Hello, my name is Jeannie Manube. I'm a faculty member here at New York-Presbyterian Columbia, Department of Family Medicine Residency Program. I'm also board certified in family medicine and addiction medicine. The module that I have created is called Screening, Brief Intervention and Referral to Treatment or SBIRT for Substance Use Disorders in Primary Care Settings. I have no disclosures to report. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well for the prevention and treatment of substance use disorders. Some of the objectives of this module are to identify appropriate screening tools to detect substance use disorders, to determine the severity of substance use disorders to help guide treatment, to describe when and how to provide follow-up appointments and referrals, and to review the components of a brief intervention. I wanted to provide some statistics here. Some recent data from multiple primary care sites found that over a quarter of adult patients reported use of an illicit drug or misuse of a prescription drug. This is not including alcohol or tobacco in the last year. However, tobacco use is the leading cause of preventable death in the US. I wanted to provide one statistic about the opioid epidemic. In April 2021, the CDC reported that more than 100,000 Americans died of drug overdoses in a single year, an increase of 28.5 percent from a year before. Opioids, especially the synthetic opioid fentanyl, drove the rise. A bit of good news, in December 29th, 2022, there was the signing of the Consolidated Appropriations Act of 2023, which eliminated the data waiver program. What that means is that the X waiver is no longer required to treat opioid use disorder with buprenorphine, and it also removes the federal limit on the number of patients you can treat with buprenorphine. Then the DEA will require new training requirements starting June 2023. That's good news for those with opioid use disorder. I just wanted to talk first about the importance of screening. Patients may not be aware of the risks of drug and alcohol, on their health. If clinicians do not ask about substance use, problematic use may not be identified. Primary care providers offer continuity of care, often over years, ideal for screening and implementing brief interventions for problematic substance use. Primary care settings can also offer a comprehensive care with a team of social workers and medical assistants. What is SBIRT? It stands for Screening, Brief Intervention, Referral to Treatment, and it is an evidence-based practice that has shown significant success in varied clinic settings across all age groups, genders, races, and ethnicities. This is an older citation, but I just wanted to include it because it showed that at six months of SBIRT interventions, they showed that the rates of illicit drug use reduced by 67.7 percent and rates of heavy alcohol use were reduced 38.6 percent. More recent studies have shown mixed results on the effects of SBIRT on clinically important outcomes in primary care medical settings. I guess one of the criticisms in this paper cited by sites in 2015 is that the expectation to engage an individual with a newly identified substance use problem to treatment can be a tall order. However, we know that brief counseling to inform treatment options can be beneficial. Also, with time constraints for delivering brief interventions, it is likely to be more effective if repeated over several visits even over years. Many of the studies look at results three months, six months, a year later. But in clinical practice, we often see that it may take time for someone to accept any change in their behavior. It can take years, but it can still lead to success. I wanted to talk about the USPSTF recommendation for screening for unhealthy alcohol use. They recommend screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. This is a B recommendation, and I'll talk about that more in the next slide. They also concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for alcohol use in primary care settings in adolescents aged 12-17 years old. It is an I statement, insufficient evidence. I just wanted to show you a table which defines what these recommendations mean for practice. An A recommendation is something that they recommend doing. It is with high certainty that the net benefit is substantial. For alcohol, it was a B recommendation. They'd still recommend the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. They do recommend providing the service. For alcohol, in adults, it's a B recommendation. One example of an A recommendation is for tobacco use. They actually say that screening for tobacco use is an A grade recommendation and for unhealthy drug use, for adults, it's a B recommendation. When it comes to screening for alcohol use in adolescents, the I statement is below there. