Assessing Alcohol and Substance Use in Youth. Disclosers. Learning Objectives 12/12/2015. Nothing to disclose.

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1 Assessing Alcohol and Substance Use in Youth Holly Hagle, PhD Director of Training and Education Institute for Research, Education, and Training in Addictions (IRETA) National Screening, Brief intervention and Referral to Treatment ATTC (National SBIRT ATTC) Nothing to disclose. Disclosers Learning Objectives Review current statistics on alcohol and drug use among school-age students Describe the process of screening, brief intervention, and referral to treatment or SBIRT Review potential prevention activities for the school age population 1

2 Review brain development and current statistics on alcohol and drug use among school-age students Adolescent Brain Development Adolescent Brain 2

3 Brain Development May Influence the Behavior of a Teenager 1.Sensory and physical activities may be favored over complex, cognitive-demanding activities 2.Activities with high excitement and low effort may be preferred 3.Poor modulation or control of emotions (e.g., the teenager emotionally over-reacts to a minor incident) 4.Propensity toward risky, impulsive behaviors 5.Poor planning and judgment 7 The Adolescent Brain The greatest changes to the parts of the brain that are responsible for impulse-control, judgment, decision-making, planning, and organization (and that are involved in other functions like emotion), occur in adolescence. This area of the brain (prefrontal cortex) does not reach full maturity until around age 25. Video: The Adolescent Brain continued 3

4 School Performance During the Past 12 Months among US High School Students during 2003 M iller J W et al. Pediatric 2007 by American Academy of Pediatrics 2007;119: Negative Impact of Binge Drinking Increased frequency of binge drinking results in increased prevalence of other health risk behaviors: poor school performance riding with a driver who had been drinking being currently sexually active smoking cigarettes or cigars being a victim of dating violence attempting suicide using illicit drugs. Source: Binge Drinking and Associated Health Risk Behaviors Among High School Students. Jacqueline W. Miller, Timothy S. Naimi, Robert D. Brewer and Sherry Everett Jones Pediatrics 2007;119; rics. org /cgi/c ont ent /full/1 19/ 1/ Harmful Effects to Adolescent Brain Regions related to decision making, judgment, impulse control, emotion, and memory are not yet fully developed; teens more prone than adults to taking risks, including experimenting with tobacco, alcohol, and other drugs Addictive substances physically alter its structure and function faster and more intensely than in adults, interfering with brain development - further impairing judgment and heightening the risk of addiction Emerging evidence of the heightened vulnerability of the developing adolescent brain to the harmful effects of AOD use 12 4

5 Effectiveness of SBIRT for Adolescents Preliminary research shows promising effects of SBIRT on adolescent AOD use: Project CHAT (D Amico et al., 2008) Less likely to report intentions to use marijuana Lower perceived prevalence of marijuana use and fewer friends who use marijuana Increased readiness to change, increased self-efficacy, decreased marijuana use SBIRT in 2 continuation high schools (Grenard et al., 2007) Youth willing to discuss personal drug use Reported satisfaction with SBIRT Greater readiness to change drug use at follow-up 13 Effectiveness of SBIRT for Adolescents Knight et al., 2005 pilot study Reduction in substance use and risk of drinking after driving at three month follow-up Harris et al., 2011; 2012 computerized SBA Lower past 90 day alcohol and drug use than control group csba prevented or delayed initiation of alcohol use 44% fewer csba adolescents started drinking during the twelve month study period than adolescents in the control group 14 Describe the process of screening, brief intervention, and referral to treatment or SBIRT 5

6 Screening, Brief Intervention and Referral to Treatment (SBIRT) Public health approach to addressing substance use Universal screening in a variety of settings Substance Use 17 Responding with a Public Health Approach SBIRT and Youth 6

7 Delivering SBIRT to Adolescents 19 SBIRT for youth in Healthcare Settings The American Academy of Pediatrics recommends that pediatricians provide alcohol screening and counseling to all adolescents. The Massachusetts Department of Public Health states that Every adolescent should be asked yearly about use of alcohol and drugs. 20 Relatively Few PCPs Screen According to Guidelines An American Academy of Pediatrics survey found that only 45 % of fellows routinely screened young patients for alcohol use, and only 16 % reported using standardized instruments American Academy of Pediatrics: Research update: 45 % of fellows routinely screen for alcohol use. In another study, they found that, while 14 % of the sample scored 2 on the CRAFFT, providers only identified only 4.8 % of the patients with problem use Moreover, almost 20 % of those perceived by the providers to have an AOD problem still did not receive a recommendation for an intervention H assan A, et. al., Primary care follow-up plans for adolescents with substance use problems. Pediatrics 2009, 124:

