Course 1: Understanding SBIRT (Pediatric Version)


Introduction to SBIRT: The Problem and a Solution

Patients use, misuse, and abuse alcohol and other substances.

These patients can be helped. They often aren’t. They often aren’t, because they simply are not asked.

Substance use, misuse and abuse affect a very large number of people, including adolescents. They can substantially damage people’s mental, physical, personal, and professional lives. No matter the specialty you choose to practice, you will encounter patients who are affected by their own or a significant other’s substance abuse. Often, their abuse will affect the management of some other medical issue about which you are concerned. As a pediatrician, you will be in a position to advise parents and your young and adolescent patients about the serious consequences of early substance use.

No matter how long you practice and how experienced you are, you cannot tell just by looking or talking to a patient what their pattern or frequency of substance use is. You have to ask and you have to be specific.

Do I have to tell parents?

A minor who voluntarily seeks treatment for alcoholism, alcohol abuse, or drug abuse may receive treatment without notification of consent of the parents/guardians (IC 12-23-12-1) BUT Parental notification of minors who seek care for substance abuse is at the discretion of the clinician (IC 12-23-12-2).

You don’t have to, but you can, and if you can get the minor to agree that it is a good idea, then that is the best outcome. A Motivational Interviewing (MI) approach, discussed later in this course, can help!

How Can a Physician Address These Issues?

Like most chronic diseases, substance use must be identified before it can be treated and managed. Like the developmental delays and disabilities for which you regularly screen your patients, substance use must be identified before it can be treated and managed. Screening for and intervening on these substance use issues can be done in many ways: a 2-question screening tool, a single-sentence advice statement, a comprehensive formal screening tool or in-depth counseling session.

SBIRTScreening, Brief Intervention and Referral for Treatment (SBIRT) is a simple method that any physician can adopt to help identify and briefly intervene to help their patients with substance use issues. And, as you will see, these small interventions can have a big impact.

The primary goal of SBIRT efforts is to identify and respond to patients who use substances, including alcohol, in a hazardous, risky, or harmful manner.  A secondary benefit of SBIRT is that patients with substance use disorders (i.e. abuse, dependency) are recognized too and may be referred for additional assessment and/or specialty addiction treatment.

Substance What?

In this course, “substances” includes alcohol, as well as illicit drugs, prescription medications, and tobacco.

We also use the terms use, misuse, and abuse, somewhat interchangeably, although they have, especially abuse, clinical differences which are discussed later.

Any substance use can have negative consequences. In terms of illicit use, or tobacco, substance use of any kind can be detrimental. For alcohol and prescription medications, use may be okay but misuse, that is hazardous drinking, overuse, or use without a prescription, is a problem.

Regardless of the substance and the terms used to describe use, many of your patients will be affected adversely by substance use. By using SBIRT with each and every one of your patients, each and every visit, you can play a significant role in reducing these adverse effects.

Thus, the much larger population of patients seen in primary care who screen positive for hazardous and/or harmful substance use are the target group for SBIRT.

Thus, in pediatric practice, the main target groups of SBIRT are those “non-users” who may benefit from brief advice to maintain abstinence and those non-dependent early users who may benefit from early intervention such as brief counseling.

A considerably smaller sub-set will be detected who have a clinical condition (i.e. substance use disorder), and these patients should be appropriately referred for more specialized assessment and treatment. That is, for a typical substance user pyramid, SBIRT specifically targets the often overlooked middle of the pyramid and also has the benefit of frequently identifying those at the top end as well.

Will you help?

 


Common Myths

  • Screening takes too much time.
  • Providers may annoy patients by screening them.
  • There is no available place to send a patient who screens positive.
  • The costs associated with screening and treatment will not be compensated and will be prohibitive.
  • My patients are not at risk.

These are usually simply not true.

Realities about Screening and Intervention for Substance Use

  • Screening can be accomplished by as little as a single question
  • Numerous studies report patient preference of physician screening and intervention
  • Multiple resources exist for treatment for substance abuse disorders
  • Screening and brief intervention is covered by many insurance plans, including Medicaid and Medicare

Dr. Nora Volkow, Director of NIDA, strongly conveys NIDA policy that physicians screen their patients, and NIDA has several other related videos on implementation of substance use screening.

Before turning to an introduction to the benefits,  effectiveness, and steps for implementing SBIRT, the next modules will briefly discuss the prevalence of substance use and the diverse and significant detrimental effects it can have on our patients’ lives.


Alcohol Prevalence

Consider the following, in the United States in the year 2000 alone, 537,000 preventable deaths resulted from tobacco, alcohol, and illicit drug use, Americans comprise 4% of the world’s population but consume 2/3 of the world’s illicit drugs, almost ¼ of U.S college students meet clinical criteria for substance abuse and addiction, and every American child will be offered illegal drugs at least once before graduating from high school.

Adolescents drink…a lot. Did you know…?

Alcohol is the most commonly used drug among adolescents and is responsible for more mortality and morbidity in this age group than all other drugs combined.

  • By 12th grade, 80% of high school seniors report having used alcohol, 62% report having gotten drunk, and 31% report heavy episodic use.
  • 9th grade girls drink as frequently as boys. 36.2% girls and 36.3% boys reported drinking in the past month.17.3% girls and 20.7% boys reported binge drinking.
  • Rates of drinking differ among racial and ethnic minority groups. Among students in grades 9 to 12, binge drinking is reported by 29.9% of non-Hispanic white students, 11.1% of African American students, and 25.3% of Hispanic students.

Prevalence of Alcohol Use and Abuse Among Adolescents

Adolescent Drinking Behaviors
Percent lifetime reporting. Data Source: Monitoring the Future (University of Michigan).

Pregnant Women Are At-Risk. Did you know…?

Among pregnant women aged 15 to 44…

  • An estimated 10.0 percent reported current alcohol use, 4.4 percent reported binge drinking, and 0.8 percent reported heavy drinking. Binge drinking during the first trimester of pregnancy was reported by 11.9 percent of pregnant women aged 15 to 44.
  • 4.5 percent used illicit drugs in the past month with a similar percentage reporting current drug use. This is down from the 10.6% in general female population yet remains wholly unacceptable. Among pregnant women aged 15 to 17, the rate of illicit drug use jumps to 13.0 percent
  • The rate of past month cigarette use among those who were pregnant (15.3 percent) is lower than it was among those who were not pregnant (27.4 percent). However, among those aged 15 to 17, the rate of cigarette smoking was higher for pregnant women than non-pregnant women (20.6 vs. 13.9 percent).

All of these remain unacceptably high.

Prevalence of Alcohol Use and Abuse (Age 12+)

Prevalence of Alcohol Use and Abuse (Age 12+)
SAMHSA, 2005

Other Drugs

The chart below is not comprehensive, but serves to illustrate percentages of use for some of the more common substances.

US Population Who Have Ever Used Illicit Drugs for Non-Medical Purposes

Prescription Narcotic Abuse

It may surprise you to find out that among 12th-graders, 8 of the 13 most commonly abused drugs (excluding tobacco and alcohol) were prescription or over-the-counter medications, over half of which were given to them or were purchased from a friend or relative. According to the 2009 Monitoring the Future survey (NIDA-sponsored), nearly 1 in 10 high school seniors reported past-year nonmedical use of Vicodin, and 1 in 20 abused OxyContin. In 2008, the number of individuals aged 12 or older who abused prescription pain relievers for the first time (2.2 million) was roughly even with that of marijuana (National Survey on Drug Use and Health)

Marijuana use

The numbers on marijuana abuse are equally striking. According to the National Survey on Drug Use and Health, in 2007, 14.4 million Americans aged 12 or older used marijuana at least once in the month prior to being surveyed. About 6,000 people a day used marijuana for the first time in 2007 —2.1 million Americans. Of these, 62.2 percent were under age 18.

Cocaine Abuse

In addition, over 5 million Americans used cocaine in the past year. 1.0 million had abused crack at least once in the year prior to being surveyed. National Survey on Drug Use and Health.

Methamphetamine Abuse

Methamphetamine is also prevalent in the United States: an estimated 529,000 Americans were current (past-month) users of methamphetamine (0.2 percent of the population). Of the 157,000 people who used methamphetamine for the first time in 2007, the mean age at first use was 19.1 years, which is down from the mean age of 22.2 in 2006 (National Survey on Drug Use and Health). However, the number of individuals aged 12 years or older reporting past-year methamphetamine use declined from 1.9 million in 2006 to 1.3 million in 2007.

Inhalant Use

Although inhalants are not often perceived as a substance of misuse or abuse yet, this is an increasingly common risky behavior affecting your patients. The NIDA-funded 2010 Monitoring the Future Study showed that 8.1% of 8th graders, 5.7% of 10th graders, and 3.6% of 12th graders had abused inhalants at least once in the year prior to being surveyed.

Tobacco Use

Finally, according to the CDC’s State Tobacco Activities Tracking and Evaluation (STATE) system report, in 2008, 26.1% of Indiana residents used tobacco which was second in prevalence only to West Virginia, at 26.6%. In 2008, nearly 71 million Americans age 12 and older had used a tobacco product at least once in the month prior to being surveyed (National Survey on Drug Use and Health). Such tobacco use is linked to increased morbidity and mortality.

Prevalence and Possibilities

Substance use is a problem, one that is prevalent and growing, and that affects many of our patients, even in the absence of an obviously related primary complaint. This prevalence is troubling but it also represents an opportunity for health care providers. SBIRT is a tool set to assist in taking advantage of this opportunity. And, SBIRT can help us reduce the likelihood that substance use will lead to serious adverse personal and health consequences. Those consequences are diverse, pervasive, sometimes subtle, and are the subject of our next section of this module.


Consequences of Substance Use, Misuse, and Abuse

Substance use is a highly significant cause of preventable death in the United States. Substance abuse and misuse are responsible for a large number of annual deaths. As illustrated in the table below, in 2000, tobacco use was responsible for 435,000 deaths, alcohol consumption for 85,000, and illicit drug use 17,000. This does not take into account the many non-fatal physical, personal, and social consequences of use, misuse, and abuse of substances.