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. The evidence is lacking of poor quality, conflicting, and the balance of benefits and harms cannot be determined. It's indeterminate for this recommendation. While they found that there was inadequate evidence, we do know that brief behavioral counseling interventions in adolescents have been associated with reduced alcohol use, and some trials actually do suggest benefit. Because risk-taking in adolescents is common, it is particularly important to reduce drinking among youth. Alcohol-related injury is a leading cause of death among adolescents and young adults. We know that the development of alcohol use disorder is also strongly related to the age of first drink. Further, it is likely that screening and brief counseling for adolescents could be more efficacious than in adults, as drinking patterns among adolescents have yet to be established. An opportunity to prevent a lifetime of risky exposures and consequences is significant. I wanted to go over the DSM-5 criteria for substance use disorders. This will span a wide variety of problems and cover 11 different criteria related to physical dependence, risky use, social problems, and impaired control. And this severity is determined over a 12-month period. I will be going over this list, but just keep in mind that a mild substance use disorder will be two to three of these symptoms, moderate is four to five symptoms, and severe substance use disorder is six or more of these symptoms. Also keep in mind that we can't just use dependence and tolerance as the only two symptoms to characterize something as a mild substance use disorder, because this could just mean physical dependence on a drug, which does not mean it is a substance use disorder. So we'll go over these criteria. So number one, taking the substance in larger amounts or for longer than you're meant to. Number two, wanting to cut down or stop using the substance but not managing to. Number three, spending a lot of time getting, using, or recovering from use of the substance. Number four, cravings and urges to use the substance. Five, not managing to do what you should at work, home, or school because of substance use. Six, continuing to use even when it causes problems in relationships. Seven, giving up important social, occupational, or recreational activities because of substance use. Number eight, using substances again and again, even when it puts you in danger. Number nine, continuing to use even when you know you have a physical or psychological problem that could have been caused or made worse by the substance. Number 10, needing more of the substance to get the effect you want, which is tolerance. And number 11, development of withdrawal symptoms, which can be relieved by taking more of the substance. Some additional specifiers are in early remission, which means it has not met criteria for three months to one year. In sustained remission, which it has not met criteria for over one year. On maintenance therapy, for example, on methadone or on buprenorphine. In a controlled environment, such as a detoxification center. Understanding the severity of a substance use disorder can help clinicians better determine which treatment to recommend. And matching the appropriate level of care can help improve a person's chances of recovery. So I wanted to define what risky use is. Positive screens who do not meet criteria for a substance use disorder, who have used the following substances in the past 30 days. So for tobacco, this is any use of tobacco or nicotine products. For alcohol, for women, it's more than one drink a day or more than seven drinks a week. And for men, greater than two drinks a day or greater than four drinks per week. For other drugs, it would be any non-medical use of controlled prescription drugs or other medications or any use of illicit drugs. For risky alcohol use, a positive screen would be use of alcohol in the last month for those under age 21, those who are pregnant, those who take medication that interacts with alcohol, in patients with certain medical conditions, such as liver disease or pancreatitis, for those that while driving, operating machinery or taking part in other activities that require attention, skill or coordination, and also in situations that could cause injury or death, such as swimming. So I'm going to go over some examples of screening tools for substance use disorders. There have been several validated screening tools that exist for use in primary care. Here at Columbia, we used to use NIDA quick screen, which we have changed to TAPS now. I'll talk about that a little bit later. CAGE-AID, AUDIT, which is for alcohol, DAST for drug use, TWEAK, which is used in pregnant populations, CRAFT, which is used in adolescents. And I'll go over each of these. So the NIDA quick screen, in the initial screening questions, it asks in the past year, how many times have you used the following? So it places them in the categories of alcohol, tobacco products, prescription drugs for non-medical reasons and illegal drugs. And then the answers are never one to two times monthly, weekly or daily or almost daily. And I provided links to all of these screening tools at the bottom of each slide. TAPS refers to tobacco, alcohol, prescription medication, and other substance use tool. It is a four-item screen. It can be self or clinician administered. Endorsement of any substance use during the initial screening phase in TAPS 1 prompts few additional questions regarding use-related behaviors through a brief assessment. So TAPS 2 will identify the specific substance use and risk level, ranging in severity from problem use to the more severe substance use disorder. And this is great to implement when you have a portal at Columbia. This will populate two days before a visit to internal medicine, family medicine, gynecology for their annual visit, and for pregnant women prior to their first appointment, after 24 weeks of pregnancy, and then postpartum. So these are nice tools to have if you have an electronic medical record, which can be incorporated right into the chart. CAGE-AID is a four-question screening tool which lasts about one minute, refers to cut down, annoyed, guilty, and eye-opener. And two or more positive responses is a positive screen. And any score one and above places someone at increased risk. Audit is developed by WHO to detect at-risk or hazardous drinking. It asks about quantity and issues not included in quick screening tools. It's 10 questions lasting about two to four minutes. Each question can score from zero to four. There's a cutoff of eight, which could indicate potential alcohol misuse, with a maximum score of 40. DAS-10 is for drug use screening. 