SBIRT Handouts from Integrative Health Week: UVM 2014

1. AUDIT-10 Scores & Risk Level
— 2.5% 20+ = Severe = RT
— 2.5% 16–19 = Moderate = BT
— 15% 8–15 = Mild = BI
Percentages may change depending on population sample.
Initial screening shows 80% screen in the low risk category and
don’t require further screening.
— 80%
0–7 = Low Risk
healthvermont.gov • sbirt.vermont.gov • 802-225-6066
Low-Risk Drinking Limits
Drinks/
day
4
3
0
Drinks/
week
14
7
0
Drinks/
day
Men
Women & 65+
Pregnant Women
12 oz of 8–9 oz of 5 oz of 1.5 oz shot of
regular beer craft beer wine 80-proof spirits
whiskey, vodka,
tequila, etc.
5% 7% 12% 40%
alcohol alcohol alcohol alcohol
Percent of alcohol may vary.
Effects of High-Risk Drinking
Aggressive, irrational behavior.
Arguments. Violence. Depression.
Nervousness.
Cancer of throat & mouth.
Frequent colds.
Reduced resistance to infection.
Increased risk of pneumonia.
Liver damage. Ulcer.
Trembling hands. Tingling fingers.
Numbness. Painful nerves.
Impaired sensation leading to falls.
Numb, tingling toes. Painful nerves.
Sleep disturbance.
Alcohol dependence. Memory loss.
Premature aging. Persistent facial reddening.
Weakness of heart muscle. Heart failure.
Anemia. Impaired blood clotting.
Breast cancer.
Vitamin deficiency. Bleeding.
Severe inflammation of the stomach.
Vomiting. Diarrhea. Malnutrition.
Inflammation of the pancreas.
In men: Impaired sexual performance.
In pregnant women: Consuming even
one drink daily can lead to serious birth
defects, including facial deformities and
neurological deficits.
High-risk drinking may lead to social, legal, medical, domestic, employment and financial problems.
It may also reduce your life span and lead to accidents and death from drunken driving.
1 2 3 4 5 6 7 8 9 10
Readiness Ruler
1 = Not ready at all
10 = Ready right now

2. healthvermont.gov • sbirt.vermont.gov • 802-225-6066
1. Raise the subject
2. Pros & Cons
Brief Negotiated Interview (BNI) Algorithm
1 2 3 4 5 6 7 8 9 10 Readiness Ruler
1 = Not ready at all
10 = Ready right now
Elicit
Summarize
3. Information & feedback
Provide
Elicit
4. Readiness ruler
Reinforce positives
Ask about lower number
5. Negotiate a plan
Identify strengths
& supports
Have patient
write down steps
Offer appropriate
resources
Is it OK if we discuss the health & wellness questionnaire you completed?
Help me understand the good things about using [X]. What are some of
the negatives?
So, on the one hand [PROS], and on the other hand [CONS].
I have some information on low-risk guidelines for drinking and drug use, would
you mind if I shared them with you?
We know that ...
• drinking 4 or more (Women) / 5 or more (Men) drinks in a few hours,
• drinking more than 7 (Women) / 14 (Men) drinks in a week, and/or
• using illicit drugs of any kind
... can put you at risk for social or legal problems, as well as illness and injury.
It can also cause health problems like [insert medical information].
What do you think about that?
On a scale from 1–10, with 1 being not ready at all and 10 being completely
ready, how ready are you to change your [X] use?
You marked ___. That means you’re ____% ready to make a change!
Why did you choose that number and not a lower one like a 1 or 2?
What are some steps you can take to reduce your risk?
What will help you to reduce the things you don’t like about using [X]?
What supports do you have for making this change?
How can you use those supports/resources to help you now?
Why don’t we write down your Prescription for Change?
This is what I heard you say ...
I have some additional resources that people sometimes find helpful. Would you
like to hear about them?
• Primary care, outpatient counseling, mental health treatment

