Alcohol - IRETA

Screening, Brief Intervention and Referral to Treatme ent in Adolescents Sharon Levyy, y MD, MD MPH Director, Adolescent Substance Abuse Program g Boston Children’s Hospital

Supporrted by: The Substance Abuse and Menta al Health Services Administration SAMHSA Grant Number: N TI020267 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

OBJEC CTIVES • Demonstrate the orderly progression of neurodevelopment • Review studies demonstrating the Review studies demonstrating the toxic effects of alcohol and toxic effects of alcohol and marijuana on the adolescent brain n • To review epidemiology of adolesccent substance use and short and long term consequences. • To demonstrate a screening and asssessment algorithm that aids clinicians in quickly and accuratelyy assessing risk associated with clinicians in quickly and accurately y assessing risk associated with substance use. • To define “motivational interviewing” and demonstrate techniques g q • To demonstrate an approach to the “Brief Motivational Interview” that is practical for a general clinical settting © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Sou urce: urce: US News & World Report, Report 2005

© Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Brain Growth in Childhood Throughout the first three yearss of childhood, the brain undergoes rapid growth: • Rapid development of lim p p mbic system and cortical y neurons • Increase Increase in the number of in the number off connections between f connections between neurons (synaptic blossom ming) • The The increase in brain weig increase in brain weigght is complete by age 10‐12 ght is complete by age 10 12 years © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Brain Weig ght by Age

Newborn

Males

Females

A Age

Source: Dekaban, A.S. and Sadowsky, D. Annals of Neurology, 4:345‐356 6, 1978 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

© Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions rmissions contact SBIRT project manager at www.CeASAR.org.

Brain Growth in n Adolescence In ado olescence the amount of gray matteer decreases: • Ap poptosis of neurons and pruning of syn naptic connections • Myyelination forms white matter traacts that indicate maturity


© Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions rmissions contact SBIRT project manager at www.CeASAR.org.

Brain Ma aturation Source: Gogtay et al. PNAS. 2004:101(21):8174-8179.


Source: Caseyy BJ,, et al.,, Development p Reviews. 2008;; 28(1): ( ) 62-77 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Brain Ma aturation •

Limbic System (mature in adolescence). Includes hippocampus and amygdyla. – Emotional memory – Fear response – Pleasure response – Fight or Flight Fight or Flight

Birth

•

• Nucleus Accumbens – Pleasuree center within Liimbic System – Active du uring pleasuraable p activitiess, including feeding, sex and drug use. – Plays a m major role in addiction n

Prefrontal Cortex (mature in adulthood) – Impulse control – Decision‐making – Organizing and planning Organizing and planning – Abstract thought, rational thinking – Attention, focus Attention focus – Working memory

Adulthood © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Children ages 7-11

Teens ages a 13-17

Adults ages 23-29

Source: Galvan A, Hare AT, Parra, CE, Penn J, Voss H, Glover G, Casey BJ, Earlier E Development of the Accumbens Relative to Orbitofrontal Cortex Might Underlie Risk-Taking g Behavior in Adolescents. Journal of Neuroscience, 2006,26(25):68 ( ) 85–6892 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Ventral Tegmental Area © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org. Source: NIDA

marijua j ana


Source: NIDA

The developing adolescent brain is especially vulnerablee to the habit especially vulnerable e to the habit‐forming forming effects of alcohol and d drugs. Age of onset of alcoh hol or marijuana use is inversely correlated w inversely correlated w with increased risk for with increased risk for a substance use diso order diagnosis later in life. lif © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Prevalence of Lifetime Diagnosis of Alcohol or Marijuana Dependencee by Age of Use Initiation % Lifetime Dx. Of Alc. or MJJ Dependency

60 50

47

45 38

40 32 28

30 15

20

1 17 11

9

10 0 =21

Hingson RW et al. Arch Pediatr Adolesc Med. 2006;160(7):739-746. Substance Abuse and Mental Heaalth Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publiccation No. SMA 10-4586Findings). Rockville, MD. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

MARIJUANA AND OTHER CANNABINOIDS © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Marijuana • Contains many chemicalss called cannabinoids such as… as – delta‐9‐tetrahydrocannabino ol (THC) – delta‐8‐tetrahydrocannabino ol – cannabidiol – cannabinol – cannabichromene – cannabigerol Source: Mechoulam m R, Hanus L, The cannabinoid system from the point of view of a chemist. In – Etc. Marijuana and Mad dness. ed. Castle, Murray. Cambridge University Press, 2004 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Content of THC in ma arijuana has increased over time 10%

9%

8% 6%

2) will have a substance use disorder substance use disorder. Adolescents who screen positive for “high risk” substance use need further assessment which further assessment, which can be included in a brief, motivational intervention.