10 questions lasting about three minutes can be used for adults and adolescents. And for each positive response, there is one point. So if someone scores one to two, you will monitor and reassess later. For three to five, you investigate the substance use further. And for six to eight points, you address the problem immediately. For special populations, so for pregnant women, TWEAK screens for alcohol use. The CRAFT 2.1 is used for adolescents less than 21 years old. Three to nine questions lasting five minutes. Screens for both alcohol and drug use. And there's a version that also screens for vaping and tobacco and nicotine dependence as well. So in terms of electronic medical records, one advantage of screening tests is that they can be embedded into electronic medical records that record score responses and display results. And a provider can see the results and actually see, you know, use the EMR for decision support and recommendations for further assessment and advice specific to patients based on the results. Front desk staff can provide electronic tablets for patients to complete in the waiting room. Or medical assistants can enter answers prior to the medical encounter. Or like I said before, if you have a portal, you can send this to a patient to complete prior to them coming to the visit. So brief interventions can include brief counseling or patient education during a clinic visit to help reduce risky behavior. This can be conducted in less than 10 minutes, and it has been shown to reduce alcohol consumption, binge drinking, tobacco use, and illicit drug use. Some examples are to further assess the problem, making specific recommendations for more healthy behavior, and possibly suggesting a treatment approach. You target the level of risk to the complexity of the problems. So you determine which problems can be managed in the practice. For example, reductions of use or trial of abstinence and low to moderate addiction. You can talk about medications for addiction treatment and provide buprenorphine if needed. Determine which problems need referral to specialists, which problems need referral to specialists. And for example, this would be patients who have psychiatric comorbidities, severe addiction issues, or polysubstance misuse. So what can be accomplished in a brief intervention? Even expressing concern is very important to know the seriousness of the issue, especially if screening questions are positive. Assess the patient's understanding of the situation, their readiness to change, potential obstacles for reductions in use or abstinence. You can discuss what the treatment options actually are and the benefits of quitting. You can examine prior successes and failures. You can come up with realistic goals and schedule follow-up. You can support the patient's effort and commitment toward a goal. You can encourage the patient to solicit support from family members and friends or support groups, or you can just provide patient education and resources if they're just really not ready to talk. Helps to elicit motivational statements from patients. I'm gonna list some motivational interviewing skills here. You wanna use a very nonjudgmental manner with a patient-centered approach. This has been shown to be effective with substance use disorders. Examples are asking open-ended questions, expressing empathy, eliciting personal insight to problem to understand motivations and explore ambivalence. Employ reflective listening. Repeat what you have learned from the patient. And sometimes when you repeat something you've heard, a patient may say, no, that's not how it is. This is actually how it is. The more they talk, the more they can understand what's going on. And then you can highlight discrepancies. And this is one way to figure out, do some problem solving to see what may work. We recommend follow-up care within two weeks to a month, which allows time for a patient to work on short-term goals and check in with a clinician to monitor success. This way, you can problem solve challenges and barriers to change. You can provide support and guidance, assess mood and possibly enlist help from other colleagues in the practice such as medical assistants or social workers to also provide follow-up phone calls to address housing, childcare or other psychosocial issues if you are able to. And I just wanted to show that you can get reimbursed for the time you spend with screening and brief interventions. So for Medicare, you can bill for alcohol and or substance misuse assessments and brief intervention services. And these are usually time-based. So if it's 15 to 30 minutes, greater than 30 minutes, you can bill accordingly. For Medicaid, you can also bill for alcohol or drug screening and specifically for brief intervention. Also, here are some more billing codes that you can use for those who are not in Medicaid or Medicare plans. You can bill for smoking and tobacco use cessation, counseling sessions. And again, these are time-based and you can also bill for brief intervention services, also time-based. So there are some situations where referrals may be indicated. For example, if there is need for medical management of withdrawal that you can't take care of in the outpatient