3. Brief Negotiated Interview Provider Checklist
Raise the subject
1. Ask the patient for permission to discuss their health and wellness
questionnaire, including alcohol and drug use (AOD).
Provide feedback
2.Review patient’s AOD patterns risk level.
3.Express concern about patient’s use patterns risk level.
4.Ask about pros and cons of AOD use.
5.Summarize and restate in patient’s own words.
6.Provide medical facts and information that there is a connection
between AOD and negative consequences.
7.Compare screening responses to NIAAA low risk AOD guidelines.
Enhance motivation
8.Ask patient to identify readiness to change on the Readiness Ruler
tool and ask why they chose that number and not a lower one.
9.Elicit other reasons for changing.
10.Identify strengths and supports.
Negotiate a plan
11.Negotiate the goal (“What would you like to do?”).
12.Summarize (“This is what I’ve heard you say . . .”).
13.Have patient write out the change plan, if appropriate.
14.Provide Health Information handout.
15.Suggest Primary Care or other follow-up as needed.
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
†Yes †No
Medicaid Billing Codes
99408 - AOD screening/BI (15–29 min.)
99409 - AOD screening/BI (30+ min.)
healthvermont.gov • sbirt.vermont.gov • 802-225-6066
Adapted from:
Miller, Rollnick, D’Onofrio, Bernstein
Boston University School of Public Health
Yale School of Medicine

4. — 2.5% 6+ = Severe = RT
— 2.5% 3–5 = Moderate = BT
— 15% 1–2 = Mild = BI
Percentages may change depending on population sample.
Initial screening shows 80% screen in the low risk category and
don’t require further screening.
— 80% 0 = Low Risk
Effects of Cocaine
Short-term
• Intense high followed by depression
• Poor appetite sleep hygiene
• Increased heart rate blood pressure
• Paranoia anxiety
• Increased aggression
Long-term
• Sleep deprivation
• Malnutrition
• Tooth decay
• Impaired sexual function
• Heart attacks and strokes
healthvermont.gov • sbirt.vermont.gov • 802-225-6066
DAST-10 Scores Risk Level
Effects of Opiates
Drowsiness. Confusion. Memory loss.
Fatigue. Hallucinations. Convulsions.
Dilation of blood vessels causing
increased pressure in brain.
Pupil constriction.
Slurred speech.
Respiratory depression.
Nausea. Vomiting.
Weight loss.
Sexual dysfunction.
Constipation.
Effects of Marijuana
Short-term
• Anxiety and panic
• Problem-solving difficulty
• Impaired attention and memory
• Impaired coordination and judgment,
especially when driving within 24 hours
• Cardiac problems for people with heart
disease or high blood pressure, because
marijuana increases the heart rate
Long-term
• Weight gain due to overeating
• Erectile dysfunction fertility difficulties
due to low sperm production
• Lack of motivation
• Chronic bronchitis
• Lung cancer

5. How much are you really
drinking?
Standard Drink Equivalencies
In the United States, a standard drink is any drink that contains about 0.6 fluid ounces
of pure alcohol. Although the drinks below are different sizes, each contains
approximately the same amount of alcohol and counts as a single standard drink.
12 fl oz
of
regular
beer
= 9 fl oz of
craft
beer
(shown
in a 16-
oz pint
glass)
= 5 fl oz of
table
wine
= 3-4 oz of
fortified
wine
(such as
sherry or
port; 3.5
oz
shown)
= 2-3 oz of
cordial,
liqueur,
or
aperitif
(2.5 oz
shown)
= 1.5 oz of
brandy
(a single
jigger or
shot)
= 1.5 fl oz
shot of
80-proof
spirits
(hard
liquor)
about 5
%
alcohol
about 7
%
alcohol
about 12
% alcohol
about 17
% alcohol
about 24
% alcohol
about 40
% alcohol
about 40
% alcohol
The percent of pure alcohol, expressed here as alcohol by volume (alc/vol), varies
What is Alcohol By Volume?
Alcohol by volume (abbreviated as ABV, abv, or alc/vol) is a standard measure of how
much alcohol (ethanol) is contained in an alcoholic beverage (expressed as a
percentage of total volume = number of ml of alcohol in 100mls. of liquid). The proof
number is twice the percentage of the alcohol content.
Why is this important?
Knowing standard drink sizes and the number of drinks per container can help you
make informed decisions about your drinking. You’ll be able to:
x Count drinks more accurately
x Pace yourself better
x Stay within low-risk drinking levels