Sample p Screen: NIAAA N 4 4--step pg guide Advantages • Quick (2 questions) • Created from national dataaset information • Screens down to age 9 • Most kids begin to use alcohol before other drugss


When should I use an alcohol scre een? • With very young patientss (age 9‐12) • With older patients (>12)) when time is limited • Whenever a patient or paarent presents with a specific concern about al p lcohol


Ask the 2 q Ask the 2 questions: q • One about friend One about friends drinking drinking • One about patien nt’s own drinking


Tips on ho ow to ask Elementaryy (9‐‐11) (9

Middle Sch hool (12‐‐14)) (12

High School g (15‐‐18) (15

• Do you have friends who drink?

• Do you have e friends nk? who drin

• In the past year how often did you drink alcohol?

• Have you ever y drank alcohol?

• In the past ye p year how often did you u drink alcohol?

• How many drinks do your friends usually have per occasion? per occasion?


Determinee Risk Level e Risk Level


Brief Inte ervention


Brief Interve ention Goals 1. No use – positive reinforcemen nt to delay initiation. ems – brief advice to encourage 2. Use without associated proble cessation. 3. Use with problems but withou ut dependence – brief negotiated interview to encourage cessatio on or reduce use. This intervention uses motivational interviewing strategies with an emphasis on uses motivational interviewing strategies with an emphasis on negotiation. 4 Dependence – referral for furth 4. referral for furth her assessment and treatments Note her assessment and treatments. Note that using a brief negotiated interview that targets accepting a referral may facilitate follow through. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

N U No Use se Positive rein nforcement A few words of enccouragement from a physician for making good decisions may physician for makin g good decisions may delay initiation of substance use. Harris SK, et al. "Computer-Facilitated Substance Use Screening and Brief B Advice for Teens in Primary Care: An International Trial.“ Pediatrics. 2012;129(6):1072-82. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

No Use e: Julie • A 14‐year old girl p A 14 ld i l presented for annual t df l physical. • She reports no passt‐year use of any substance, and has not ridden in a car with an impaired d driver.


Brief Inte ervention: Positive Reiinforcement “You have made somee very good decisions in your choice not to use h d drugs and alcohol. For d l h l h, I hope that you will the sake of your health you to know that you k keep it up, and I want i d k h can always ask me anyy questions you may h have about them. b h ” © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Riding Rissk: Brian • 16 year old boy comes in for sports physical for swim team. swim team. • He reports no past year use of any substance. • One time he accepted aa ride from a party with a friend who had been drrinking.


Brief Intervention: Car Safety • Teens should not drive even afteer a single drink – often teens don’tt notice the early effe teens don notice the early effects of alcohol that can cts of alcohol that can effect driving abilities. • Think about alternative safe wayys of getting home. y g g – get a ride from non‐user – sleep overnight, then go hom p g g me – call for a safe ride from paren nts – review the CONTRACT FOR LIFE (http://www.saddonline.com/conttract.htm) © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

The contract for life asks teens and parents to commit to always finding a safe way always finding a safe way home. Teens agree never to ride with an intoxicated driver, and parents commit to and parents commit to providing transportation home for their child from any where at any hour – no questions at any hour – no questions asked until everyone is thinking more clearly the next morning. SADD. Contract For Life: A Foundation for Trust and Caring. 2001; http://www.saddonline.com/contract.htm.


