1 Screening, Brief Intervention and Referral to Treatment SBIRT in Adolescent Primary Care Lydia A. Shrier, MD, MPH Associate Professor of Pediatrics Boston Children s Hospital Harvard Medical School Sharon Levy, MD, MPH Assistant Professor of Pediatrics Boston Children s Hospital Harvard Medical School Geetha Subramaniam, MD Deputy Director, Center for Clinical Trials Network, NIDA Supported by: NIDA CTN
2 Blending Initiative Targeting the Approach to Meet the Needs of our Expanding Audience
3 Educational Activities Update of Selected Existing Blending Offerings ( ) Update Science/Content Motivational Interviewing Buprenorphine Identify and complement existing educational offerings Explore new approaches Awareness and outreach Web-based and mobile platforms Methods for self-paced learning
4 Outreach & Dissemination 2014 Partner Audience Date Type of Activity SAHM Multidisciplinary, Adolescent Health March 2014 Embedded Session ACP Internal Medicine April 2014 Half-Day Workshop on MI ASAM Addiction Medicine April 2014 Embedded Session STFM Family Medicine May 2014 Pre Conference on MAT
5 Percent Past Year Marijuana Use versus Perceived Risk th graders Past Year Use Perceived Risk Occasional Marijuana users: Monitoring the Future Study
6 Leading Causes of Death (12-19year-olds) Source: CDC-National Vital Statistics System-Mortality
7 Referral to Treatment
8 Learning Objectives To demonstrate: a screening tool that quickly and accurately assesses the risk associated with substance use and an associated SBIRT algorithm.
9 Adolescents Are Not Little Adults
10 Severe SUD Mild/ Moderate SUD No SUD No Use 12 Age (years) 25
11 Do you screen teens annually? % "Yes" 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 86.0% 89.8% 45.0% AAP 2007-MA AAP unpublished Harris, SK, et al. Substance Abuse Oct;33(4): American Academy of Pediatrics. Needs Assessment 2013: Alcohol Screening and Brief Intervention in Adolescents, unpublished data.
12 Percent of physicians using tool What tool do you use to screen adolescent patients for substance use? 80% 70% 60% 71.0% 69.8% 50% 40% 30% 20% 33.9% 30.2% % 0% Validated Tool No tool Harris, SK, et al. Substance Abuse Oct;33(4): American Academy of Pediatrics. Needs Assessment 2013: Alcohol Screening and Brief Intervention in Adolescents, unpublished data.
13 Practicing physician: I think that most physicians are already engaging in necessary screening techniques and identifying their patients with unhealthy substance use. Bureau of Substance Abuse Services, Massachusetts Department of Public Health, Unpublished data.
14 Comparison of Provider Impressions with Diagnostic Interview Medical Provider Impressions Sensitivity Specificity Any use.63 (.58,.69 CI).81 (.76,.85 CI) Any problem.14 (.10,.20 CI) 1.0 (.99, 1.0 CI) Any disorder.10 (.04,.17 CI) 1.0 (.99, 1.0 CI) Dependence Source: Wilson CR, Sherritt L, Gates E, Knight JR. Are clinical impressions of adolescent substance use accurate? Pediatrics, 2004;114:
15 Brief Advice with Low-Risk populations Delayed onset of drinking Increased alcohol cessation rates Brandon is a 12 year old boy did not use substances last year. Ana is a 15 year old girl who used marijuana 1-2 times last year. Harris, SK, et al. Computer-facilitated substance use screening and brief advice for teens in primary care: an international trial. Pediatrics Jun;129(6): Colby, SM, et al. Brief motivational intervention for adolescent smokers in medical settings. Addictive Behaviors. 2005(30):
16 How do you respond to a negative screen? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 67.6% Brief Advice 72.3% Positive Reinforcement American Academy of Pediatrics. Needs Assessment 2013: Alcohol Screening and Brief Intervention in Adolescents, unpublished data. Hingson, R., Zha, W., Iannotti, R., & Simons-Morton, B. (2013). Pediatrics, 131(2),
17 MI compared to BA for high risk teens MI reduced use by high risk teens more than BA Eric is a 15 year old boy who drinks once a month. Corrie is a 16 year old girl who smokes marijuana every week. Monti, P. M., Barnett, N. P., Colby, S. M., Gwaltney, C. J., Spirito, A., Rohsenow, D. J., & Woolard, R. (2007). Motivational interviewing versus feedback only in emergency care for young adult problem drinking. Addiction, 102(8),
18 Refer teens with severe SUD Addiction is a chronic neurological condition requiring long term care and monitoring Matt is a 17 year old boy with weekly opioid use
19 Dicola LA, Gaydos LM, Druss BG, Cummings JR. Health insurance and treatment of adolescents with co-occurring major depression and substance use disorders. J Am Acad Child Adolesc Psychiatry. Sep 2013;52(9): Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Abuse Treatment Admissions Referred by the Criminal Justice System: The DASIS Report 2004; Accessed November 27, 2013.
