SUD Screening Flashcards
What does SBIRT stand for?
Screening, Brief, Intervention, Referral to Treatment
What are the purposes of SBIRT?
Quickly assess severity of SUD Identify appropriate LOT Increase insight/awareness of SUD Motivate toward behavioral change Identify and refer those needing extensive treatment/speciality care
Essentials of AUD diagnosis
Physiologic dependence (withdrawal symptoms)
Tolerance
Alcohol-associated illnesses (liver disease, cerebellar degeneration)
Continued consumption despite consequences
Impaired social/occupational functioning
Depression
Blackouts
What are the two phases of AUD syndrome?
At-risk drinking - minor
Alcohol misuse - moderate to severe
How is “At-risk drinking” classified?
Repetitive use of ETOH, used frequently, often to alleviate anxiety or solve emotional problems
At-Risk Drinking classification per NIAAA
Males: >4 drinks/day or >14 drinks/week
Females: >3 drinks/day or >7 drinks/week
How is “Alcohol Misuse” classified?
Recurrent use of ETOH despite disruptions in social roles (work, family, friend)
ETOH-related legal problems
Safety risks by oneself and with others
AUD DSM-5 Criteria
In the past 12 months have you
- Drank more than intended
- More than once wanted to cut down or stop, but couldn’t
- Spent a lot of time
- Craved so badly, couldn’t think of anything else
- Drinking/after effects interfered with social roles
- Drank despite consequences with fam/friends
- Cut back on things that once gave pleasure
- More than once engaged in risky behaviors
- Continued to drink despite negative mood effects or after blackout
- Drinking more to get desired effect, usual amount less effective
- Withdrawal s/s
AUD DSM-5 Diagnosis per Criteria
Presence of at least two symptoms in the past 12 months
AUD DSM-5 Severity Indicator
Mild: +2-3 s/s
Mod: +4-5 s/s
Severe: 6+ s/s
Standard ETOH drink amounts
1 drink:
- 12 oz beer 5%
- 5 oz of wine
- 1.5 oz of liquor
What is a fifth of ETOH?
26 oz of liquor
What is a handle of beer?
1/2 gallon or 3-5L
How many drinks in a bottle of wine? (26oz, 1 fifth)
6 drinks
AUD risk factors
At-risk drinkers at >r/f AUD Male:Female = 4:1 Psychiatric disorders Japanese more susceptible to ETOH s/e Majority of suicides/homicides involve ETOH R/F rapes and assaults
What is the CAGE questionnaire?
Screening for AUD
- Cut down
- Annoyed you/criticized
- Guilt
- Eye Opener
No or Yes = 0 or 1
Score/4
Score 2+/4 is significant, further assessment required
Score 1+ in women should raise concern
What is the AUDIT questionnaire?
Alcohol Use Disorder Identification Test
10 items, 0-4
Score/40
AUDIT questionnaire classifications
Scoring/Intervention
0-7: Low-risk/Feedback
8-14: Hazardous-harmful/Feedback, brief intervention
15+: Alcohol-dependent range/Feedback, referral, detox? meds?
Clinical findings of AUD
Acute intoxication
Withdrawal
Alcoholic (Organic) hallucination
Chronic alcoholic brain syndromes
S/S of acute ETOH intoxication
drowsiness, errors, psychomotor dysfunction, disinhibition, dysarthria, ataxia, nystagmus
Severe overdose: resp depression, stupor, seizures, shock, coma, death
Dysarthria - speech impaired by motor impairment
S/S of ETOH withdrawal
anxiety, decreased cognition, tremulous, irritability, hyperreactivity, DTs
S/S may persist for 3-12 months and become chronic
S/S of Alcoholic (organic) hallucinations
paranoid psychosis without tremulousness, confusion or withdrawal symptoms
S/S of chronic alcoholic brain syndromes
Encephalopathies causing erratic behavior, impaired memory/recall, emotional instability
Eg: Wernicke encephalopathy & Korsakoff psychosis caused by thiamine deficiency results in confusion, ataxia, ophthalmoplegia
AUD lab findings
Increased liver enzymes GGT>30u/L suggestive of heavy drinking MCV >95 for males, >100 for females Increased uric acid Increased triglycerides Decreased K+ and Mg+
Elevated MCV and GGT helpful identifiers
Physical complications of AUD
chronic brain syndromes, cardiomyopathy, cirrhosis, esophageal varices, liver failure, ETOH-related hypoglycemia, protein abnormalities (low albumin), impaired coagulation (increased r/f bleeding)
Characteristics of fetal alcohol syndrome (FAS)
Low birth weight, small size (SGA), MR, Low IQ (avg 60), birth defects (facial, cardiac)
Psychological management of AUD At-Risk Drinking
Psychological:
- Clinician non-judgmental
- Deal with enabling behavior of spouse/friends
- Total abstinence goal, start with harm reduction model
- Motivational interviewing
Social Management of AUD At-Risk Drinking
AA, Al-Anon, SOS, Religious counseling
Medical Management of AUD At-Risk Drinking