Screen Neg g gative/Lower Riskk Use 1. Advise to stop usin ng alcohol/drugs 2. Provide relevant m medical information


Lower Riskk: Marcus M i 16 ld b y who comes to the • Marcus is a 16 year old boy h t th office after injuring his ankle at football practice. • You screen him and he sayss that he has been high on marijuana on severral occasions, but not at the time of this injury at the time of this injury. • He has never used other drugs and his CRAFFT score is 0. i 0 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

1

Brief Interventio on: Brief Advice • I would recommend for th he sake of your health that yyou stop smoking marijua p g j ana altogether g • Heavy marijuana use can affect your concentration. Over time it can impact your mood and affect your Over time it can impact y your y mood and affect your performance on the footb ball field. • You are such a good athle You are such a good athleete, I would hate to see ete I would hate to see anything get in the way o of your future.” The advice given here is personalized and strengths‐bassed. It is focused on health issues that might affect Marcus, and encourages him to stop in order to p protect his ability on the football field.


Slide 90 l1

We need a nicer graphic presentation for this slide. levy_s, 3/23/2010

Sample Brrief Advice • Alcohol and marijuana can afffect your weight and appetite. • Marijuana directly affects you ur brain and your ability to think clearly. It can hurt your schoo y y ol performance and grades. p g • Kids make bad decisions when they are drinking or using drugs drugs. • Alcohol impairs memory. Other examples could include the negative medical effects o h l ld l d h d l ff of alcohol (gastritis, stomach cancer, interference with f l h l( h f h other medications or worsening of underlying disease (if ap ppropriate). Marijuana can result in gynecomastia, decreased fertility and problems with mental health, including increases in the risk for depression, anxiety and schizophrenia. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Screen Positiive/High Risk • Do a brief motivational intervention. Brief motivational interventions are based on the cou unseling style of motivational interviewing (MI), which is covered in more detail in the motivational in nterviewing module. Key components of MI captured in brief motivational interventions include 1)build a discrepancy, 2)empathetic approach, captured in brief motivational interventions include 1 1 1)build a discrepancy, 2)empathetic approach, 3)respect patient autonomy, 4)support self‐efficacy. TThese interventions are brief enough (3‐5 mins) to be incorporated into a routine care appointment.. Brief motivational interventions are covered in greater detail in the motivational interviewing section.


Brief Motivational Interventions • Ask Ask assessment questions assessment questions • Summarize and repeat for em mphasis any problems associated with substance usse as identified by patient associated with substance us se as identified by patient • Advise to stop p uld like to make changes g • Ask whether the patient wou • Assist with planning


Ask assessmen nt questions to develop a d discrepancy • • • • • •

Tell me about your use Tell me about your use. u first drank? How old were you when you About how often do you drink now? About how often do you dri nk now? Do you get drunk? Have you had any problems related to alcohol or marijuana? Have you had any problems related to alcohol or marijuana? Have you ever done anythin ng you regretted because of alcohol or drugs? alcohol or drugs? • Have you ever tried to quit?? Why? © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Consider a referral • High risk screen + in a patient ≤ 14 years old • Daily or near daily il d il use of any substance f b • Alcohol‐related “bllackout” (anterograde amnesia), or substance use‐re bt elated hospital visits l t d h it l i it • Alcohol use with an nother sedative drug The signs and symptoms above are highly suggestivve of substance dependence (addiction). Substance dependence is a chronic relapsing disord der that needs ongoing treatment. All adolescents who have developed substance dependence should be referred to a mental health or addictions specialist for more thorough assessm ddi i i li f h h ent and treatment planning. If any of these d l i If f h signs are present target a brief intervention toward ds referral


Consider an acute intervention • • • •

Very heavy alcohol usee (2X “binge” for age and gender) Mixing sedatives (alco ohol, opioids, benzodiazepines) T ki Taking unknown pills k ill IV drug use

Certain behaviors put kids at acute risk for hurting t Certain beha iors p t kids at a te risk for h rtin tthemselves accidentally. Whenever a minor themsel es a identall Whene er a minor patient is at risk of harm an acute intervention with h contracting, safety planning and informing parents is indicated. Adolescents who have suicidaal (or homicidal) ideation should be referred to an Emergency Department for further mental heealth evaluation. Adolescents who are not suicidal can be monitored at home but should have i id l b it d t h b t h ld h e an urgent assessment with a mental health t t ith t l h lth or addiction specialist.