Preventable Death

Medical Consequences of Substance Use and Abuse

High Risk Drinking Effects handout
High Risk Drinking & the Body (PDF)

In addition to death, substance misuse and abuse can lead to a wide variety of negative personal consequences for our patients, including physiological effects and interpersonal ones.

Considering alcohol alone, the statistics are grim. Approximately 5,000 individuals under the age of 21 die annually from injuries related to alcohol use. Of these, about 1,900 individuals died from motor vehicle accidents, 1,600 from homicide, and 300 from suicide. In fact, in 2000, individuals from 12 to 17 years old who reported past-year alcohol use (19.6%) were more than twice as likely as youths who did not (8.6%) to be at risk for suicide during this time period. And of all children under age 14 killed in vehicle crashes in 2006, 23% were killed in alcohol-related crashes. U.S. high school students who frequently binge drink are at higher risk of physical and sexual assault, multiple types of non-fatal injuries including motor vehicle accidents and engaging in risky sexual behavior.
But these numbers only tell a small part of the story. Alcohol and other substance use have numerous short and long-term consequences for the mental, physical, and social well-being of the adolescent. For example, among adolescents who drink alcohol, 38-62% report having had problems related to their drinking, such as interference with work, emotional /psychological health problems, development of tolerance, and inability to reduce frequency and quantity of use.

Fetal consequences of maternal substance use

Substance

Fetal consequence

Alcohol Microcephaly; growth deficiency; CNS dysfunction, including mental retardation and behavioral abnormalities; craniofacial abnormalities (ie, short palpebral fissures, hypoplastic philtrum, flattened maxilla); behavioral abnormalities; abortiona, still birth
Cannabis Reduction of 0.8 weeks in length of gestation, corresponding decrease in birth weight; subtle behavioral alterations, impaired executive functioninga, ventricular septal defecta
CNS sedatives (barbiturates, benzodiazepines, meprobamate, methaqualone) Cleft palatea; depression of interactive behavior; neonatal withdrawal
CNS stimulants (amphetamines, cocaine, methylphenidate, phenmetrazine) Abortiona; excess activity in utero; congenital anomalies (heart, biliary atresia); depression of interactive behavior; urinary tract defects; symmetric growth restriction; placental abruption; cerebral infarction; brain lesions; cranial defectsa; fetal death; neonatal necrotizing enterocolitis; shortened labor
Hallucinogens (LSD, ketamine, mescaline, PCP) Chromosomal breakagea (LSD); dysmorphic face; Lysergic acid behavioral problems; possible increase in spontaneous abortions
Inhalants Similar to the fetal alcohol and fetal hydantoin syndromesa; growth restriction; preterm labor; increased risk of leukemia in children; impaired heme synthesis
Narcotics Absent birth defect syndrome; intrauterine withdrawal with increased fetal activity; depressed breathing movements; preterm delivery; preterm rupture of the membranes; fetal growth restriction; meconium stained amniotic fluid; perinatal mortality; neonatal abstinence syndrome; sudden infant deatha
Tobacco Reduced birthweight (200 g lighter); preterm birth; placenta previa, placental abruption; reduced risk of pre-eclampsia; spontaneous abortiona

a Conflicting reports in human literature
Adapted from Rayburn WF. Maternal and Fetal Effects from Substance Use. Clinics in Perinatology. 34(2007):559–571.

Effects of substance use on female reproductive system

Alcohol consumption during adolescence is known to affect growth, body composition and the menstrual cycle. Even moderate alcohol intake has been shown to depress estrogen levels for up to 2 weeks in adolescent girls aged 12 to 18.
Menstruating women with moderate to high alcohol intake are known to have a variety of menstrual and reproductive disorders, from irregular menstrual cycles to complete cessation of menses, absence of ovulation (i.e., anovulation), and infertility. Among women with infrequent, non-binge pattern alcohol, pituitary LH secretion can be affected resulting in temporary anovulatory states.
In the post-menopausal period, alcohol intake among individuals taking hormone replacement therapy (HRT) may cause abnormal fluctuations in estradiol levels that are not observed among women not using HRT who drink alcohol. Acute alcohol exposure in these women can cause a temporary increase in estradiol while chronic alcohol exposure may cause lower levels. This may have implications for use, risks
Source: Emanuele MA, Wezeman F., and Emanuele NV.  Alcohol’s Effects on Female Reproductive Function. Alcohol Research & Health. 2002. 26(4):274-281.

Hazardous alcohol consumption, for example, can affect practically every aspect of a person’s health and well being, as illustrated in this poster courtesy of the Academic Edge, Inc.

Moreover, although specific detrimental effects of substance use vary by substance type, level of use, and individual patient factors, in general, it can affect all body systems. The table below captures a few of these effects.

Physiological Consequences of Substance Use

Substance Alternate Names Forms Selected Medical Consequences
Anabolic steroids pumpers, stackers, weight trainers oral, injectable hepatic tumors, HTN, male hypogonadism, gynecomastia, infertility, hirsuitism, amenorrhea, premature skeletal maturation and accelerated puberty in adolescents, irritability, psychosis
Alcohol Beer, wine, liquor, malt liquor oral gastritis, peptic ulcer disease, pancreatitis, chronic diarrhea, steatohepatitis, hepatitis, cholestasis, portal HTN, cirrhosis, arrhythmia, cardiomyopathy, HTN, CVA, malnutrition, cytopenias, menstrual irregularities, gestational/neonatal complications (fetal alcohol spectrum disorders, miscarriage, low birth weight, preterm birth, placental abruption, intracranial hemorrhage), withdrawal syndrome,   cerebral degeneration, encephalopathy, polyneuropathy, myopathy, traumatic injuries
GHB G, liquid ecstasy, soap oral, injectable somnolence, coma, death due to CNS depression, cognitive impairment, hallucination, seizure, headache, amnesia
Cocaine base, blanca, blow, coke, crack, flake, rock Powder can be snorted or liquefied and injected IV; hydrochloride form (crack) is smoked sudden death, HTN, arrythmia, myocardial ischemia/infarction, headache, CVA (ischemic and hemorrhagic), cerebral vasculitis, pulmonary hypersensitivity (“crack lung”), pulmonary edema, pneumothorax, pneumonia, rhabdomyolysis, intestinal ischemia, gestational/neonatal complications (low birth weight, preterm birth, placental abruption, microcephaly), gingival ulceration/erosion of enamel, increased risk of contracting HIV/hepatitis C/other STDs
Heroin dope, H, horse, smack snorted, injected, smoked vomiting, constipation, somnolence, death due to CNS depression, cognitive impairment, venous sclerosis, bacteremia, septic or inorganic (from additives often found in street heroin) emboli to various organs, increased risk of contracting HIV/hepatitis B&C/other STDs/pneumonia/TB, immune-mediated arthritis
Inhalants whippets, poppers, snappers inhaling chemical vapors nausea, vomiting, somnolence, unconsciousness, death, disinhibition, dizziness, agitation, confusion, seizure, delirium, ataxia, headache, flushing, vasodilation, tachycardia,  hepatic failure, renal failure
Ketamine special K, vitamin K,  jet oral, injectable dissociative anesthesia, hallucination, impaired memory, anxiety, delirium, HTN, rhabdomyolysis
Lysergic acid diethylamide (LSD) acid, blotter, pane oral, topical ocular use hallucination, delusion, mood changes, pupillary dilatation, increased temp/BP/pulse
Marijuana blunt, ganga, grass, joint, MJ, pot, weed smoked memory impairment, cognitive impairment, motor incoordination, tachycardia, anxiety, bronchogenic carcinoma
Methylene
dioxymeth
amphetamine (MDMA)
ecstasy, love drug, X, XTC oral nausea, vomiting, anorexia, anxiety, depression, impulsivity, hyperthermia, HTN, rhabdomyolysis
Methamphetamine cystal, glass, ice, meth, speed oral, injectable, snorted, smoked anorexia, psychosis, insomnia, anxiety, seizure, irritability/aggression, hallucination, myocardial infarction, CVA
Phencyclidine (PCP) angel dust, ozone, rocket fuel, wack oral, snorted, smoked nausea, vomiting, blurred vision, agitation, violent behavior, psychosis, seizure, coma, death
Rohypnol roofies, circles, forget me drug oral, snorted amnesia, disinhibition, somnolence, ataxia
Tobacco smoked, “chewed” or “dipped” by placing in oral cavity for absorbtion by oral mucosa COPD; cancer of the head, neck, lungs, esophagus, bladder, cervix, pancreas, kidneys; gestational/neonatal complications (low birth weight, miscarriage, SIDS, increased risk of child being addicted to nicotine in future if that child starts smoking)

The important thing to remember is not which substances affect which systems,  although understanding such a relationship can suggest when a particular patient’s symptomology may in fact be related to substance use, but rather than substance use has a pervasive effect on our patients’ health and that by screening each and every patient on a regular basis we can do our part in reducing these negative outcomes.

Many substances, particularly alcohol, are related to or exacerbate mood disorders. For example, girls ages 12 to 16 who are current drinkers are four times more likely than their nondrinking peers to suffer from depression.

Social Consequences of Substance Use and Abuse

isolation
Beyond physiological effects, the social costs of substance use and abuse can be very serious as well.

  • Personal Relationships
    • Increasing isolation from non-using individuals
    • Strongest connection is with drug of choice
    • Connections with friends and family become secondary or cease altogether
    • Loss of social support can cause vicious cycle, furthering isolation
  • Financial
    • Cost of substance use affects personal and/or family
    • Lack of professional growth
    • Loss of income/job
    • Costs of consequences of use, including arrest
  • Family
    • Loss of spouse/significant other
    • Loss of dependent or adult children
    • Loss of child custody
  • Legal
    • Direct consequences of drug use such as possession of illegal substances, driving under the influence of substance use, etc.
  • Personal Relationships
    • Increasing isolation from non-using individuals
    • Strongest connection is with drug of choice
    • Connections with friends and family become secondary or cease altogether
    • Loss of social support can cause vicious cycle, furthering isolation
  • Financial
    • Cost of substance use affects personal and/or family
    • Loss of income/job
    • Costs of consequences of use, including arrest
  • Academic
    • Penalties issued from school including expulsion
    • Poor performance in school that may lead to failure to progress/graduate
  • Legal
    • Direct consequences of drug use such as possession of illegal substances, driving under the influence of substance use, etc.