setting, in cases where there is polysubstance misuse, someone may be with an alcohol use disorder and opioid use disorder, those who have a comorbid psychiatric disorder. When you find that brief interventions or brief treatment is unsuccessful, for those patients who are non-compliant with office policies, when a patient requests a referral or needs more intensive treatment, or when chronic pain issues cannot be managed. So there are some patient placement criteria developed by ASAM, the American Society of Addiction Medicine. It is a comprehensive set of guidelines to help direct treatment for patients with addiction and comorbidities. And this is for placement, continued stay and transfer and discharge. Typically this is used under the supervision of an addiction specialist. However, there's also SAMHSA's National Helpline and I have in bold there, this is for individuals and family members facing mental and or substance use disorders for anyone to call. And it's great that they have these services which are confidential, 24 hours a day, 365 days a year. So this service provides referrals to local treatment facilities, support groups and community-based organizations. I just wanted to go over what some of these treatment options include. So inpatient hospitalization is for managing severe withdrawal symptoms or medically complicated patients. Residential treatment are for patients who lack motivation and social support and patients who are medically and psychiatrically stable. Intensive outpatient treatment provides more structure to patients who have a support system, but require more counseling. Self-help groups offer free and they're readily accessible to provide peer support. Okay, so now I'm gonna talk about the various treatments for addiction. This can include medications, psychosocial therapies or self-help groups. This is individualized for each patient. Some patients do not wanna start with medication and they wanna start with therapy first. So you can monitor how that is going and then later if it is not effective, you can offer medication. And it has been shown that combinations of treatment are most effective, meaning medication and psychosocial therapy combined. So the medications available to assist with smoking cessation, which are FDA approved, are variniclin, bupropion and nicotine replacement therapy, which can be the patch, the gum, lozenge, inhaler, or nasal spray, or combining some of these therapies. Medications available for alcohol use disorder, the ones that are FDA approved, are acamprosate, disulfiram and naltrexone. And Vivitrol is the injectable version of naltrexone that can last for one month. Also used for opioid use disorder. And again, the medications for opioid use disorder, like I mentioned before, buprenorphine, methadone and naltrexone. Psychosocial therapies can include motivational interviewing, motivational enhancement therapy, CBT, community reinforcement approach, contingency management, or couples or family therapy. So other considerations during your visit are to screen for coexisting psychiatric disorders as patients may use substances to self-medicate. You want to check prescription drug monitoring programs to track pharmacy activity as patients may see multiple doctors to obtain controlled substances. You want to consider random urine toxicology testing. Utilize treatment contracts, especially if controlled substances are being prescribed. And you want to coordinate care with addiction specialists, psychiatrists, or pain specialists when necessary. Okay, so now I'm going to go over a case study. A 17-year-old female arrives for her annual physical. She is given the craft questionnaire to complete in the waiting room before she meets with a doctor. So here is an example here of what it looks like. So for this, they ask that you answer these questions that reflect your use in the last 12 months. So how many days did you, number one, drink more than a few sips of beer, wine, or any drink containing alcohol? So she reports 10 days in the last 12 months. It also asks about use of marijuana or synthetic marijuana. She said zero. Or number three, anything else to get high like other illegal drugs, pills, prescription, or over-the-counter medications and things that you can sniff, puff, vape, or inject. And she said zero. If it was zero for all of them, then you can stop. If there was one for anything, any of these in the boxes above, then they have to go on to answer questions four to nine. So here, number four, have you ever ridden in a car driven by someone, including yourself, who was high or had been using alcohol or drugs? And she reported yes. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? No. Do you ever use alcohol or drugs while you are by yourself or alone? No. Do you ever forget things you did while using alcohol or drugs? Yes. Do your family or friends ever tell you that you should cut down on your drinking or drug use? No. And have you ever gotten into trouble while you were using alcohol or drugs? No. So the doctor reviews her answers before entering the exam room. And in preparation, he refers to the following slides that include recommendations as a point of reference to determine the level of intervention he plans to take. So this patient received a CRAFT score of two, and the cutoff score of two or more on the CRAFT is associated with the risk of developing a substance use disorder. The clinician knows that he needs to provide a brief intervention. So you can remember this with the five R's. So you can use these talking points for brief counseling. You can, number one, you