6. Drink Calculator
Alcoholic Beverage Size ABV % # of Standard
Drinks
Regular Beer 12 oz. (standard) 5 1
Regular Beer 16 oz/Pint 5 1.3
Craft Beer Pint 5 1.3
Craft Beer Pint 5.5 1.5
Craft Beer Pint 6 1.6
Craft Beer Pint 7 1.9
Craft Beer Pint 8 2.1
Craft Beer Pint 9 2.4
Craft Beer Pint 10 2.7
Craft Beer Pint 11 2.9
All Beers are Not Created Equal:
Type ABV % Type ABV %
American Amber 5.5 Pilsner 8
Barleywine 11.5 Pale Ale 5.5
Blonde 5.5 Red Lager 5
Brown Ale 6.0 Stout 5.5
Double IPAs 9.2 Pale Ale 5.5
IPA 6.7 Porter 6
IPA Imperial 10.5 Wheat 5.5
Easy to Use Drinking Calculator:
http://rethinkingdrinking.niaaa.nih.gov/toolsresources/drinksizecalculator.asp
The Craft Beer Revolution:
During the Industrial Revolution, the production of beer moved from domestic artisanal
manufacture to industrial manufacture. By the mid-1970s there were still fewer than
forty breweries in America and most bars only had four beers on tap – Budweiser, Miller
Lite, Beck and Heineken. Currently, there are more than 2700 breweries nationwide
and another 1500 coming – allowing most Americans to live within ten miles of a
brewery (Brewer’s Association, 2014). The craft beer revolution is a shift back toward
the artisanal – producing stronger and more varieties of beer then ever.

7. healthvermont.gov • sbirt.vermont.gov • 802-225-6066
5 Tips for Improving Health, Wellness Safety
Tip #1: Prevent distracted driving
Using your phone while driving is a dangerous distraction. 5,000 deaths per year are attributed
to distracted driving. Texting takes the driver’s eyes off the road for an average of about 5
seconds; that’s like driving the entire distance of a football field blindfolded. As of 10/1/2014,
it is illegal in Vermont to use a handheld cellphone while driving. If you need to text or talk
while in your car, do yourself and everyone else on the road a favor and pull over!
Tip #2: Always wear a helmet
Wearing a helmet while participating in certain sports and activities can prevent significant
brain injury and permanent neurologic damage. Vermont boasts great skiing, snowboarding,
skating, and biking. Cuts, bruises, and even broken bones will heal, but damage to your brain
can be permanent. Even a low-speed fall can result in serious head injury. Wearing a helmet
reduces the risk of serious head and brain injury by 85%. Children 5 to 14 years of age have
the highest injury rate of all bicycle riders, and bike accidents are a leading cause of death
for children. Protect your head!
Tip #3: Always wear a seat belt
Seat belt use is the most effective way to save lives and reduce injuries in crashes. Motor
vehicle crashes are the leading cause of death among those age 5–34 in the United States.
Millions of adult drivers and passengers were treated in emergency departments last year
as the result of being injured in motor vehicle crashes. Use a seat belt on every trip, no matter
how short and make sure children are properly buckled up in an appropriate seat belt, booster
seat, or car seat. Have all children 12 and under sit in the back seat and never seat a child in
front of an air bag. Place children in the middle of the back seat when possible because it is
the safest spot in the vehicle. Buckle up!
Tip #4: Quit smoking
Are you ready to stop smoking cigarettes? Use the 4 D’s to help you handle cravings while
you’re trying to quit: delay, drink water, deep breathing, do something else! For many
tobacco users, support from others makes the difference in staying tobacco-free. There is
help out there. Call the Vermont QUIT Network at 1-800-QUIT-NOW (784-8669) or quit online
at 802Quits.org.
Tip #5: Get a flu shot
Influenza is a serious disease that can lead to hospitalization and sometimes even death.
Every flu season is different and even healthy people can get very sick from the flu and spread
it to others. The “seasonal flu season” is from October to May. During this time, flu viruses
are circulating in the population. An annual seasonal flu vaccine (either the flu shot or the
nasal-spray flu vaccine) is the best way to reduce the chances that you will get the flu. Flu
vaccines cause antibodies to develop in the body about two weeks after vaccination which
protect against infection.