Adolescent Use, College Abuse and Consequences

For those of you who are involved in the care of older adolescents and young adults, let’s consider the spectrum of problems associated with risky drinking during the college years.

Alcohol abuse and dependence 31% college students met criteria for alcohol abuse and 6% for alcohol dependence in past 12 mos, by self-reports
Law enforcement involvement ~ 5 % of 4-year college students are involved with police as a result of drinking
Drunk driving 3,360,000 students (18-24yo) drive under the influence
Vandalism ~11% college student drinkers damaged property under the influence
Health problems >150,000 students develop alcohol-related health problems
Academic problems ~ 25% college students report academic consequences of drinking
Risky sex behavior : >100,000 students (18-24yo) report being too intoxicated to know if they consented to sex
Sexual assault 97,000 students (18-24yo) are victims of alcohol-related sexual assault
Non-sexual assault 696,000 students (18-24yo) are assaulted by intoxicated student
Injury 599,000 students (18-24yo) are unintentionally injured under the influence
Suicide attempt 1.2-1.5% tried to commit suicide within past year due to drinking or drug use
Death 1,825 U.S. college students (18-24yo) die from alcohol-related unintentional injuries, including MVA’s

Big Problems. What to do?

Substance misuse and abuse are prevalent and lead to significant personal and societal consequences. But small steps that all providers can easily take with each and every one of their patients can lead to earlier detection of problems, increased effectiveness of treatment, and reduction in long term prevalence and sequalae. The question is, how?


SBIRT Can Help

Moving Toward a Potential Solution

There is no panacea for substance use, misuse, and abuse, but there is an emerging technique called Screening, Brief Intervention and Referral to Treatment (SBIRT) that has proven to be effective in many cases. Not only has it been shown to be effective, it is efficient in terms of time and effort expended!

What is SBIRT?

An Early Intervention Approach

The SBIRT Initiative represents a paradigm shift in the provision of treatment for substance use and abuse. The services are different from, but designed to work in concert with, specialized or traditional treatment.

New Target Population

SBIRT flowchart

The primary focus of specialized treatment has been persons with more severe substance use or those who have met the criteria for a Substance Use Disorder. The SBIRT Initiative targets those with non-dependent substance use and provides effective strategies for intervening with these individuals while also including procedures for referring those who need more extensive or specialized treatment.

SBIRT addresses those relatively small but frequent problems that are related to alcohol and other drug use, and in addition, allows for opportunistic identification and referral of patients who may have a clinical alcohol or drug use disorder.

With SBIRT, providers can address myriad relatively small problems early and rapidly (e.g. insomnia, stomache ache, drug interactions, etc.) and prevent another set of problems from occurring (i.e. injury, infection, etc.). Even though these problems are relatively small compared to alcoholism (i.e. liver disease, esophagel varices, Wernicke-Korsakoff syndrome, etc.), there are so many more of them and collectively they affect a wider range of our patients and, in the long run, may contribute a much larger cost to our health care system. SBIRT allows you to systematically address these smaller substance use problems with each and every one of your patients while it also enables you to identify patients with more significant substance misuse and abuse issues. Its a win-win for you and your patients.

SBIRTSBIRT consists of three key components, the S, BI, and RT:

  • Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
  • Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
  • Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care.

SBIRT has been shown to be effective in multiple settings and is endorsed by numerous organizations and government agencies, including the USDHHS Substance Abuse and Mental Health Services Administration. In this course, evidence and procedures for each of the three major SBIRT components are discussed in their own learning modules after a brief module on substance abuse basics.


Summary

  • Unsafe patterns of tobacco, alcohol and other substance use are very common
  • Substance use is associated with myriad personal adverse health and social effects
  • Substance use prevalence and effects among our patients represent an important opportunity
  • SBIRT: Screening, Brief Intervention, and Referral to Treatment helps us capitalize on this opportunity
  • SBIRT addresses the often overlooked middle of the substance use pyramid while also identifying those at greater risk
  • SBIRT is an efficient and cost effective approach to identify and address one of the most common problems you will see in your practice: substance use, misuse, and abuse
  • SBIRT is effective and easy to use in any practice setting

Learning Objectives

julie suggested moving this to front. I am not sold but we could remove it or make it a linked piece. adding this as note to revisit

This web-based course is designed to promote your knowledge of and understanding related to the following learning objectives.

By the end of this course, you should be able to…

  • Understand the extent of the problem of substance use in the United States.
  • Identify the key components of SBIRT.
  • Understand and describe the necessary steps involved in proper screening, brief intervention, and referral to treatment process.
  • Understand and explain how SBIRT services are integrated into the clinic setting.
  • Understand how SBIRT can be incorporated into clinical sessions in a quick (little time required) manner.
  • Understand and explain why it is important to identify and address alcohol/drug use during the clinical session.
  • Understand how to use the Audit-C screening tool.
  • Understand and relate appropriate levels of brief intervention to level of alcohol use risk.
  • Describe and provide a brief intervention for substance use in a primary care clinic setting.
  • Describe and provide a referral to treatment for substance use in a primary care clinic setting.
  • Describe the value of SBIRT to patients in terms of rate of abstaining from a substance or reducing alcohol use to recommended levels in response and the resulting health benefits.
  • Explain one or more different ways how SBIRT can be implemented in his/her practice.

By the end of this course, you should be able to…

  • Understand the extent of the problem of substance use among adolescents in the United States.
  • Understand the stages of substance use from potential for use to addiction in adolescents and adults.
  • Understand the medical and social consequences of adolescent substance.
  • Identify the key components of SBIRT.
  • Describe the value of SBIRT to patients in terms of rate of abstaining from a substance or reducing alcohol use to recommended levels in response and the resulting health benefits.
  • Understand and describe the necessary steps involved in proper screening, brief intervention, and referral to treatment process.
  • Understand and explain how SBIRT services are integrated into the clinic setting.
  • Understand and explain why it is important to identify and address alcohol/drug use during the clinical session.
  • Understand how to use the CRAFFT screening tool within the context of an adolescent interview.
  • Understand and relate appropriate levels of brief intervention to level of alcohol use risk.
  • Understand and describe an approach to anticipatory guidance regarding risky behavior in adolescents.
  • Describe and provide a referral to treatment for substance use in a primary care clinic setting.
  • Understand the extent of the problem of substance use among adults, adolescents and pregnant women in the United States.
  • Understand the stages of substance use from potential for use to addiction in adolescents and adults.
  • Understand the medical and social consequences of substance use for the pregnant and non-pregnant adult or adolescent.
  • Identify the key components of SBIRT.
  • Understand and describe the necessary steps involved in proper screening, brief intervention, and referral to treatment process.
  • Describe the value of SBIRT to patients in terms of rate of abstaining from a substance or reducing alcohol use to recommended levels in response and the resulting health benefits.
  • Identify differences in substance use terminology and choose appropriate terms for use on counseling.
  • Understand and explain how SBIRT services are integrated into the clinic setting.
  • Understand how SBIRT can be incorporated into clinical sessions in a quick (little time required) manner.
  • Understand and explain why it is important to identify and address alcohol/drug use during the clinical session.
  • Understand how to use the Audit-C screening tool with adult patients.
  • Understand how to use the CRAFFT questionnaire with adolescent patients.
  • Understand how to use the TWEAK & T-ACE screening tools within the context of an obstetric interview.
  • Understand and describe an approach to anticipatory guidance regarding risky behavior in adolescents.
  • Understand and relate appropriate levels of brief intervention to level of alcohol use risk.
  • Describe and provide a referral to treatment for substance use in a primary care clinic setting.

Introduction

Substance use, misuse, and abuse terminology can be complex, so can the idea of use limits, and even what constitutes a drink. This module introduces basic clinical terminology, drinking limits, and the standard drink.Substance-use-word-collage

Stages of Adolescent Substance Abuse

Potential for substance use and abuse

Several behavioral and environmental risk factors have been identified that increase the risk of substance abuse in the adolescent years. Individuals characteristics associated with childhood or adolescent substance use include decreased impulse control, the need for immediate gratification, and the need for peer acceptance. Parental use and/or abuse of alcohol, tobacco and other drugs is one environmental risk earlier in life. In the adolescent years, peer substance use and the availability of tobacco, drugs, alcohol, inhalants are additional risk factors for substance use and abuse.

Experimentation: learning the euphoria

Prevalence of Lifetime Alcohol Dependence by Age of Onset of DrinkingPeer influence plays a significant role in the decision if and when to experiment with tobacco, alcohol and other drugs including marijuana and inhalants. At this point in the adolescent substance use spectrum, few, if any, consequences of use exist. This, in addition to the “high” associated with the early stages of use may serve to reinforce the use behavior. Occasional, episodic use may increase to regular weekend use. There may be little apparent behavior change from the point of view of parents or other family members, teachers and health care providers.

Age at onset of use may play a role in future substance use disorders. For example, of those individuals who began drinking before age 14, 47% became dependent at some point, compared with 9% of those who began drinking at age 21 or older.

Regular substance use: seeking the euphoria

This stage may be marked by the use of other new drugs, eg, stimulants, lysergic acid diethylamide (LSD), or sedatives. At this stage, behavioral changes may be noted by parents and family or teachers and counselors, including:

  • Changes in friends
  • Negative changes in schoolwork, missing school, or declining grades
  • Increased secrecy about possessions or activities
  • Use of incense, room deodorant, or perfume to hide smoke or chemical odors
  • Subtle changes in conversations with friends, e.g. more secretive, using “coded” language
  • Change in clothing choices: new fascination with clothes that highlight drug use
  • Increase in borrowing money
  • Evidence of drug paraphernalia such as pipes, rolling papers, etc.
  • Evidence of use of inhalant products (such as hairspray, nail polish, correction fluid, common household products); Rags and paper bags are sometimes used as accessories
  • Bottles of eye drops, which may be used to mask bloodshot eyes or dilated pupils
  • New use of mouthwash or breath mints to cover up the smell of alcohol
  • Missing prescription drugs—especially narcotics and mood stabilizers

Some consequences may be incurred by the adolescent at this point including punitive consequences from family/legal or school system as a result of substance use or trauma as a result of intoxication. The adolescent may increase the frequency of use or use alone and engage in buying or stealing drugs.