review the screening results, and for each yes response, you can ask, can you tell me more about that? You can recommend not to use, for example, as your doctor or nurse or healthcare provider, my recommendation is not to use any alcohol, marijuana, or other drug because they can, one, harm your developing brain, two, interfere with learning and memory, and three, put you in embarrassing or dangerous situations. Number three, you can provide riding or driving risk counseling, and say motor vehicle crashes are the leading cause of death for young people. I give all my patients the contract for life. Please take it home and discuss it with your parents or guardians to create a plan for safe rides home. Number four, response, elicit self-motivational statements. If someone asked you why you don't drink or use drugs, what would you say for non-users? For users, what would be some of the benefits of not using? And number five, reinforce self-efficacy, saying something like, I believe you have what it takes to keep alcohol and drugs from getting in the way of achieving your goals. And you can actually give a patient that contract for life, which I will show in the next page. But this is just an example of a reference you can look at before you go into the room to talk to a person and decide how you would approach your counseling. First, I just wanted to show you this study here, which shows that the percentage who, with a DSM-5 substance use disorder by craft score, the likelihood of having a substance use disorder by the score that you get in the craft. So the higher the score, the more likely it is that you have a substance use disorder. So once in the exam room, the doctor introduces himself and asks what brings her in, and if she has any specific concerns. She says she is here for a routine physical and has no specific concerns. He says he looked at her craft results and noted she responded yes to a few items. She elaborates on her answers and reports that her best friend is the designated driver since she never drinks more than one mixed drink when they go out and does not appear to be impaired. The patient also admits that she drank four to five mixed drinks on two occasions and does not recall parts of the night, but luckily she was driven home safely by her best friend. The doctor then expresses concern and asks if he can share some information with her. She consents. As your doctor, my recommendation is to not use any alcohol, marijuana, or other drugs because they can harm your developing brain, interfere with learning and memory, and put you in embarrassing or dangerous situations like not being able to remember what happened during the night. Is this something you would consider? She responds, yes, I didn't think about it that way. I also vomited both times, which was really embarrassing. I don't think I want to drink that much again. The doctor also tells her motor vehicle crashes are the leading cause of death for young people. I give all my patients the contract for life. Could you take it home and discuss it with your parents to create a plan for Safe Rides Home? And here's the example of the contract for life. So, you know, the young person would read that section and sign in the bottom. You know, it says, finally, I agree to call you if I am ever in a situation that threatens my safety and to communicate with you regularly about issues of importance to both of us. And the parent or the guardian also signs a pledge that they will not drive under the influence of alcohol or drugs and will always seek safe, sober transportation home and will always wear a seatbelt. So it's to ensure that both the parent, guardian and young person have this contract for life to protect each other. So there is evidence of the efficacy of using the contract for life to reduce riding risk in kids with baseline reports of riding with a driver under the influence. At the end of the visit, the doctor says, I would like to set up a follow-up appointment in a month to discuss this contract and to see if you have any other questions or have come up with any plans. She responds, I think that would be a good idea. You scared me when you showed me the graph and told me the statistics about motor vehicle accidents. Maybe I do need to make some changes. Let me read the contract and talk to my parents. The doctor replies, that sounds great. I look forward to seeing you again. And if you have any questions or concerns before your appointment, please feel free to reach out to me. So that concludes the module, but here are my references. And I also wanted to talk about the PCSS mentoring program. I would like to make you aware of two resources offered through PCSS that may be of interest to you. First, PCSS's mentor program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues who address clinical questions. You have the option of requesting a mentor from our mentor directory, or we are happy to pair you with one. To find out more information, please visit the website using the web link noted on the slide. And second, PCSS offers a discussion forum, which is comprised of PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor on call each month. This person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are part of the PCSS project. Finally, please reference the slide for contact information and website, Twitter, and Facebook links to find out more about the resources and educational offerings from PCSS. Thank you very much.

SBIRT

Substance Use Disorders

Primary Care Settings

Opioid Use Disorders

Screening Tools

Brief Intervention

Referral to Treatment