Wh All Else When l F Fails… il • I care about yo ou. • I am concerned d about you. y • I will be here fo or you. Some adolescents will refuse to make changes in theeir substance use and do not have acute enough risk to warrant an acute intervention (see below). Giive a message of caring and concern and leave the door open. Some adolescents may return to disccuss their substance with you again if they develop more problems or decide they would like to make a change.


Office Pre esentation • Jane is an 18‐year‐old girrl with past history of language‐based LD. With g g h hard work and academic support, she graduated h high school in the middle of her class. • She lives with her parentts and 2 younger siblings. Jane will be the first mem mber of her family to attend college. • She reports occasional drinking with friends at parties, but denies ever u i b d i using illicit drugs. i illi i d • She is on no medicationss. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

M Manag anag gementt • Jane receives meningoco g occal vaccine. • Her PCP discusses academic support services available at her college. • Jane has not used alcoho ol or other drugs in the past year but she has ridden w with an intoxicated driver. Her PCP talks to Jane for 2‐3 minutes about car safety and gives her a “Contracct for Life” to bring home and discuss with her parents. discuss with her parents. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Epilo p ogue g • 3 days later, Jane attend ds an end‐of‐summer party with some high school ffriends with some high school f friends. • Her boyfriend, Jim, who o drove her to the party has been drinking heavily. Ja g y ane recalls the Contract for Life. • She calls her parents forr a ride home. Jim is angry and leaves without her. • Four years later, Jane grraduates college with h honors. Her parents are H t e very proud. d © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

The Brief Motiva ational Interview


Motivational Interviewing: g The Basis of a Brief Mo otivational Intervention Motivational Interviewing (MI) M ti ti l I t i i (MI) is a coll i llaborative, patient‐centered form of b ti ti t t df f guiding to elicit and strengthen motivation for change. The Spirit of MI: • Respects patient’s autonomy • Fosters patient‐centered collaboratio Fosters patient‐centered collaboratio on • Evokes/elicits patient’s own reasons ffor change

Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New w York, New York: The Guildford Press. Miller W.R., Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychoter, 2009; 37:129-40. . © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Evidenc ce for MI Meta-analysis of 21 MI studies found d a small but significant reduction in adolescent substance use, which is sustained over time. MI is recognized by the SAMHSA Na ational Registry of Evidencebased Programs and Practices MI is particularly suited for brief inte erventions because behavior change can be accomplished even with w very brief counseling. Jensen, C.D., et al. Effectiveness of Motivational Interviewing Interventions for Adolescent Substance Use U Behavior Change: A Meta-Analytic Review. Journal of Consulting and Clinical Psychology, 2011; 79(4): 433-440. Monti PM, Barnett NP, Colby SM, et al. Motivational interviewing versus feedback only in emergency caare for young adult problem drinking. Addiction. Aug 2007;102(8):1234-1243. http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=130 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Core Assum mptions of MI 1. Motivation is a state, NOT a trait Motivation can be influenced by Motivation can be influenced by interpersonal interactions. interpersonal interactions Lecturing, directing or ordering aan adolescent to change an entrenched or pleasurable habit will result in resistance (decreased motivation), while collaborative i i ) hil ll b i exploration of ambivalence will l i f bi l ill result in increased motivation.

2 Ambivalence to chang 2. Ambivalence to changge is normal ge is normal Stress, frustration, anger or resisttance may indicate that an individual is considering the implications of change very seriously. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Channge (3rd ed.). New York, New York: The Guildford Press. Miller W.R., Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychoter, 2009; 37:129-400. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

MI Prin nciples • Express Express em em mpathy • Support Support sellf Support sel lf‐‐efficacy • Develop Develop dis disscrepancy • Roll Roll with re with re esistance


Express p Empathy p y A clinician can set an empat p thetic tone in various ways – by asking permission n to discuss a personal topic, acknowledging and v p , g g g g alidating a strong emotion or even by signalin ng that you are listening without judging. j g g


Support Se elf-Efficacy Patients need to believe they caan be successful in order to be willing to attempt a behavior ch illi b h i hange. Positive messages from P ii f a clinician, especially those that build on strengths, can help a teen prepare for a behavioral ch teen prepare for a behavioral ch hange. hange.