20 Be prepared to manage acute risk Some behaviors are dangerous enough to warrant an immediate intervention. Naomi is a 16 year old girl with weekly alcohol use who says that she also uses benzos to help her black out faster.
21 S2BI In the past year, how many times have you used Tobacco? Alcohol? Marijuana? STOP if all Never. Otherwise, CONTINUE. Prescription drugs that were not prescribed for you (such as pain medication or Adderall)? Illegal drugs (such as cocaine or Ecstasy)? Inhalants (such as nitrous oxide)? Herbs or synthetic drugs (such as salvia, "K2", or bath salts)?
22 Sensitivity/Specificity of S2BI CIDI-SAM interview vs. screen frequency item for detecting a substance use disorder; N=215. Criterion Standard Dx Screen Frequency Sensitivity Specificity Any SUD > Monthly use 90% 94% Severe SUD > Weekly use 100% 94% Levy, S. Ziemnik, R., Shrier, L., Sherritt, L., Spalding, A. (2013). Using a brief assessment tool to identify substance use disorders in teens. AMERSA 37th Annual National Conference, Bethesda, MD.
23 Frequency screen discriminates between 4 groups based on DSM-5 diagnoses Mild/ Moderate SUD Severe SUD No SUD No Use
24 DSM-5 Criteria for Substance Use Disorders 1 Use in larger amounts or for longer periods of time than intended 2 Unsuccessful efforts to cut down or quit. 3 Excessive time spent taking the drug 4 Failure to fulfill major obligations 5 Continued use despite problems 6 Important activities given up 7 Recurrent use in physically hazardous situations 8 Continued use despite problems 9 Tolerance Severity is designated according to the number of symptoms endorsed: 0-1: No diagnosis 2-3: mild SUD 4-5 : moderate SUD 6 or more: Severe SUD 10 Withdrawal 11 Craving American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
25 S2BI No Use Couple of Times Monthly Use Weekly Use 1. Positive Reinforcement Ask 2 nd S2BI Question Ask 2 nd S2BI Question 2. Brief Advice 3. Brief Motivational Intervention: -Assess for problems -Advise to quit -Make a plan Reduce use and risky behaviors Reduce use/risky behaviors and refer to treatment
26 S2BI No Use Couple of Times 1. Positive Reinforcement Ask 2 nd S2BI Question 2. Brief Advice
27 Positive Reinforcement Brief Advice Give positive feedback Advice abstinence Frame as a decision if appropriate Talk about health consequences For younger kids include norms correction Use a strengths based approach
28 S2BI Monthly Use Ask 2 nd S2BI Question 3. Brief Motivational Intervention: -Assess for problems -Advise to quit -Make a plan Reduce use and risky behaviors
29 Brief Motivational Intervention Ask questions to identify common problems Use problems as a pivot point in the conversation Give clear medical advice to stop, while acknowledging agency Assist with planning; target highest risk behaviors Ask permission to include parents in the discussion Invite back for follow up
30 Sample screen: CRAFFT C R A F F T Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol /drugs? Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? Do you ever use alcohol/drugs while you are by yourself, ALONE? Do you ever FORGET things you did while using alcohol or drugs? Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or drugs? Knight JR. The CRAFFT questions: A brief screening test for adolescent substance abuse. Boston, MA: Copyright Children's Hospital Boston; 1999
31 S2BI Weekly Use Ask 2 nd S2BI Question 3. Brief Motivational Intervention: -Assess for problems -Advise to quit -Make a plan Reduce use/risky behaviors and refer to treatment
32 Referral to Treatment Teens with severe SUD are often treatment seeking Assess for acute risk Be familiar with the levels of care and provide acceptable options Involve parents if at all possible Continue to follow and monitor in your practice
33 Manage Acute Risk Screen for SI/HI Involve parents or other adults, break confidentiality if needed Ensure an expedited urgent evaluation Contract for safety Have parents monitor, review indications for an emergent evaluation
34 Other Screening and Assessment Tools CRAFFT GAIN DSM-5 NIAAA AUDIT BSTAD Car, Remember, Alone, Friends/Family, Forget, Trouble The CRAFFT is a good tool for quickly identifying problems associated with substance use Global Appraisal of Individual Needs Screens for both substance use disorders and mental health Diagnostic criteria for determining levels of substance use disorders. 2 questions Friends use and own use Alcohol Use Disorders Identification Test Assesses risky drinking Not used as a diagnostic tool Brief Screener for Tobacco, Alcohol, and Other Drugs Identifies problematic tobacco, alcohol, and marijuana use in pediatric settings.
35 Summary Recommendations Screen all teens for substance use as part of routine care Use a validated tool Make the appropriate level of intervention based on screen results Record any behavior change plans and follow up progress at regular intervals
36 Instructions for Case Exercise Form groups of 4 people Send 1 representative from group to collect materials Decide roles 2 people will be the Adolescent (1 actor, 1 coach) 2 people will be the PCP (1 actor, 1 coach) Read your role Act out scenario If PCP, can refer to Help for PCP Have fun!
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