Regular substance use: preoccupation with the “high”

At this stage, the adolescent engages in the daily use of drugs. He or she may perceive a loss of control over their substance use.  Multiple consequences of the substance use are occurring which may not deter use. An increase in risk-taking behavior may increase including risky sexual behavior and driving under the influence of substances. The adolescent often experiences estrangement from family and “straight” friends.

Burnout: use of drugs to feel normal

The adolescent may engage in the use of multiple substances and may be dependent or addicted to more than one substance. Feelings of guilt, alienation, shame, remorse, and depressed mood are common in the adolescent at this stage. Physical and mental deterioration are also often seen and can manifest as withdrawal from organized sports, exercise intolerance, insomnia, poor memory, poor concentration, apathy and/or mood lability. Continued risk-taking behavior, self-destructive behavior, and/or suicidal behavior may mark this stage of adolescent substance use.


Substance Use Terminology

Before we talk about screening and intervening for substance use, there are some related terms that you should consider: dependence, tolerance, and addiction.

If you think that these terms are difficult to pin down, well, they are, and we should all remember that our patients likely struggle with them as well. Many patients see all these terms as being the same. Other patients may bristle at certain terms such as “addiction” and just hearing this word may shut down further open dialogue. So let’s begin by defining these terms for our own clarification before we use them with our patients.

The following definitions are drawn from DSM-IV, NIAAA and NIDA.

Use

  • Any use of tobacco, alcohol or other substance

Physiologic tolerance

  • Decrease in susceptibility to the effects of a drug due to its continued administration
  • Physiologic phenomenon not under control of patient

Physiologic dependence

  • Refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction
  • Physiologic phenomenon not under control of patient

Substance abuse

  • Excessive use of a substance
  • No universally accepted definition

Addiction

  • Addiction is a persistent, compulsive dependence on a behavior or substance
  • The term has been partially replaced by the word dependence
  • The term addiction can be offputting to patients, sometimes shutting down conversation.

Alcohol Use Terminology

These terms are used in concert with the previous terms but are used exclusively when discussing alcohol.

Low-risk Use

  • Drinking that is within legal and medical guidelines and is not likely to result in alcohol-related problems

Hazardous Drinking  (“At-risk”)

  • Pattern of substance use carrying with it a risk of harmful consequences to the drinker
  • Consequences may include physical or mental health problems or social consequences
  • Hazardous drinking may present as binge drinking or dependence

Alcohol Use Disorders

  • Abuse or dependence

Binge Drinking

  • Drinking 4-5 drinks in a short period of time (e.g. a few hours)

Alcohol Use Disorder

The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) no longer distinguishes between abuse and dependence. Instead the term “Substance Use Disorder”is used to outline a cluster of cognitive, behavioral and physiological symptoms experienced by an individual who continues using the substance in spite of significant consequences related to substance use.

Specifically, Alcohol Use Disorder is characterized by a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Alcohol is often taken in larger amounts or over a longer period than was intended
  • There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
  • A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects
  • Craving, or a strong desire or urge to use alcohol
  • Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school or home
  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol
  • Important social, occupational or recreational activities are given up or reduced because of alcohol use
  • Recurrent alcohol use in situations in which it is physically hazardous
  • Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
  • Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
    • A markedly diminished effect with continued use of the same amount of alcohol
  • Withdrawal, as manifested by either of the following:
    • The characteristic withdrawal syndrome for alcohol
    • Alcohol (or closely related substance, such as a benzodiazepine) is taken to relieve or avoid alcohol withdrawal symptoms

Changes to the DSM-V

In 2010, the new DSM-V was released and several changes were made regarding the definitions of substance use disorders. The Substance-Related Disorders Work Group has been responsible for addressing these disorders. Among the work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions. The work group had extensive discussions on the use of the word “addiction.”  There was general agreement that “dependence” as a label for compulsive, out-of-control drug use has been problematic. It has been confusing to physicians and has resulted in patients with normal tolerance and withdrawal being labeled as “addicts.” This has also resulted in patients suffering from severe pain having adequate doses of opioids withheld because of fear of producing “addiction.” Accordingly, the word “dependence” is now limited to physiological dependence, which is a normal response to repeated doses of many medications including beta-blockers, antidepressants, opioids, anti-anxiety agents and other drugs. The presence of tolerance and withdrawal symptoms are not counted as symptoms to be counted for the diagnosis of substance use disorder when occurring in the context of appropriate medical treatment with prescribed medications.

Words: The Bottom Line

discussionRemember, the important thing about these definitions isn’t so much that you memorize them, but rather that you and your patient (and colleagues) communicate clearly and effective using terminology of which you share a common understanding. Without that common understanding, we may misunderstand our patients, they may misunderstand us, they may answer our questions incorrectly–”No, I’m not addicted.”–because they key into the word and not into their behavior.

Moreover, certain terms, like addiction can be counterproductive to your relationship with your patient. So it is best to avoid using it unless you have already established a pattern of behavior and level of comfort with your patient.


Substance use “limits” and their implications for health

Low-Risk Drinking Limits

Low-Risk Drinking Limits

According to epidemiologic research, men who drink more than 4 standard drinks in a day (or more than 14 per week) and women who drink more than 3 in a day (or more than 7 per week) are at increased risk for alcohol-related problems. Individual responses to alcohol vary, however. Drinking at lower levels may be problematic depending on many factors, such as age, coexisting conditions, and use of medication. Because it isn’t known whether any amount of alcohol is safe during pregnancy, the Surgeon General urges abstinence for women who are or may become pregnant. An illustration that can be used to explain these limits to patients is provided courtesy of Academic Edge, Inc.

There are no defined low-risk drinking limits for children, adolescents, or women who are or may be pregnant.
gender

Gender and Drinking Limits

  1. Research shows that women are at an increased risk when drinking above low-risk limits and develop other health problems at lower drinking levels than men because:
    • Alcohol disperses in body water and women have less water in their bodies than men do.
    • If a man and woman of the same weight drink the same amount of alcohol the woman’s blood alcohol concentration will tend to be higher putting her at greater risk for harm.
  2. Alcohol may produce different end-organ damage in women than in men (in areas such as breast tissue).

When is “Low-Risk” Drinking Still too Much?

Although “Low-Risk” establishes a general threshold above which it is increasingly dangerous to consume alcohol, it functions more as a guideline than as a hard and fast rule; there are several situations for which it is safest to avoid alcohol altogether:

  • Taking medications that interact with alcohol
  • Managing a medical condition that can be made worse by drinking such as uncontrolled diabetes, high blood pressure, and other chronic illnesses
  • Underage
  • Planning to drive a vehicle or operate machinery
  • Pregnant or trying to become pregnant

What About Other Substance Use?

other drugsIt is important to remember that the concept of “low-risk” use is currently limited to alcohol consumption.

There is little research to support “safe” or “low-risk” limits on other substances such as tobacco, marijuana or other drugs (that are used non-medically).

For substances other than alcohol, therefore, clinicians cannot provide advice that indicates a certain level of non-medical use is no risk or even low risk. Our patients may seek re-affirmation that their ‘minimal’ recreational use of a ‘safe’ drug is okay, but providers cannot, of course, provide this validation. Instead, we can turn to motivational interviewing strategies, which will be discussed later, to help the patient explore their use and ways they might cut back or abstain altogether.


What is a Standard Drink?

One component of the ability to effectively address substance use and abuse is the ability to communicate clearly with a patient about his or her behavior.

In many cases, a patient may not know what constitutes a “drink” of alcohol. For example, a “mixed drink” may contain 3 or 4 standard drinks of alcohol.

It is important to quantify substance use if possible. Similar to asking how many cigarettes a patient smokes, you should ascertain how many drinks a patient has per day and per week. You need to start by having a common definition of what a “drink” is. A handout, provided here with permission of Academic Edge, Inc., may help your patients better understand drink sizes.

Some other common alcohol drink sizes are listed in the graphic below.

Standard Drink table


Summary: Substance Use Terminology

  • Substance use terminology is important to define precisely for patients to prevent misconceptions. If we are not using words the same way, we are likely to miscommunicate!
  • Data exists that define relative low-risk alcohol consumption limits
  • Little data exist to define low-risk use of other substances
  • There is a ‘standard drink’ and patients often badly estimate the size of a ‘drink’

There are materials to help us explain limits and standard drinks to patients. These can make our patient interactions more accurate and effective as we screen, briefly intervene, and refer to treatment.


Introduction to Screening

screening-instrument-slantedIn general, screening is the examination of a group of usually asymptomatic people to detect those with a high probability of having a given disease, typically by means of an inexpensive diagnostic test or simply some straightforward questions. Screening does not establish definitive information about diagnosis and possible treatment needs.

Screening for substance use is a quick, simple way to identify risky and harmful use of substances and respond in an appropriate and effective manner. In some relatively rare instances, screening may lead the physician to refer the patient for further assessment or treatment.

One goal of SBIRT is, therefore, to establish substance use screening as a part of usual care in order to identify patient issues that would not otherwise be noticed or would not be detected until much further along.

There are many validated tools that can be used to assist you to screen patients. These will be introduced in this module. In fact, you can screen a patient with as few as two, or even one, question.

Remember that how you ask these questions is as important as the screening tool you choose.

 


Why Screen?

question-mark

The majority of patients express concern that their health care provider is neither involved with their substance abuse- or addiction-related issues nor capable of detecting addiction or substance use issues when they are present.