8 Any Questions, Comments or Reflections? The CRAFFT Screening Instrument CRAFFT Screening Tool The CRAFFT is a validated screening tool for use with adolescents Because it screens for both alcohol and other drug problems simultaneously, it is especially handy for providers CRAFFT consists of Part A: 3 pre-screening questions and Part B: 6 items Scoring Algorithm A positive CRAFFT means the student should be assessed for alcohol/drug use severity (mild, moderate or severe). Source: Arch Pediatr Adolesc Med. 2002;156:

9 CRAFFT - Part A Review Ask: During the Past 12 months, did you: 1. Drink any alcohol (more than a few sips)? 2. Smoke any marijuana or hashish? 3. Use anything else to get high? ( Anything else includes illegal drugs, over the counter and prescription drugs, and things that you sniff or huff.) If answers NO to all, Ask the CAR question in Part B, then STOP. If answers YES to ANY, ask all of Part B 27 9

10 IF: No to All Part A and No to Car question. Praise and Encouragement: You made some good choices not to use drugs or alcohol. IF: No to All Part A and Yes to Car question. Please don t ever ride with a driver who has had a single drink, because people can feel that it s safe to drive even when it s not. 28 THE CRAFFT Part B: 1. Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? 2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? 3. Do you ever use alcohol or drugs while you are by yourself, or ALONE? 29 THE CRAFFT 4. Do you ever FORGET things you did while using alcohol or drugs? 5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? 6. Have you ever gotten into TROUBLE while you were using alcohol or drugs? 30 10

11 THE CRAFFT A score of 2 or greater is a positive screen and indicates that the adolescent is at high-risk for having a substance use disorder. 31 IF: CRAFFT = 1 Brief Advice: CRAFFT Part B I recommend that you stop (behavior) and now is the best time. Alcohol and drugs have a detrimental affect on your growing brain and you may do some things that you could come to regret. Affirm their strengths and supports. teens.drugabuse.gov/ 32 CRAFFT Part B CRAFFT > 2 Brief Assessment Tell me about your alcohol and drug use. Has it caused you any problems? Have you tried to quit? Why? No Acute Danger or Red Flag Red Flags for At Risk for Substance Use Disorder Signs of Acute Danger 33 11

12 CRAFFT > 2 CRAFFT Part B Brief Assessment Tell me about your alcohol and drug use. What are the good things about your alcohol and drug use- reasons you want to use? What are some of the downsides to drinking or using? Where would you like to go from here? No Acute Danger or Red Flag Red Flags for At Risk for Substance Use Disorders Signs of Acute Danger 34 CRAFFT >2: No Acute Danger or Red Flag BI: To stop or cut down Give Brief Advice and summary Give praise and encouragement if willing to quit. Plan follow-up Red Flags At Risk for Substance Use Disorder CRAFFT >5; < 14 years; daily or near daily use; alcohol related blackouts (memory lapses) Use BNI Summarize Refer to treatment (5 or 6) Invite Parents Plan follow-up 35 CRAFFT >2: Signs of Acute Danger: Drug-related hospital visit; use of IV drugs; combining alcohol use with benzodiazepines barbiturates or opiates; consuming potentially lethal volume of alcohol (14 or more drinks); driving after substance use Make an immediate intervention Discuss increase safety Use BNI Discuss confidentiality and possibly contacting parents Plan follow-up 36 12

13 A little more about: Screening At ages 12 to 15 years, o any drinking is considered at least moderate risk, and o half of drinkers in this age group drink frequently enough to be in the highest risk category. At ages 16 to 18, o about one-third of drinkers are at lower risk, o one-fifth at moderate risk, and o just under half are at highest risk (NIAAA, 2011). 38 For Students who drink ASSESS RISK, and Provide Feedback 39 13

14 Estimated Binge Drinking Levels for Youth BOYS Ages drinks Ages drinks Ages drinks Girls Ages drinks Screening Does Not Provide A Diagnosis 41 Brief Intervention 14