Develop a Discrepancy D Individuals who have experienced pro oblems or negative consequences related to substance use will have both positive and negative feelings about it. (Remember that motivation ( nal interventions are targeted at teens g who screen positive for “high risk” su ubstance use, indicating they have begun to experience problems.) Explo oring consequences from the p patient’s perspective moves the indiv p p vidual towards behavior change. g


Roll with Resistance R A patient may start to “arggue” if a clinician “gets ahead”. If this happens, p pull back to common ground or simply acknowlledge the point. Avoid arguing, lecturing or ordering which can result in d decreased d motivation to c ti ti t change. h


MI Too ols • • • • • •

Open‐ended que estions Reflective listeningg Affirming Negotiating Reframing Summarizing


Open-ended p d Questions Q Open‐ended questions cannot be answered with a single word. They can be a particularly useful tool to initiate conversation and to explore for areas of ambivalence. areas of ambivalence.


John John is 17 years old and has been drriving a car for the past year. He hasn’t had any accidents. However, he often drives home after drinking at a party. “What’s the big deal? I caan hold my beer. And anyway, my dad’s car has an airbag.” Open‐‐ended question: What would happen if you did have a car crash? Open


Reflective listening g Reflective listening involvess repeating or (slightly) interpreting what a patient p g p p has said for emphasis. Reflections can help to flesh h out ambivalence, which is p presented in the patient’s o p own words.


Ma aria Maria is 16 years old and has been n smoking marijuana with her steady boyfriend for the past year. y y p y Her grades have fallen. She tells g you “I love Jack and he would not be interested in hanging out with me if I quit.” Reflection: You really like Jack, an nd he encourages you to smoke even though you don’tt want to. even though you don want to Open‐ended question: What do yyou think you should do about that?


Affirm ming Affirming is the act of commenting on a patient’s g ld self esteem. strengths in order to buil Affirmations can help to set an empathic tone and also support self‐effiicacy and also support self‐effi icacy.


Kare eem Kareem is a 16 year old boy who comes to your office at his mother’s insistence because of marijuana usee. Kareem does not think marijuana use is harmful and does not want to o make any changes at this time. He spends a lot of time talking about th he difference of opinion between his mother and him. Affirmation: I can see that you aree very scientifically minded and really did your research. You know y y w quite a bit about marijuana. q j Open‐ended question: Why do you think your mother is so worried about your marijuana use?


Negoti g ation Negotiation involves settin ng goals that a patient accepts as meeting his/heer needs. Negotiation can accepts as meeting his/he er needs Negotiation can help to insure that the clin nician does not “get ahead” of the patient and ahead of the patient and can also signal the can also signal the importance of the patientt’s point of view.


Tay ylor y Taylor is a 17 year old girl who comes ffor a physical. On screening she tells en she was drunk, and had a bad y you that she recently tried cocaine wh y , experience. She does not want to use cocaine again, but she gets annoyed at the suggestion that she stop drinking. Negotiation: As your doctor who cares about your health, I recommend that you quit drinking until you are older beecause teens often make bad decisions when they are drunk. We both know that you need to decide for yourself what to do. Open‐ended question: How can you p Open ended question: How can you protect yourself from doing things you p protect yourself from doing things you regret in the future? © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Refra ame Reframing involves exam mining a patient’s perceptions in a new ligh ti i li h ht ht or a reorganized form, i df giving new meaning to w what has been said.


Daw wna Dawna is 1 15 years old and recently committed to stop drin p nking alcohol, after a school g , suspension n. She did well for the first few weeks, but had a b beer at a friend’s birthday party last weekend. weekend Reframe e: You only drank once in the past couple o p of months; that’s a really big change. ; y g g Open‐ended question: What was happening last weeekend when you decided to have a drink? What could you do if that happened drink? W W What could you do if that happened again? © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Summa arizing Summarizing is a way of pu Summarizing is a way of pu ulling a long discussion ulling a long discussion together. It involves reflectting back the various factors underlying a patient’ss decis underlying a patient decissions and behaviors in order sions and behaviors in order to help weigh them out. A careful summary also demonstrates that the clinician has been attending the demonstrates that the clini cian has been attending the conversation and understan nds the patient’s point of view. view © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Tom m

He was kicked out of his dorm because of Tom is 19 years old. y drinking. He wants to stop so that he can go back to school, but he is worried that it will be difficult when he is with friends who drink. He has decided to gget a job on Friday nights to keep him from going has been spending more time with his friend Jake to parties. He also h who does not drink.