In particular:

  • 54.8 percent of patients believed that physicians do not know how to detect addictions
  • 53.7 percent of patients said their primary care physician did nothing about their substance abuse
  • 74.1 percent of patients said their primary care physician was not involved in their decision to seek treatment

These numbers are a cause for concern and patients’ perceptions are not entirely unfounded nor do they fail to represent physicians’ own perceptions of their involvement with patents’ substance use.

  • 94 percent of primary care physicians missed or misdiagnosed alcohol-abusing patients
  • 88 percent of physicians said they asked new outpatients whether they drank alcohol, but only 13 percent used a formal alcohol screening tool
  • Only 19.9 percent of primary care physicians considered themselves “very prepared” to identify “alcoholism”

answerThe answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening tools are validated, quantifiable, and reproducible. They provide us key data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances.

In turn, the processes enabled by the use of screening–the repeated asking and tracking of standardized substance use questions and answers–should, over time, address both patients’ and physicians’ perceptions about physicians’ ability to detect or identify substance use, misuse, abuse, or addiction.

In short, where these statistics suggest a problem, a gap in our performance, the regular and systematic use of screening tools with each and every one of our patients represents a means of scientifically closing that gap while simultaneously offering the possible of improve patient outcomes.

question-markThe majority of patients express concern that their health care provider is neither involved with their substance abuse- or addiction-related issues nor capable of detecting addiction or substance use issues when they are present.  In particular:

  • 54.8 percent of patients believed that physicians do not know how to detect addictions
  • 53.7 percent of patients said their primary care physician did nothing about their substance abuse
  • 74.1 percent of patients said their primary care physician was not involved in their decision to seek treatment

These numbers are a cause for concern and patients’ perceptions are not entirely unfounded nor do they fail to represent physicians’ own perceptions of their involvement with patents’ substance use.

  • 94 percent of primary care physicians missed or misdiagnosed alcohol-abusing patients
  • 88 percent of physicians said they asked new outpatients whether they drank alcohol, but only 13 percent used a formal alcohol screening tool
  • Only 19.9 percent of primary care physicians considered themselves “very prepared” to identify “alcoholism”

answerThe answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening tools are validated, quantifiable, and reproducible. They provide us key data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances.

In turn, the processes enabled by the use of screening–the repeated asking and tracking of standardized substance use questions and answers–should, over time, address both patients’ and physicians’ perceptions about physicians’ ability to detect or identify substance use, misuse, abuse, or addiction.

In short, where these statistics suggest a problem, a gap in our performance, the regular and systematic use of screening tools with each and every one of our patients represents a means of scientifically closing that gap while simultaneously offering the possible of improve patient outcomes.

question-markWhy screen for substance use? Screening for a variety of disorders is common in pediatric practice. In the case of substance use, screening can actually open up discussions that reveal more than just usage history and patterns. Let’s look further at some of the reasons for routine substance use screening of pre-adolescents and adolescents.

We Routinely Screen for Common Conditions

When you think about screening, what disorders come to mind? The purpose of screening is to detect common diseases and disorders in the populations we care for. As it turns out, substance use disorders are among our most common conditions in any patient age category. Data from the National Institute on Drug Abuse’s 36th annual Monitoring the Future Survey revealed that in 2010, 48% of U.S. 12th graders surveyed had reported at use in their lifetime of at least one illicit substance. Of those, nearly half had used in the past month (23.8% of respondents).

The consequences of early alcohol and drug use can be far-reaching. Substance use before age 18 has been associated with an eightfold greater likelihood of developing substance dependence in adulthood. Adults who began to use alcohol before age 15 are five times more likely to report previous-year alcohol dependence or abuse than those who began alcohol use at age 21 or older.

answerSo given the frequency of adolescent alcohol and drug use and the potential for significant future adverse health outcomes, it makes sense to screen just from a “numbers” standpoint.

Patients Want a Chance to Talk

Part of the difficulty in screening for substance use among adolescents comes from a sensitivity regarding patient privacy and a desire to establish trust. It may be difficult or impossible to discuss these issues in front of a parent or ask to interview the patient alone. However, studies do show that patients do not mind being asked about their substance use. In some cases, patients genuinely want to discuss these issues with their primary care physician. A survey of adolescent females in the U.S. revealed that though only 35 percent of adolescents reported discussing substance use with their primary care physicians, 65 percent of the sample said they wanted to.

Screening Tools Are A Reliable, Efficient Way to Identify Problems

Have you ever been shocked to learn a patient was using an illicit substance? It turns out that, as physicians, we do a terrible job of judging a book by its cover. Physical signs, mode of speech, dress and manner provide very poor clues about which patients are engaging in risky substance use behaviors, particularly in the experimental and early regular use phases of adolescent substance use.

Screening tools are validated, quantifiable, and reproducible. The adolescent population has been well-studied in terms of what screening tools do and don’t “work.” These screening tools have been shown to provide us reliable data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances. Plus, they only take a few minutes to administer by healthcare personnel. Some screening tools have been validated for self-administration, allowing for even greater time efficiency.

Screening can lead to prevention

Screening can open the subject of substance use with the adolescent patient. A negative result on a screening test can provide an opportunity for the pediatrician to focus on the individual’s beliefs about and experience with substance use in their lives.

For adolescents, a complex interplay of individual, family, peer, school and community characteristics can put them at greater risk of beginning or continuing substance use. Within all these “domains” of influence also lie factors, which can prevent the individual from engaging in experimental or regular substance use. The grid below outlines the relationship between the risk and protective factors that the pediatrician can use to tip the balance in the favor of safe behaviors.

The table below is adapted from Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse (Kulig, JW, Pediatrics2005;115;816-821) and outlines the interplay of these factors within the domains of influence. The pediatrician can use this knowledge to leverage their influence upon protective factors in the adolescent’s life.

Domain Risk Factor Protective Factor
Individual Early initiation of substance use Late initiation of substance use
Attitude favorable to substance use Perceived risk of substance use
Low self-esteem or poor coping skills Positive sense of self, assertiveness, social competence
Attention-deficit/hyperactivity disorder Pharmacotherapy for attention-deficit/hyperactivity disorder
Sensation seeking, impulsivity, distractibility Resilient temperament
Low intensity of religious beliefs and observance High intensity of religious beliefs and observance
Rebelliousness and alienation from the dominant values of society and conventional norms Positive social orientation, adoption of conventional norms about substance use
Family Permissive or authoritarian parenting Authoritative parenting, parental monitoring of activities
Parental and older sibling use of alcohol, tobacco, or other drugs Clearly communicated parental expectation of nonuse and clear rules of conduct consistently enforced
Family history of alcoholism Parent in recovery
High levels of family conflict Positive, supportive relationships with family
Parental divorce during adolescence Open communication with parents
Child abuse and neglect or sexual abuse Supportive relationships with pro-social adults
Peers Friends who drink, smoke, or use other drugs Friends not engaged in substance use
School Perceived peer drug use Peer disapproval of substance use
Poor academic achievement and school failure Good academic achievement and school success
Low interest in school and achievement High academic aspirations
Community Disorganization in the community or neighborhood Less acculturation and higher ethnic identification
Availability of tobacco and alcohol Increased legal smoking and drinking ages
Marketing of tobacco and alcohol Increased excise taxes on tobacco and alcohol
Availability of licit and illicit drugs Strict law enforcement
Sociocultural Media portrayal of substance use Media literacy
Advertising licit substances Comprehensive, theory-based antidrug education programs

Don’t Miss Opportunities to Open the Door!

The answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

 

question-markWhy screen for substance use? Screening for a variety of disorders is common in pediatric practice. In the case of substance use, screening can actually open up discussions that reveal more than just usage history and patterns. Let’s look further at some of the reasons for routine substance use screening of pre-adolescents and adolescents.

We Routinely Screen for Common Conditions

When you think about screening, what disorders come to mind? The purpose of screening is to detect common diseases and disorders in the populations we care for. As it turns out, substance use disorders are among our most common conditions in any patient age category. Data from the National Institute on Drug Abuse’s 36th annual Monitoring the Future Survey revealed that in 2010, 48% of U.S. 12th graders surveyed had reported at use in their lifetime of at least one illicit substance. Of those, nearly half had used in the past month (23.8% of respondents).

The consequences of early alcohol and drug use can be far-reaching. Substance use before age 18 has been associated with an eightfold greater likelihood of developing substance dependence in adulthood. Adults who began to use alcohol before age 15 are five times more likely to report previous-year alcohol dependence or abuse than those who began alcohol use at age 21 or older.

answerSo given the frequency of adolescent alcohol and drug use and the potential for significant future adverse health outcomes, it makes sense to screen just from a “numbers” standpoint.

Patients Want a Chance to Talk

Part of the difficulty in screening for substance use among adolescents comes from a sensitivity regarding patient privacy and a desire to establish trust. It may be difficult or impossible to discuss these issues in front of a parent or ask to interview the patient alone. However, studies do show that patients do not mind being asked about their substance use. In some cases, patients genuinely want to discuss these issues with their primary care physician. A survey of adolescent females in the U.S. revealed that though only 35 percent of adolescents reported discussing substance use with their primary care physicians, 65 percent of the sample said they wanted to.

Screening Tools Are A Reliable, Efficient Way to Identify Problems

Have you ever been shocked to learn a patient was using an illicit substance? It turns out that, as physicians, we do a terrible job of judging a book by its cover. Physical signs, mode of speech, dress and manner provide very poor clues about which patients are engaging in risky substance use behaviors, particularly in the experimental and early regular use phases of adolescent substance use.

Screening tools are validated, quantifiable, and reproducible. The adolescent population has been well-studied in terms of what screening tools do and don’t “work.” These screening tools have been shown to provide us reliable data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances. Plus, they only take a few minutes to administer by healthcare personnel. Some screening tools have been validated for self-administration, allowing for even greater time efficiency.

Screening can lead to prevention

Screening can open the subject of substance use with the adolescent patient. A negative result on a screening test can provide an opportunity for the pediatrician to focus on the individual’s beliefs about and experience with substance use in their lives.

