-family doctor-role to address alcohol problems, and proactively find out whether people have problems even though it might not be apparent.-hidden problems among people.ObjectivesYou will be able to describe:The rational for delivering SBIRT (Screening, Brief Intervention and Referral-to Treatment) in clinical settingsHow to deliver itHow to ensure systematic deliveryAgenda:Continuum of substance useSBIRT overviewRationale for SBIRT-need and evidence on effectivenessClinical skills-Overall approach-Screening and brief assessment-Brief intervention and referral to treatment-Follow-upSystems change to enable universal SBIRTContinuum of substance useSubstance Use ContinuumNegative Consequences:Goes from Low Risk Problems -> Severe ProblemsLow Risk High risk Mild Problems Severe Problems ProblemsAbstinence Heavy Use UseStandard Drinks12 ft oz of regular beer is about 5% of alcohol8-9 fl oz of malt liquor is about 7% of alcohol5 fl oz of table wine is about 12% of alcohol1.5 ft oz shot of 80-proof spirits is about 40% of alcohol# of ounces in a standard drink = 60 / % of alcoholSubstance Use ContinuumNegative Consequences:Low Risk High risk Mild Problems Severe Problems ProblemsAbstinence Heavy Use UseTalking about Low Risk:No illicit drug use ANDNo misuse of potentially addictive prescription drugs ANDAlcohol use within low-risk limits:Men < 4 standard drinks in an episode and < 14 standard drinks per weekWomen: < 3 standard drinks in an episode and < 7 standard drinks per weekSide note:Marijuana is a very addictive substance for some people. Many people addicted these days to it because it is 3-4 times as strong as it used to be. It affects learning and memory, which is terrible for students. There are lots of reasons why marijuana is risky certainly safest not to use it.A lot of prescription drugs can be addictive as well such as Percocet or Vicodin.Also other stimulants that people may need for attention disorders.Substance Use ContinuumNegative Consequences:Low Risk High risk Mild Problems Severe Problems ProblemsAbstinence Heavy Use UseTalking about high risk:-Illicit drug use OR - Misuse of potentially addictive prescription drugs OR- Alcohol use beyond low-risk limits (standard drinks): Men: >4 drinks in an episode or >14 drinks per week Women: >3 drinks in an episode or > 7 drinks per weekSubstance Use ContinuumNegative Consequences:Low Risk High risk Mild Problems Severe Problems ProblemsAbstinence Heavy Use UseNow we are talking about Negative Consequences associated with Mild Problems and Severe Problems:Common Negative Consequences of Substance Use:Psychological - Dysphoria, depressed mood, anxious mood, and full-fledged dep/anx disorders- Irritability, mood swings, hostility - Paranoia, psychosis - Any psychiatric symptom can stem from intoxication, overdose, withdrawalFamily - Marital and family dysfunction- Behavioral and school problems among children - Mental health problems and somatic symptoms among family membersSocial- Alienation from or loss of old friends - Gravitation toward others with similar substance useWork and SchoolLateness, absence, requests for excusesDeclines in performanceFrequent job changes and flat career trajectoryFinancial-Spending more than one can afford-Financial strain, indebtedness, selling possessionsLegal-OWI, disturbing the peace, domestic and other violence-Drug possession, dealing, burglary, robberyReligion and spirituality-Disconnection, alienation, shame, disgraceExtra notes:-People want to be away from regular friends or family. Want to be around people who use as well.Common consequence is that “spending more than I can afford on drinking and related activity”Alcohol can take a toll on religious beliefs as wellCommon Alcohol-and Drug-Related Biomedical ConditionsAlcohol and drugs cause:Injury and disabilityViral hepatitisHIV/AIDSOther STIsUnplanned pregnanciesPoor birth outcomesPsychiatric disordersAlcohol Causes:HypertensionDyslipidemiaHeart diseasesStrokeNeuropathyDementiaCancers-Oropharynx-Esophagus-Breast-Liver-ColonHepatitisPancreatitisAlcohol impedes tx for…HypertensionDyslipidemiaDiabetesGERD and other GI disordersSleep disordersDepressionAnxiety disordersPsychosesAll chronic diseasesOther notes:Injury is very common that can be caused by drugs. A lot of common diseases like raising blood pressure, raised calesteral. Also contributes to certain kinds of cancers. (11% of breast cancer can be attributed to alcohol)Maybe drinking didn’t cause these problems, if drinking above low risk limits it becomes harder to treat those problems. Sleeping problems, anxiety, very important in justice settings, if we don’t find out someone is drinking a lot and help that person it will be harder to address other issues.Proportion of Other Poor Outcomes Involving Alcohol or DrugsCrimeHomicides 46-86%Sexual assaults < 60%Other assaults 37-40%IncarcerationAdults 65%Juveniles 67% (41% alcohol)Suicides 20-37%Falls 44%Drownings 69%Fires 26%Child abuse/neglect 70%Domestic violence?Unintended pregnancies and STIs ?Fetal alcohol spectrum disorders 100%Other notes:Social and criminal realms alcohol and drugs are contributing to lots of crime. 2/3 of people incarcerated are there because of alcohol. A lot of tragedies of people’s lives include alcohol and drugs.We should be looking at these issues and trying to prevent these consequences and helping people live longer happier lives.Dependence symptoms from the Substance Use Continuum…Dependence Symptoms:Physical dependencePropensity to withdrawMost dangerous withdrawal: alcohol and other sedativesOccurs in a different part of the brain than where true addiction occursPreoccupation with using or obtaining substancesUrges and cravings to useLoss of controlFurther notes:Can be physical dependence. People are drinking enough, using drugs enough, that when they suddenly quit or cut down they are likely to withdrawal.Physical dependence means that you have high propensity to withdrawalNo serious withdrawal symptoms in: cocaine, heroin etc.Alcohol withdrawal can cause seizures or cardiac arrhythmia.There is a misconception that alcoholism means withdrawal when you stop drinking, but that is a side issue. Central to the core of what addiction is: other symptoms which are the ones listed above as preoccupation to use, urges and cravings, and loss of control.(would most likely be a man)Most alcoholics are employedHave familiesDon’t meet stereotypes that most people think