Summary: Quittingg drinking is hard, but you have decided to do it. Your work schedule will keep you away from parties. You th Jake if you don’t want to be around y can spend time wit p alcohol. Affirmation:: It’s grreat that you want to get back to school. What else can you do if you find Open ended questtion: What else can you do if you find Open‐ended quest yourself around alccohol? © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Putting P tti it all all together t th A guide to Conducting a Brief Motivational Interview to address high risk substance use in 5 minutes or less…


Brief Inte ervention Traditional MI is framed in th di i l i f d i he context of counseling f li sessions. However, the MI “to oolbox” is versatile and can b ff i l be effectively employed by a l d b physician even in a fast‐ h i i i f paced setting.


SBIRT in Prrimary Care Ask about paast year use +

-

Screen for “high high risk use” use

Positive Reinforcement

+

-

Brief Advice

+ Brief Motivational Intevention

+ Follow-up


Introduce the Topic p Start St t a brief motivational bi f ti ti l intervvention by asking permission. For exxample, “I would like to ask you somee follow‐up questions regarding f ll ti di your use of alcohol. Can we do that now??” This signals that the adole d lescent’s opinions are respected t’ i i t d and aalso sets an empathetic tone.


Ass sess The goal of the assessment is to get a quick understanding of the types and severity off problems associated with substance use that have been experienced by the patient. substance use that have be en experienced by the patient The goal of assessment is th hree‐fold: 1. Identify adolescents who y ose use puts them at risk of p immediate harm and maake an acute intervention. 2. Identify adolescents who o have developed addiction (d (dependence) and need d ) d d referral to an addiction or f l ddi i mental health specialist.. In this case, referral becomes the goal of the interventtion. the goal of the intervent 3. Identify areas of ambivalence that can be reflected upon as part of the interventio on. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Suggested gg Asse essment: Alcohol 1. Tell me about your use of alc y cohol. 2. How much do you usually drrink? What is the most you ever had? 3. Have you ever had a black ou ut or alcohol poisoning? 4. Have you ever had a problem m because of alcohol? 5. Have ever done anything you u regretted because of alcohol? 6. Have you ever tried to quit d drinking? 7. Does anyone in your family h f l h have an alcohol problem? l h l bl © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Suggested gg Asses ssment: Marijuana j 1. Tell me about your use off marijuana. 2. Have you ever been a daily smoker? blem or gotten into trouble 3. Have you ever had a prob because of marijuana? 4. Have you ever tried to quit smoking? 5 Do you get “lazy” or lose 5. D “l ” l energy when you smoke? h k ? 6. Do you ever get paranoid when you smoke? 7 Have you ever seen or he 7. H h ard things that weren’t there? d thi th t ’t th ? © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Assess Readin ness to Change g

school beer

ary: You really like drinking with : You really like drinking with Summaary riends and can’t imagine quitting. t imagine quitting. your frriends and can’ ve had a couple of blackouts, had a couple of blackouts You havve You hav which is scary for you. q How can you y Open‐ p ‐ended question: e Open protectt yourself from having another ut? blackou


Advise to Quit We botth We bot th know that only you can know that only you can decide what to do, but I recommend that yo ou quit entirely for the sake of your heealth. A blackout means that your he ealth A blackout means that you draank enough to poison your brain ccells, at least temporarily, and as you know, kids often get k kid ft t themseelves into trouble when they are “blacked out”.


Assist in ma aking a plan Target High Risk R Behaviors on: You don’t want to on : You don’t want to Reflectio , y quit righ q ght now, but you would like own. to cut do nded Question: How do nded Question : How do Open‐‐en Open you think you will do that?


Arrange follow-up f Affirm:: : I think you are smart to cut Affirm Affirm: I think you are smart to cut down, aand your plan is a good one. like for you to come back in you to come back in I would like for a month h or two and tell me how it is going. Open‐ended question: What do Open‐ nded question d d ti : What do Wh t d you thin nk?