For adolescents, a complex interplay of individual, family, peer, school and community characteristics can put them at greater risk of beginning or continuing substance use. Within all these “domains” of influence also lie factors, which can prevent the individual from engaging in experimental or regular substance use. The grid below outlines the relationship between the risk and protective factors that the pediatrician can use to tip the balance in the favor of safe behaviors.

The table below is adapted from Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse (Kulig, JW, Pediatrics2005;115;816-821) and outlines the interplay of these factors within the domains of influence. The pediatrician can use this knowledge to leverage their influence upon protective factors in the adolescent’s life.

Domain Risk Factor Protective Factor
Individual Early initiation of substance use Late initiation of substance use
Attitude favorable to substance use Perceived risk of substance use
Low self-esteem or poor coping skills Positive sense of self, assertiveness, social competence
Attention-deficit/hyperactivity disorder Pharmacotherapy for attention-deficit/hyperactivity disorder
Sensation seeking, impulsivity, distractibility Resilient temperament
Low intensity of religious beliefs and observance High intensity of religious beliefs and observance
Rebelliousness and alienation from the dominant values of society and conventional norms Positive social orientation, adoption of conventional norms about substance use
Family Permissive or authoritarian parenting Authoritative parenting, parental monitoring of activities
Parental and older sibling use of alcohol, tobacco, or other drugs Clearly communicated parental expectation of nonuse and clear rules of conduct consistently enforced
Family history of alcoholism Parent in recovery
High levels of family conflict Positive, supportive relationships with family
Parental divorce during adolescence Open communication with parents
Child abuse and neglect or sexual abuse Supportive relationships with pro-social adults
Peers Friends who drink, smoke, or use other drugs Friends not engaged in substance use
School Perceived peer drug use Peer disapproval of substance use
Poor academic achievement and school failure Good academic achievement and school success
Low interest in school and achievement High academic aspirations
Community Disorganization in the community or neighborhood Less acculturation and higher ethnic identification
Availability of tobacco and alcohol Increased legal smoking and drinking ages
Marketing of tobacco and alcohol Increased excise taxes on tobacco and alcohol
Availability of licit and illicit drugs Strict law enforcement
Sociocultural Media portrayal of substance use Media literacy
Advertising licit substances Comprehensive, theory-based antidrug education programs

Don’t Miss Opportunities to Open the Door!

The answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening can help identify those at risk, and screening takes very little time. For alcohol, for example, 25% of the population will score an 8 or above on the AUDIT, a brief screening tool for alcohol use and abuse.

SBIRT_Drinkers_Pyramid

 


Available Screening Tools

There are a variety of validated screening tools, each of which differs on several dimensions, including:

What is being screened?

  • Are they specific to alcohol use only?
  • Do they cover alcohol and other drugs?

What is the method of administration?

  • Self administered?
  • Administered as part of a clinical interview?

Are they designed for special populations?

  • Pregnant patients?
  • College students?
  • Adolescents?
  • ED Patients?

Screening instruments also vary somewhat in length, from the fairly comprehensive ASSIST, which can take up to 10 minutes to complete, to the very brief, comprised on only a couple initial questions.

Screening Tests at a Glance

While the following table is not comprehensive nor does it cover all potential screening tools, it provides a good summary of test names, type of screening, method(s) of administration, and whether it is designed for a specific special population.

Test What is Being Screened Method of Administration Special Population
AUDIT Alcohol Self or interview No
CAGE Alcohol Interview No
MAST Alcohol Self or interview No
T-ACE Alcohol Interview Women/pregnant women
TWEAK Alcohol Interview Pregnant women
AUDIT-C Alcohol Self or interview No
DAST Drugs (not alcohol) Self No
ASSIST Alcohol, tobacco, illicit drugs Self or Self and Interview No

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and have evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients

Screening Tools for Adolescent Substance Use

As you can see, many tools exist for screening patients but not every tool is effective for screening adolescents. The CRAFFT questionnaire is a simple, brief tool that can be administered via paper or computer or verbally. The tool was developed to screen adolescents 14 years and older for high-risk alcohol and other drug use disorders simultaneously. CRAFFT is a mnemonic acronym of key words in 6 screening questions preceded by opening questions and is administered in 2 stages.

The first stage begins with asking 3 opening questions:

Please answer these questions honestly. 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? (note: “anything else” refers to illegal drugs, over-the-counter or prescription drugs, and things that you sniff or “huff”)

The second stage depends on the answers to the stage one questions:

  • If the answers to all the opening questions are “no,” ask only the CAR question (see below) from CRAFFT
  • If any of the answers are “yes,” proceed with all 6 questions

CRAFFT Questionnaire

  • Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
  • Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  • Do you ever use alcohol or drugs while you are by yourself, or 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?

A score of 2 or more “yes” answers on the actual CRAFFT questions is considered a positive screen and indicates a high risk for substance abuse.

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients.

Screening Tools for Substance Use in Pregnant Patients

As you can see, many tools exist for screening patients but not every tool is effective for screening pregnant patients. The T-ACE and TWEAK screening tools have been validated for the use of screening for alcohol use in pregnant patients.

The T-ACE was the first validated sensitive screen for risky drinking in pregnant women. Interestingly, an obstetrician developed the T-ACE after observing that asking patients about their tolerance to the intoxicating effects of alcohol did not trigger denial.

T-ACE

Tolerance: How many drinks does it take to make you feel high?

Have people Annoyed you by criticizing your drinking?

Have you ever felt you ought to Cut down on your drinking?

Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

One point is given for each affirmative answer to the A, C, or E questions. Two points are given when a pregnant woman reports that more than two drinks are necessary for her to feel “high” or experience the intoxicating effects of alcohol. A score of 2 or more on the T-ACE is considered positive for at-risk alcohol use.

The TWEAK is a validated five-item screening tool for risky alcohol use in pregnant women. Like the T-ACE, it asks a question about tolerance that is weighted higher than the other questions when scoring.

TWEAK

Tolerance: How many drinks can you hold?

Have close friends or relatives Worried or complained about your drinking in the past year?

Eye Opener: Do you sometimes take a drink in the morning when you get up?

Amnesia:Has a friend or family member ever told 
you about things you said or did while you were 
drinking that you could not remember?

K(C): Do you sometimes feel the need to Cut downon your drinking?

The TWEAK is scored on a 7-point scale. On the tolerance question, 2 points are given if a woman reports that she can consume more than five drinks without falling asleep or passing out. A positive response to the worry question yields 2 points, and positive responses to the last three questions yield 1 point each. A score of 2 or more on the TWEAK is considered positive for at-risk alcohol use.

Few validated tools exist for screening pregnant women for illicit drug use. One tool with good sensitivity and specificity for illicit drug use is the 4P Plus.

4P Plus

Parents:     Did either of your have any problems with drugs or alcohol?

Partner:     Does your partner have any problem with drugs or alcohol?

Is your partner’s temper ever a problem for you?

Past:                   Have you ever drunk beer/wine/liquor?

Pregnancy:         In the month before you knew you were pregnant, how many cigarettes did you smoke?

In the month before you knew you were pregnant, how much beer/wine/liquor did you drink?

Plus:          In the month before you knew you were pregnant, how much marijuana did you use?

Depending on the answers to these questions, a woman is categorized by her predicted risk status. In one of the original studies of this tool by Chasnoff et al, those women who had never used alcohol were considered low risk because they had only a 1.4% risk of using tobacco, alcohol or drugs during their pregnancy. Those women who had used alcohol in the past but not in the month before pregnancy and did not smoke >3 cigarettes in the month before pregnancy were considered average risk (9% of these were found to be using alcohol or drugs during their pregnancy). Lastly, those women who used any alcohol or smoked >3 cigarettes in the month before pregnancy were considered high-risk (34% of these were found to be using alcohol or drugs during their pregnancy).

Any positive answers to the Pregnancy or Plus questions requires further assessment regarding how often and what kind of substances were and are currently used. If no current use, no referral is needed. Educational interventions and substance abuse treatment is reserved for regular use of alcohol or illicit drugs.

Which screening tool you use will be in part dependent on personal preference, experiences, and the nature of the environment in which you practice. Most of the above screening tools have been extensively validated and evidence supporting their efficacy. The important thing: choose a screening method and use it with all of your patients. It will become second nature both to you and, importantly, to your patients.

Chan AK et al. The TWEAK test in screening for alcoholism/ heavy drinking in three populations. Alcoholism: Clinical and Experimental Research 6: 1188 1192, 1993.

Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, et al. The 4P’s Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol 2005;25:368–74.

Sokol RJ, Martier SS and Ager SS. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 160: 863 871, 1989.

 

The screening process follows the same steps regardless of the instrument; in other words, the instrument is the tool that is used in the process, not the process itself. Read More»


Setting the Stage for Screening

For many of your patients, you will be the first one to ask them about substance use.

consultation

This may come as a shock to them and cause some initial or ongoing discomfort for them. There are steps that you can minimize the discomfort and maximize the trust between you so that the answers you get are more open and honest.

Physical setting

The discussion involving alcohol and drug use should be held in a private setting and without parents present. Having reading material regarding substance use and abuse on display and at the ready for distribution may be helpful in augmenting or reinforcing your message.

confidentialityConfidentiality

The adolescent patient should be reassured that your discussion is private. Let the patient know that, unless you have concerns about serious health risks or problems, you will not reveal the details of your conversation to parents or family members without the patient’s permission.

assessing-factors

Assessing risk factors for substance use or abuse

Inquiring about individual risk factors for adolescent substance use and abuse can help frame your brief intervention after screening takes place. This information may be helpful in determining what preventive or treatment strategies you employ.