8. What’s really in the weed you’re
smoking?
Marijuana’s Chemical Makeup
¾ Contains more than 460 active chemicals – and over 70 known cannabinoids! Eight produce
the most effect (THC, THC-V, THC-A, CBD, CBD-A, CBD-V, CBN, CBG, CBC)
¾ Delta-9-Tetrahydrocannabinol (Delta-9-THC) is the primary and most familiar psychoactive
compound. Research shows that THC interacts with the brain similar to the endogenous
cannabinoid neurotransmitter anandamide, which is involved in the neurological processes of
memory and pleasure seeking1
Cannabinoid Potency
¾ Potency is a result of many variables – plant genetics and strain, cultivation method,
harvesting, and processing
¾ The cannabinoid potency profile is the concentration of cannabinoids expressed in percentage
of weight per weight (% wt/wt). This is the weight of the cannabinoid divided by the total plant
weight. Edibles, tinctures, and topical are displayed in milligrams of cannabinoids per sample
serving size (mg/serving)
¾ Marijuana users in the 1970s were most likely to smoke the leaves and initiate use around 20
years of age. Marijuana users today, however, start in their mid-teens and prefer to smoke the
more potent flowering tops, (buds) of the plant
¾ Marijuana Plant Flower = 8% – 25% THC-A
¾ Edibles (brownies, candies, chocolate) = .05 mg to 105 mg cannabinoids per serving
¾ Cannabis Concentrates (hash oils, tinctures, waxes, etc.) = often exceed 70% THC
¾ Vaporizers with Cartridges (much like e-cigarettes) = 15 - 30 % THC
¾ Synthetic Marijuana (K2, fake weed, Yucatan Fire, Skunk, Moon Rocks) = contains dried,
shredded plant material and chemical additives that are responsible for their psychoactive
(mind-altering) effects and their potential toxicity
Cannabinoid Averages of
Illicit Cannabis Samples by Year
Siezed1,2
0.74 2.06 2.82 3.35 3.75 4.87
7.17
13.01
15
20
15
10
5
0
1975 1980 1985 1990 1995 2000 2005 2009 2012
% of Delta-9-THC
Year

9. Effects of Marijuana Increase with Potency
¾ Marijuana is stronger today than in the past. For a new user, this may mean exposure to
higher concentrations of THC, with a greater chance of an adverse or unpredictable reaction
¾ Using marijuana can lead to altered perceptions and mood, impaired coordination, difficulty
with thinking and problem solving, and disrupted learning and memory
¾ At higher levels of THC (70% plus), negative effects include psychosis, irritability and paranoia
¾ Marijuana also raises heart rate by 20-100 % shortly after smoking which lasts for hours
¾ Smoking is an irritant to the lungs and can cause respiratory problems and diminished
pulmonary functioning, including bronchitis, coughing, phlegm, and lung infection
Oral Inhaled Medicine
¾ Areas of therapeutic potential include
o Analgesia in chronic neuropathic pain
o Appetite stimulation in debilitating diseases (e.g., cancer AIDS)
o Spasticity in multiple sclerosis
Does Smoking Marijuana as a Teen Really Matter?
¾ 1 in 6 teenagers who try marijuana, become addicted which results in withdrawal symptoms
including irritability, sleeplessness, decreased appetite, anxiety, and drug craving1
¾ Individuals who used cannabis before the age of 17 were 60% less likely to graduate high
school and college, lost an average of 8 IQ points, used illicit drugs more frequently, and were
more likely to attempt suicide than their non-using peers over the next two decades3
What do Studies Show About Casual Use?4
¾ THC can disrupt focus, working memory, decision-making and motivation for 24 hours after
use
¾ Even young adults who smoked 1-2 x weekly showed structural brain differences
¾ Many dangerous Pesticides, Fungicides, and Plant Growth Regulators (PGR's) are used on
Cannabis, often indiscriminately throughout the flowering stages of growth. These residual
toxins create potential safety issues to individuals when consumed
References:
1. NIDA Drug Facts 2014. Retrieved from http://www.drugabuse.gov/publications/drugfacts/marijuana.
2. Zlatko Mehmedic, Suman Chandra, Desmond Slade, Heather Denham, Susan Foster, Amit S. Patel, Samir A. Ross, Ikhlas A.
Khan, and Mahmoud A. ElSohly. Potency Trends of D9-THC and Other Cannabinoids in Confiscated Cannabis Preparations
from 1993 to 2008. J Forensic Sci, September 2010, Vol. 55, No. 5. Available online at: interscience.wiley.com
3. Silins, L John Horwood, George C Patton, David M Fergusson, Craig A Olsson, Delyse M Hutchinson, Elizabeth Spry, John W
Toumbourou, Louisa Degenhardt, Wendy Swift, Carolyn Coffey, Robert J Tait, Primrose Letcher, Jan Copeland, Richard P
Mattick. Young adult sequelae of adolescent cannabis use: an integrative analysis. The Lancet Psychiatry. September 2014
(Volume 1 Issue 4 Pages 286-293.
4. Sullivan-Moore, A. (2014, October 29). This is Your Brain on Drugs. The New York Times. Retrieved from
http://www.nytimes.com