Invite parents p Refllection: You said that your mom caugght you with marijuana and was very concerned. I would like to tell her that you just spoke with me about it and have agreeed to speak with our social worker next week. Ope en‐ended question: What do you thin nk about that?


ette: ette Katie at e Case Vigne g e is 17 year old girl who comes • Katie Katie iiis 17 year old girl who comes in for eemergency contraception. g y • On scrreening she says she drinks ol and uses marijuana every alcoho months, but never used other few m drugs.. nswered “Yes” to Relax, • She an y and Trouble questions Familyy and Trouble questions © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

As sk Tell me about you y ur use of alcohol. Katie started drinking at parties as a freshman. Now she drinks about twice a month drinks about twice a month h 4 6 shots which is enough to h, 4‐6 shots, which is enough to get drunk. She has never h had a black out or alcohol poisoning. She has never tried to quit. Her mother once poisoning. She has never t ried to quit. Her mother once told her that a distant cousin had alcohol problems.


As sk Have you ever had p Have you ever had problems roblems related to related to drinking? Katie was suspended for 2 daays because she brought a bottle of vodka to a school fo ootball game last year. Her parents were upset and grou d nded her. She said she would d d h Sh id h ld stop drinking but did not. Now w that she is 18 she thinks they are less concerned they are less concerned. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

As sk Have you ever done anything you regretted? Katie had consensual sex at aa party 2 days ago while drunk. She did not use contraaception and now regrets the decision to have sex in the firrst place.


Assess Readiness R Reflection: Itt seems that drinking has become an im become an im mportant activity for you and mportant activity for you and your friends, and it has also gotten you into trouble. Open‐ended d question: What would you like to do abo out it?


Ka atie Katie says that she has no K ti th t h h o interest in quitting because i t ti itti b all of her friends drink, an nd doesn’t think drinking is a problem She continues to say that she has done problem. She continues t to t say that she has done some “stupid things” wheen she was drunk and she would like to “control” heer drinking better.


Advise to quit • Advice: We both know th hat only you can decide how often and how much to drrink. As a physician, I recommend that you stop d th t t p drinking entirely for the sake d i ki ti l f th k of your health, and because people often make bad decisions when they drinkk. decisions when they drink • Open‐ended question: How can you protect yourself better in the future? better in the future?


Assist in making a plan Arrange follow-up • She will try to cut down to 1‐2 2 drinks when out with her friends. • You give her positive feedbac Y i h i i f db k and then k d h ask her what else she can do. • She cannot think of anything She annot think of an thin else. You l Y suggest that she avoid sexual activity after alcohol and she agrees alcohol and she agrees. • She also agrees to return in 1 month. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Eriic • Eric is a 17 yyear old male who comes to the office with fflu‐like symptoms. On screening, he reveals th hat he has drank alcohol, smoked marijuana and used several other drugs, including oxxycodone including ox xycodone. • His CRAFFT score is 6; he thinks he is addicted to opioids and he would like to addicted to opioids and he would like to quit. Twice in the past he tried to quit unsuccessfu ully, so he thinks he might need y, g help. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

As sk You ask Eric the critteria for opioid dependence and hee meets all 7.


Assess Readiness R Affirm: From your history it seems y y that you have lost control over use y of pain medicine. I know how hard it can be for patients to ask for help and am really glad that you aree here. Ad i Advise: Usually people who becom U ll l h b me addicted need help to quit. That ddi t d dh l t it Th t could be anything from hospitalizattion to help with withdrawal, to an outpatient medication treatment. Open‐ended question: What do you think would work best for you?


Arrange g Referral •

Eric says that he does not waant to go to an inpatient program, b h but he would be interested i ld b i d in medications and counseling. di i d li

•

You tell him that you will hel You tell him that you will help him find an appropriate p him find an appropriate treatment program.


Referral to Treatment Identify local resources: Find mental health program ms and practitioners with ms and practitioners with • Find mental health program experience in treating adolescents Use online treatment locattors: SAMHSA, local resources tors: SAMHSA, local resources • Use online treatment locat Involve parents in treatment: Involve parents in treatment: • Best chance for good outco ome with family support • Special considerations whe Special considerations wheen parents themselves use en parents themselves use substances © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Referral to Treatment Treat co‐occurring disorders simultaneously: ADHD, mood/anxiety disorders (e.g. d d/ i di d ( d depression). i ) • Special caution with stim mulant medications. Involve parents in treatment. • Special issues with subs Special issues with subsstance‐using parents. stance using parents • Best chance for good ou utcomes with parental involvement American Academy of Pediatrics. Periodic Survey of Fellows #31: Practices and Attitudes Towardd Adolescent Drug Screening. Elk Grove Village, IL: American Academy of Pediatrics, Division of Child Health Reesearch;1997. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Invite Parents P Ask: Do your parents know ab Do your parents know ab bout your drug problem?