Ask questions about self-esteem, family relationships, academic performance and sports and other organized or leisure activities. It is also helpful to learn about other health risk behaviors such as tobacco use or risky sexual activity.

bringing-upBringing up the topic of substance use

One of the most important aspects of beginning and continuing a discussion about substance use is the tone that you use. By introducing the topic in a non-judgmental way, you may be able to diffuse some of the emotional charge that can commonly accompany these discussions. Opening up with some statements such as “I know that some kids your age use alcohol, or smoke, or

use other drugs.” You can follow this with offering a reason for discussing their habits, letting them know that you are concerned with their overall health and those things that can affect it.

severityAssessing problem severity

Of course, the purpose of the screening tool is to efficiently and accurately identify those patients who require more intervention. So the next step after you screen involves a conversation to help you gauge the severity of the problem.  Specific follow-up questions can help get you more information to target your intervention appropriately. Ask about:

  • Drinking frequency – “Do you drink regularly? About how often?”
  • Drinking quantity –  “How much did you drink the last time you got drunk? How much to do usually drink?”
  • Drug use frequency – “About how often do you use drugs?
  • Setting of alcohol or drug use – “Where do you drink/take drugs? Parties only? With friends in cars? Home? School? By yourself at home? At school?”
  • Dependence – “Do your social activities usually involve alcohol/drugs? What would happen if you couldn’t have any alcohol/drugs?”
  • Social consequences – “What kinds of trouble have you gotten into because of alcohol/drugs? Do your parents suspect that you drink or take drugs?”

consult-endNow that you have successfully opened the discussion and completed brief screening and assessment, you are ready to give your patient some feedback. In the next module, we will discuss strategies for brief interventions that are targeted toward prevention and treatment. Even if all you do is reinforce good behavior, your words can make a difference.


Summary: Screening

A number of substance use screening instruments have been developed, and the use of instruments may vary based on state or local regulations, reimbursement policies, or personal preference.

Screening often is a 2-step process:

  1. ask a couple short questions to determine whether a patient is potentially using various substances
  2. use more targeted and longer screening tools to better explore the identified substance use areas

A screen should be simple enough that it can be administered quickly and to patients with a range of literacy levels. It should focus on the substance use severity (primarily consumption patterns) and a core group of associated factors such as legal problems, mental health status, educational functioning, and living situation.

The patient’s awareness of the problem, feelings about his or her substance use, and motivation for changing behavior may also be solicited.

The Bottom Line

In the end, is a patient using a substance? If so, how much and how often? Beyond these basic screening questions, we turn to examining the impact of use. What, how often, to what effect? That’s the bottom line when screening for substance use.


Brief Interventions: An Introduction

A brief intervention is a short interaction with a patient that targets small cognitive and/or behavioral changes.

Brief interventions can be done in a single session or there may be several across multiple sessions. BIs are patient-centered and target motivating a patient toward behavioral change through non-judgmental, open-ended questioning.

Common Elements of Brief Interventions

There are several components that are common to most brief interventions:

  • Focus on substance use and related problems, specifically patients with problematic or at-risk use.
  • Can be done in a minimal amount of time (ranging from 5–15 minutes in length).
  • Are NOT intended to treat those who may have a substance use disorder diagnosis
  • Do not take the place of specialized addiction treatment but can be used to encourage those with more serious substance use problems to accept specialized assessment or treatment..

Specifically brief interventions focus on motivating patients to adopt healthier behaviors by

  • Helping the patient to perceive his/her use as putting him/her at risk for negative health and social consequences by presenting factual information in a non-judgmental manner.
  • Exploring variables in the patient’s life which reinforce the unhealthy behavior and identify variables which may promote positive change.
  • Eliciting specific beneficial behavior changes acceptable to the patient. By asking the patient for suggestions for what they would be willing to try and what steps they might take to reduce their use or to otherwise address the identified problem, they will be more likely to adopt those changes.
  • Agreeing upon a follow-up plan. Getting a patient to “say yes” and agree to next steps is a key component of getting them to actually take those steps.

patient consultationIn the end, brief interventions are as much about how you interact with your patients as they are about what you interact about. The overarching approach is to provide information, encouragement, and support in a non-judgmental, clear, and supportive manner.

Asking questions, understanding the patients’ perspective (in large part so they come to understand it better themselves as well!), and acting as a guide is more conducive to a BI approach than directive and authoritarian approaches (“Do this and  you will be much better off” simply is not effective with behavioral change).

With BI, we acknowledge patient autonomy/responsibility in making positive changes and we build a partnership in working toward healthier behaviors.

 


Why BI? Because Brief Interventions Work!

Brief interventions (BI) have been shown to be efficient and effective. They do not take a lot of time, they are easy to do for the provider, and they help patients. The patient-centered techniques integrated in brief interventions foster behavioral change.

The medical and health literature has increasingly provided quantitative and qualitative evidence that brief interventions are a best practice approach to intervening with patients who report problematic substance use.

For example…

  • Baer et al found that a single session of feedback and advice compared favorably to a more intensive intervention in reducing alcohol-related risks among heavy drinking college students
  • Marlatt et a reported that a motivational interviewing approach resulted in reduction in both drinking rates and harmful consequences, when applied in a sample of high-risk college students.
  • Borsari and Carey found that college-aged drinkers who received a brief intervention exhibited a notable reduction on number of drinks consumed per week, number of times drinking alcohol in the past month, and frequency of binge drinking in the past month, and that students were willing and interested to participate in the study.
  • Wagner et al studied the effectiveness of a school-based intervention among 14 to 18-year olds, and found that 10% of students’ substance use stopped completely, 33% “decreased a lot,” and 42% “decreased a little.”

There is evidence for the efficacy of brief interventions in a variety of settings including the outpatient clinic. Because of the scope of the problem and the effectiveness of these interventions, the American Academy of Pediatrics recommends the use of brief intervention techniques in the clinical setting. They further advocate that pediatricians be familiar with motivational interviewing techniques to work with patients who use alcohol but do not meet criteria for immediate referral.

Some of these studies include (probably more than you want to know!):

Efficacy of Brief Interventions in Primary Care to Reduce Risky and Harmful Alcohol Use

Objectives/Methods

  • To inform clinical guidelines of the U.S. Preventive Services Task Force (USPSTF) about brief behavioral counseling interventions.
  • Systematic review of 12 controlled trials on the efficacy of brief interventions

Result

  • Those receiving brief multi-contact interventions (initial session up to 15 minutes and at least 1 follow-up) reduced their average weekly alcohol intake by 13%–34% more than controls in 4 of 7 trials
  • 10%–19% more intervention participants than controls drank safe amounts.

Screening in Brief Intervention Trials Targeting Excessive Drinkers in General Practice: Systematic Review and Meta-Analysis

Objectives/Methods

  • To examine the efficiency of screening and efficacy of subsequent brief intervention (BI) for risky drinkers.
  • Systematic review and meta-analysis of 8 randomized clinical trials that used screening as a precursor to BI for risky drinkers.

Results

  • 9% screened drank risky amounts; 3% received BI.
  • Pooled absolute risk reduction= 10.5% (from 69% of patients drinking risky amounts to 57%).
  • 10 risky drinkers need BI to yield 1 patient no longer drinking risky amounts.
  • Screening 1000 patients and giving BI to 1/3 of patients with positive screens (the average in the studies reviewed) would yield 2 –3 patients no longer drinking risky amounts.
Intervention group* Control group* Absolute risk reduction # needed to treat
600/1410 (43%) 432/1374 (31%) 10.5 (7.1 to 13.9) 10 (7 to 14)

Are Brief Alcohol Interventions Likely to Be Effective in Routine Primary Care Practice?

Objectives/Methods

  • To determine whether brief interventions (BI) decrease consumption in nondependent drinkers with unhealthy alcohol use in a range of research designs, investigators reviewed 22 randomized trials of BI including over 5800 patients.
  • Trials were classified on a spectrum from tightly controlled (efficacy design) to real world (effectiveness design).

Results

  • Participants who received BI drank 38 g of alcohol (approximately 3 standard drinks) per week less than those who did not.
  • Longer duration of intervention was not significantly associated with a larger effect.
  • The effect of BI on drinking was similar in studies, regardless of whether they were considered efficacy or effectiveness designs.
  • The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings
  • The USPSTF found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality, and good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer.

Brief Intervention in Action

SOC FRAMES MIAlthough the brief intervention component of SBIRT can often be the most difficult to implement in practice. This partly because it hinges on your ability to connect with your patient interpersonally, to communicate clearly and effectively with him or her, and to establish a rapport that can lead to personal reflection and behavioral change.

Change can be difficult for some patient to achieve, maybe even consider. Understanding that there exist “stages” of readiness for change can help you identify where your patient is in relation to changing their behavior. For those patients who are ready for change or are actively involved in changing behavior, little intervention beyond advices and goal-setting may be necessary.

But for those patients who are resistant to change, it can be helpful to use principles from Motivational Interviewing to help your patient explore and resolve ambivalence to facilitate change. So what does exploring ambivalence when talking to patients even mean, and how do you do it? Luckily, there are many practical patient communication tools and techniques that help you translate these principles into practice. One of these tools is the FRAMES technique which is covered in an upcoming section.


Stages of Change Model

SOCWe want patients to change their behavior. Do they want to change? Do they know they should? Do they even know that changing the behavior is an option? Have they tried changing and failed (or succeeded)? You can imagine how a patient might react differently to the need to change based on their answers to those questions.

A theoretical model, called the Stages of Change model captures this notion that not all of our patients come to a behavioral change from the same location. The model is illustrated in the graphic below. Similar change models have more steps, some have fewer.

The important thing is the underlying question: what experience has my patient had with trying to make this particular behavioral change? That is, at what stage are they?

Stages of Change

The premise is that individuals are typically at a specific stage of change, and that each stage of change suggests different approaches: someone who has never considered a problem may be amenable to simple information provision, for example, whereas someone who has tried to change and failed may need different support. Finally, someone who doesn’t recognize the need to change at all requires a different approach too. By understanding these stages and by identifying which stage our individual patients are at we can better help them change their behavior.

The table below lists each of the 5 steps, the associated definition, and the brief intervention element associated with that stage. The brief intervention process, as you will read in the “Brief Intervention Elements” section, suggests movement through the stages of change.

