. So acute intoxication or withdrawal, biomedical conditions, psychiatric conditions, readiness to change, relapse, continued use or continued problem potential, and then the recovery or living environment. So for inpatient treatment, so these are the six dimensions that I put in bold sort of what's important to consider. So when someone is currently intoxicated or has a high risk of withdrawal, if they have a lot of comorbid medical or psychiatric issues that require immediate attention, then that's when inpatient treatment is most often recommended. And again, as I mentioned before, for cocaine, the risk of withdrawal, while withdrawal symptoms are, they do exist, they're not medically dangerous. So they don't typically require an inpatient admission unless there's something else happening at the same time like medical or psychiatric issue, like suicidality, for example. And then for residential treatment, you actually don't want people who have those more acute medical or psychiatric issues, but there are often people that need constant supervision to support change. They're not able to stop using or remain absent on their own in the community, and they may have an unsupportive or dangerous recovery environment. And it's not uncommon for people to transition from inpatient to residential treatment, but in the case of stimulants, often people get admitted directly to residential treatment. One step down from that would be partial hospitalization. So again, not requiring acute medical or psychiatric attention, but needing daily supervision to support change, having a high relapse risk and a less supportive environment for their recovery. One more step down from that would be intensive outpatient where they may be there multiple days a week for a few hours, but not most of the day with a partial hospitalization. So these again are people that are cooperative. They may have some higher motivation, but they need more structure. They're able to maintain abstinence with less supervision, but do need closer monitoring and their environment may be less supportive, but the structure of the intensive outpatient program is helpful. And then the lowest level of care would be outpatient where they don't have these acute medical or psychiatric risks. Everything can be managed as outpatients. They may be more motivated, cooperative with discussions around change, able to maintain abstinence and have hopefully a more supportive recovery environment. These are some resources that SAMHSA has available. There is a national helpline, a 1-800 number that is staffed 24-7-365, both in English and Spanish that provides referrals to local treatment facilities, support groups, and community-based organizations. You can also order free publications and other information to put in your clinic. And then the behavioral health treatment services locator also on the SAMHSA website can be helpful for people looking for additional support. So in summary, screening tools of varying lengths are available to evaluate stimulant use. Urine toxicology screening has advantages, but also has limitations for patients on MOUD who may or may not be using stimulants. A comprehensive stimulant use assessment guides brief intervention, referral, and treatment considerations. And brief interventions lasting 10 or 15 minutes can be effective. Harm reduction has a role in all levels of care for stimulant use disorder. And appropriate treatment referrals depend on multiple medical, psychological, and psychosocial domains, and can be guided by clinical judgment and the ASAM criteria. And that concludes this second talk. And the next webinar, we'll talk about behavioral treatment approaches for stimulant use disorder.

Screening

Diagnosis

Brief Intervention

Stimulant Use

Urine Drug Testing

Comprehensive Assessment

Harm Reduction