If yes: II imagine they will be happy that you i i th ill b h th t u are ready to go into treatment. In my d t i t t t t I experience, kids do best when their p parents or other family members are supporting them. If you agree, I wou pp g y g uld like to tell them that you are y planning to start a treatment program m.


Invite Parents P Ask: Do your parents know ab Do your parents know ab bout your drug problem? If no: hey found out. Screen for • Ask what would happen if th domestic violence, active paarental mental health or substance use disorders. • If safe, encourage the teen t If f h to involve parents or other i l h family members. Offer supp port in breaking the news. Emphasize that the teen is seeking treatment. Practice Emphasize that the teen is s eeking treatment Practice the wording beforehand. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

A t Risk: Acute Ri k MOVING BEYOND M MOTIVATIONAL INTERVENTIONS © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Joh hn • John is a 15 year old boy w y y who was brought to the ED g for altered mental status 3 3 days ago. A urine test was positive for marijuana and d xanax and now John presents to you for follow‐‐up. • He reports past year use o of alcohol, marijuana, “ “mushrooms,” h ” Dextromet D thorphan and h h d benzodiazepines. • His CRAFFT score is 4. His CRAFFT score is 4 © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

As sk Tell me how you ended up in the ED last week. Tell me how you ended up in the ED last week. John was at a party with his John was at a party with hiss friends. They had been s friends They had been “pharming” ‐‐ taking unlab beled pills out of a bowl. He took a combination of 8 8 pills and did not know p what they were. He doesn’’t remember anything else until he woke up in the ED.


As sk Has anything like that ever ha y g pp ppened before? John said that he frequently g q y goes to pharming parties and p gp mixes drugs. He said that he o only ended up in the ED because he was “stupid” and took too many pills. He uses alcohol once a week, marijuan na every day and other substances intermittently. He does not think he has a problem and is not interested in treatment. problem and is not interested in treatment © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.

Acute Inttervention Remind John of limits of confid dentiality Bring parents in and discuss accute need for treatment Screen for suicidal ideation; co onsider referral to ED If stable, make an appointmen , pp nt with mental health or addiction specialist within 2‐3 days • Contract with John and parentts that he will not use drugs and that he will keep his appointm ment • Remind parents to call 911 or bring to ED if he develops altered mental status, or if they are accutely concerned about his mood or behavior. • • • •


Acute Inttervention Affirm: I am glad that you came for an appointment today. From what you told me, I am worried about your drug use. Advise: Mixing drugs can really get you u into trouble, even if you only take a couple of pills. Because I am so worried d I have to share some of this information with your parents. I want you to speak more about your drug information with your parents. I want y y to speak more about your drug you use with one of my colleagues who is a psychiatrist. Plan: In the meantime, can you promise me that you will not use any pills or d drugs at all until you have had a chance ll l h h d h e to speak with him? k hh Open ended question: What do you th hink would be the best way to share the information with your parents? the information with your parents?


Summ mary • Motivational interviewing (MI) techniq ques are especially useful when discussing difficult topics such as drug discussing difficult topics such as drugg use. g use • Brief motivational interventions use M MI techniques to facilitate behavior change. These structured interventions practical for use in the course of routine patient care. ollaboratively with a clinician. All patients • Ideally patients set their own goals co are advised to quit or cut down, patie q , p ents who have developed dependence p p are also encouraged to accept a referral to treatment. • For adolescents whose substance use puts them at risk of acute harm the intervention is targeted at safety tho intervention is targeted at safety, tho ough MI techniques are used whenever ough MI techniques are used whenever possible. © Boston Children’s Hospital 2013. All Rights Reserved. For perrmissions contact SBIRT project manager at www.CeASAR.org.