15 Brief Intervention Definition: Brief interventions are evidence-based practices design to motivate individuals at risk of substance abuse and related health problems to change their behavior by helping them understand how their substance use puts them at risk and to reduce or give up their substance use. Source: CIHS (2014). Retrieved from Brief Intervention (cont) Healthcare providers can also use brief interventions to encourage those with more serious dependence to accept more intensive treatment within the primary care setting or a referral to a specialized alcohol and drug treatment agency. Source: CIHS (2014). Retrieved from Brief Intervention (cont) In primary care settings, brief interventions last from 5 minutes of brief advice to minutes of brief conversations. Brief interventions are not intended to treat people with serious substance dependence, but rather to treat problematic or risky substance use. Source: CIHS (2014). Retrieved from 15

16 Brief Intervention (cont) The two most common behavioral therapies used in SBIRT programs are brief versions of cognitive behavioral therapy and motivational interviewing, or some combination of the two. Source: CIHS (2014). Retrieved from AMBIVALENCE All change contains an element of ambivalence We want to change and don t want to change Students ambivalence about change is the meat of the brief intervention Motivational Interviewing (MI) 16

17 Motivational Interviewing Motivational Interviewing is a person-centered, evidence-based, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence with the individual. 49 Motivational Interviewing Creates therapeutic partnerships: Motivational Interviewing encourages an active partnership where the student and counselor work together to establish treatment goals and develop strategies. Uses empathy not authority: Research indicates that positive outcomes are related to empathy and warm and supportive listening. Focuses on less intensive treatment: Motivational Interviewing places an emphasis on less intensive, but equally effective care, especially for those whose use is problematic or risky but not yet serious. 50 Motivational Interviewing Assumes motivation is fluid and can be influenced. Motivation is influenced in the context of a relationship developed in the context of a student encounter. Principle tasks to work with ambivalence and resistance. Goal to influence change in the direction of health

18 Goal of MI To create and amplify discrepancy between present behavior and broader goals. How? Create cognitive dissonance between where one is and where one wants to be. 52 UNDERLYING ASSUMPTIONS Acceptance Autonomy/Choice Less is better Elicit versus Impart Ambivalence is normal Care-frontation Non-Judgmental Change talk Avoid the righting reflex 53 How are MI principles consistent with adolescent development? Express empathy - relationship building Roll with resistance - avoid power struggles Avoid Argumentation- respect for autonomy Support self-efficacy- competency development Develop discrepancy- supports planning, anticipating risks 54 18

19 Collaboration Compassion MI Spirit Autonomy Evocation The MI Shift From feeling responsible for changing students behavior to supporting them in thinking and talking about their own reasons and means for behavior change Not at all Very Ready Ready Readiness Ruler On a scale of 1 to 10, where 1 is not at all ready and 10 is very ready, how ready are you to cut back/stop drinking/using? why didn t you choose a lower number? 57 19

20 Lets Review a Brief Intervention Risk and Protective Factors Risk factors can increase a person s chances for drug abuse, while protective factors can reduce the risk. Most individuals at risk for drug abuse do not start using drugs or become addicted. Also, a risk factor for one person may not be for another. Risk and protective factors can affect children at different stages of their lives. At each stage, risks occur that can be changed through prevention intervention. Source: 20

21 Any Questions, Comments or Reflections? Discussing confidentiality with adolescent: Helps patient understand how personal information is and is not shared Supports a trusting relationship Promotes more honest answers Soc iety for Adoles c ent Health and M edic ine (SAHM ). Confidential Health Care for Adoles c ents : Position Paper of the Society fo r Adoles cent M edic ine.j Adolesc Health Aug;35(2): What is confidential? Substance use history Other associated risk behaviors (e.g., sexual) Limits of confidentiality: Suspected physical or sexual abuse Suspected risk of suicide or homicide Distinctions are not always clear Soc iety for Adoles c ent Health and M edic ine (SAHM ). Confidential Health Care for Adoles c ents : Position Paper of the Society fo r Adoles cent M edic ine.j Adolesc Health Aug;35(2):

22 Parents need guidance too! Open communication between guardians and teens regarding sensitiv e topics is one of the best strategies to reduce teen experimentation with and use of alcohol and drugs. Settings 22

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24 Adolescence is a critical time for brain development which substance use can impair drastically. Screen all teens for substance use as part of routine care using a validated tool. Take the appropriate level of intervention based on the screening results. Confidentiality and guardian guidance are important considerations in the clinical care of adolescents. Any Questions, Comments or Reflections? 24

25 Thank you for your time. 12 Aug 2008 Contact us: 25