Three medications
PE, Labs
Medications:
Disulfiram 250-500mg daily (aversive)
Naltrexone 50mg daily (craving reduction, decreases pleasurable effects of ETOH)
Acamprosate 333-666 mg TID (decrease cravings, maintain abstinence)
Behavioral Management of AUD At-Risk Drinking
Conditioning
Aversion therapy
Naltrexone oral for AUD
Brand, dosage, route, duration, storage, cost
ReVia 50 mg oral tablets 50 mg PO daily (FDAA) Alt regimen: -50 mg weekdays, 100 mg Saturday -100 mg QOD -150 mg q3days Duration of tx: 12 weeks
Cost: 30 tabs $128.12
Store room temp
Naltrexone ER injection for AUD
Brand, dosage, route, duration, storage, cost
Vivitrol 380 mg IM gluteal injection q4wk
Duration of tx: 24 weeks
Store in refrigerator
Cost: 1 vial (380mg) $1570.80
Management of ETOH hallucinations/withdrawal
Hallucinations: Antipsychotic (haldol)
Withdrawal:
Monitor CIWA
Onset of withdrawal
Management of ETOH withdrawal
Monitor CIWA-Ar
Onset: 6-36 hours after last drink
Peak: 48-72 hours
Tx: Taper long-acting benzo (ativan, valium)
Hydrate, correct electrolytes, thiamine, folic acid, multivitamin injection (MVI)
Classifications of withdrawal per CIWA-Ar
Minimal <8
Mild 8-15
Mod 16-20
Severe >20
CIWA-Ar Symptoms/Score
N/V 0-7 Anxiety 0-7 Paroxysmal Sweats 0-7 Tactile disturbance 0-7 Visual disturbance 0-7 Tremors 0-7 Agitation 0-7 Orientation/Clouding of sensorium 0-7 Auditory disturbance 0-7 Headache 0-7
Essential of SUD diagnosis
Psychologic dependence with evidence of withdrawal Tolerance Substance-associated illness Continued use despite consequences Impaired social/occupational functioning Depression Blackouts
What screening tool should be administered prior to prescribing opioids for pain?
SOAPP - Screener and Opioid Assessment for Patients with Pain
-Screen for Risk of Substance Use Disorder - Acute Pain
14 items
Rated 0-4
Never/seldom/sometimes/often/very often
Opioid Risk Screening Tools
***REVISE SLIDE 21
Opioid Risk Tool
***REVISE SLIDE
What is another name for the Opioid Risk Tool (ORT)?
Screen for Risk of Substance Use Disorder - Chronic Pain
What is the Rapid Opioid Dependence Screen (RODS)?
In the past 12 months 1-Which drugs 2-Need to use more 3-Missing a dose make you anxious 4-Morning sickness or w/d 5-Worried about use 6-Difficult to stop/not use 7-Need to spend a lot of time or money 8-Miss important events Yes or no Score items 2-8 >3 yes = positive = opioid dependent
What is the CRAFFT screening tool?
Screening for Risk of SUD - Adolescent Part A: -Drink alcohol -Smoke MJ -Use anything to get high
Part B:
- Car - someone UI or self
- Relax - with ETOH/drugs
- Alone - used alone
- Fam/Friends - concerned, cut down
- Trouble - while using
Opioid Use Disorder Psychiatric Assessment
HISTORY
History Consumption Route Tolerance Last use Treatment hx
Opioid Use Disorder Psychiatric Assessment
ASSESSMENT
PE, labs, health risks, infections, bowel syndrome, hyperalgesia, accidents, overdose, mortality
I-STOP/PMP
Internet System for Tracking Over-Prescribing
Prescription Monitoring Program
Symptoms/Grading of Opioid Withdrawal
Grade 0 - Anxiety, craving
Grade 1 - Yawning, lacrimation, rhinorrhea, perspiration
Grade 2: Yawning, lacrimation, rhinorrhea, perspiration PLUS mydriasis, piloerection, anorexia, tremors, hot/cold flashes, aching
Grade 3: Increased intensity of Grade 2 s/s PLUS increased temp, BP, PR, RR, and resp depth
Grade 4: Grade 3 PLUS Severe w/d: vomiting, diarrhea, weight loss, hemo-concentration, spontaneous ejaculation or orgasm
Grades 2-4 require tx program
Medications for Opioid Dependence
Narcan (Naloxone): Reversal agent
Buprenorphine (Suboxone): Partial agonist, tx of w/d and maintenance (NPs need 24hrs of education to prescribe)
Methadone: Opioid agonist, tx of w/d and maintenance, Rx by speciality clinic with frequent obs. May be used for chronic pain.
Clonidine: Alpha-2 adrenergic agonist, Tx of w/d s/s
What do you need to prescribe opioids as a provider?
Specialized training
DEA number
Minimum of 3 hours of course work and training in pain management, palliative care, and addiction
USPSTF SUD Screening Recommendations
Screen all adults 18+ for drug/ETOH use and provide brief behavioral counseling
AAP SUD Screening Recommendations
Screen adolescents for alcohol and drug use during visits with developmentally appropriate screening tool
What are the preliminary research findings of OPRM1 G-allele carriers and Naltrexone for AUD treatment?
OPRM1 G-allele carriers tend to experience less benefit from naltrexone for AUD tx than those without OPRM1 G-allele.
DSM-5 AUD Met Criteria for Dx
11 criteria
2+ in the past 12 months