Stages of Change and Recommended BI Elements


Precontemplation

Patient is not considering change in the near future and may or may not know the potential health consequences of continued use at this level

Recommended Brief Intervention Elements

  • Feedback about the results of the screening
  • Information about the hazards of substance use/abuse

Contemplation

Patient may be aware of alcohol-related consequences but is ambivalent about changing

Recommended Brief Intervention Elements

  • Emphasize the benefits of changing
  • Give Information about substance use problems, the risks of delaying change and discuss how to choose a Goal

Preparation

Patient has already decided to change and plans to take action

Recommended Brief Intervention Elements

  • Discuss how to choose a Goal
  • Give Advice and Encouragement

Action

Patient has begun to cut down or stop use; however, change has not become a permanent feature.

Recommended Brief Intervention Elements

  • Review Advice
  • Continue to provide Encouragement

The Bottom Line: Identifying a patient’s stage of change helps us tailor our brief interventions so they are more efficient and effective for that particular patient.


A word about MI

Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence.

MI

Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the health professional is intentionally directive in pursuing this goal.

What is MI?

Motivational interviewing (MI) refers to a counseling approach in part developed by clinical psychologists William R Miller, Ph.D. and Stephen Rollnick, Ph.D. It is a patient-centered, semi-directive method of engaging intrinsic motivation to change behavior by developing discrepancy and exploring and resolving ambivalence within the patient.

Motivational interviewing recognizes and accepts the fact that patients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior. Remember our Stages of Change? Some patients may never have thought of changing certain behaviors and others may have thought about it but never attempted to change it. Finally, some patients may be actively trying to change their behavior and may have been doing so unsuccessfully for years.

Motivational interviewing is a non-judgmental, non-confrontational and non-adversarial approach in working with patients. The approach attempts to increase the patient’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, motivational interviewing trained health professionals help patients think about a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help patients think differently about their behavior and to ultimately consider what might be gained through change.

How are MI and SBIRT related?

SBIRT MI venn diagramMotivational Interviewing is a way of interacting with our patients. It is essentially an approach to communicating with, understanding, and attempting to change the behavior of our patients. As such, principles and strategies of MI can influence all aspects of our patient-provider interactions.

SBIRT, on the other hand, is a process for identifying and immediately addressing substance use among our patients. You will likely find yourself using the MI approach throughout your efforts to implement SBIRT in your practice.

Put another way: MI is a skill and SBIRT is a process for which that skill is an important component. Stage of change is a way to think about patients and it yields a piece of data (their stage!) you incorporate when using motivational interviewing as part of SBIRT. These get used primarily in the BI (Brief Intervention) step–when trying to change behavior–but can also be important when trying to get solid, honest, accurate information from patients (‘S’) and when getting them to accept and act upon a referral to more specialized treatment (‘RT’).

MI Core Principles

Motivational interviewing is considered to be both patient-centered and semi-directive. Motivational interviewing is based upon four general principles:

1. Express empathy
2. Develop discrepancy
3. Roll with resistance
4. Support self-efficacy

Motivation interviewing is not an approach to use with every patient that you come into contact with; however, it is a tool that can be used often. Three important goals in motivation interviewing are to build a rapport with the patient, elicit change talk, and establish a commitment.

Got the motivational interviewing approach down? Let’s look at approaches that put MI into practice….


FRAMES

FRAMES

The more specific components of a brief intervention can be summarized by the acronym FRAMES. The following process is intended to guide you through the FRAMES model step by step, addressing each component in association with its “letter.”

FRAMES FFeedback

Provide constructive, non-confrontational feedback about a patient’s degree and type of substance use based on information from structured and objective assessments.

    • Acknowledge the patient’s risky behavior.
    • Review the results of screening instrument (e.g. AUDIT/ASSIST).
    • Discuss personal risks associated with current substance use patterns.
    • Provide general information about substance related risks and harms.
    • Link the patient’s presenting complaint to his/her substance use (when applicable).
    • Compare patient’s substance use patterns and problems to similar people in the population.

FRAMES RResponsibility

Allow the patient to have an active rather than a passive role in changing his/her behavior and taking responsibility for changing.

Enable the patient to retain personal control over his/her behavior and its consequences:

    • Ask for permission to talk about substance use, “I’d like to talk about…, would you be willing…?”.
    • Do not impose personal views or goals on patient: be open and non-judgmental.
    • Acknowledge that the patient is responsible for his/her own behavior and for making choices regarding their substance use.
    • Re-state/re-affirm the patient’s choice of continuing or changing the behavior (e.g. “So, you’ve decided to X, is that right?”).

FRAMES AAdvice

Share knowledge about substance use consequences in a gentle and respectful manner to encourage positive behavioral change.

    • Listen to what type of information the patient is requesting and willing to receive.
    • Advice should be simple, not overwhelming, and matched to the patient’s level of understanding and readiness, the urgency of the situation, and his/her culture.
    • Provide educational (explaining information) or directive (giving suggestions) advice appropriately – by asking permission to do so.
    • Increase awareness of personal risks by reviewing the medical, psychological, and social harms associated with continued use.

FRAMES MMenu of Options

Work with the patient to generate a range of alternative strategies to cut down or stop their substance use.

    • Reinforce the patient’s control and responsibility.
    • Elicit what has and has not worked for the patient in the past.
    • Provide accurate information about each option.
    • Discuss possible implications of choosing one particular path.
    • Help the patient create a plan using one or more options.
    • Provide supporting materials relative to the patient’s decision.

FRAMES EEmpathy

Exercise a warm, respectful, caring, committed, and active interest throughout the brief intervention session.

    • Use reflective listening and listen attentively to each statement and reflect it back in different words so the patient knows you understand the meaning.
    • Use open-ended questions.
    • Create a safe environment that encourages free flow of information from the patient.
    • Let the conversation unfold rather than direct it or interrupt it.

FRAMES SSelf-efficacy (self confidence for change)

Eliciting self-efficacy statements from patients allows them to believe what they hear themselves say and ultimately provides confidence that they will be able to make changes in their substance use behavior.

    • Believe in your patient’s ability to change.
    • Foster hope and optimism by reinforcing the patient’s beliefs in their own capacities and capabilities.
    • Identify patient strengths to build upon past successes.
    • Affirm small steps that are taken and reinforce any positive changes.

FRAMES Revisited

The FRAMES bottom line: The best way to enable our patients to change their behavior is to allow them to play a role in determining what the change is and how it will be accomplished. This “buy-in,” coupled with your support that they can in fact implement the change, regardless of how big or small a change they choose, is often the difference between a successful substance use brief intervention and an unsuccessful one.


Go with the FLO

FLO

In addition to FRAMES, you may encounter FLO. This is another way to remember the basic steps and strategies behind motivational interviewing. Which one you use, if either, is a matter of personal and professional preference.

  • Feedback
  • Listen
  • Options explored
  • No W(arnings)!

FLO F
Feedback

Set the stage

It is best to have the parent out of the room then set the agenda with patient while being collaborative.

An example: “I’d like to talk with you about what brought you to the ER, is that OK? As I do with all the young people I see, I’ll ask you a number of questions about different parts of your life, including school, friends, and activities you’re involved in.”

Goal: Acquires permission, explains why you are there, normalizes interview.

Segue to Questioning

Begin with some open ended questions to enable your patient to begin to open up on their own, if they are willing, prior to you presenting the results of the screening.

  • “What are you most concerned about?”
  • “What do you think is important to discuss?”
  • “What are your concerns?”

Follow up on any answers and summarize what you have heard so that you can be sure that you and the patient have a shared understanding.

Share the results

Substance use may have come up in the previous open questions. If so, then you have a natural segue to screening results. If not, then you will need to provide one and then share the results.

For example: “Do you remember the questions I asked you about substance use?  That test was given to thousands of teens across the US. Scores can range from 0 to 6. You scored a 3 which is much higher than other youth your age. What do you think of that?”

From that point forward, you role is primarily to provide feedback based on how he or she responds. You are likely to encounter resistence, something like:

  • “I don’t have a drinking problem.”
  • “Everyone I know gets high as often as I do.”
  • “I can quit whenever I want.”

This is natural, and how you respond can be extremely important. You are not trying to prove to them they have a problem and any attempt to directly do so will usually simply lead to more resistance and defensiveness. Some response starters could include:

  • “I’m not here to convince you you’re an alcoholic…I’d simply like to discuss the situation…”
  • “I’d just like to give you some information…”
  • “I’d really like to hear your thoughts about . . .”

If there is an injury involved, or some physiological signs of misuse/abuse, then you can use those as a entryway into further discussion: “What role do you think alcohol played in your injury?” or “How do you think alcohol (or other substances) may be affecting your body? (life, etc)?”

In the end, you have to let go at this point of trying to change the patient’s behavior and focus primarily on getting him or her to be willing to talk to you about your concerns, and, for that, you will have to listen, show them that you are listening, and truly empathize with them, that is, understand them.


FLO L
Listen (and understand!)

They won’t buy what you are selling if they think you aren’t paying attention to what they are saying.

Ambivalence is very normal as a dialogue ensues.

Start with positives of remaining the same

  • “What do you like/ the upside about (current behavior)?  What would you miss if you did not (current behavior)?”

Explore the negatives of remaining the same

  • “What’s not so good/the downside of (current behavior) for you?”

Listen for change talk

  • “Maybe drinking did play a role in what happened.”
  • “It’s not that fun anymore.”
  • “I know I can quit because I have quit before.”

Summarize pros and cons of changing behavior for them and ask for an active affirmative of agreement on the summary, and reinforce change talk when you hear it, and highlight reasons for change, then, when you sense that the discussion is on a positive note that you can capitalize on, ask for an rating:

  • “On a scale of 1 – 10, how important is it for you to change your drinking?”
    • “Why didn’t you give it a higher number?”
    • “Why didn’t you give it a lower number?”

Recap of Listen (and understand)

  • Summarize
  • Acknowledge ambivalence
  • Summarize Pro and Con
  • Summarize importance/confidence
  • Highlight reasons for change
  • Seek a rating of change

FLO O
Options explored

Assuming the patient has indicated some desire to change, then we need to support them in making a change, even if that change may be to continue to think about changing. To do this, we start with open-ended questions again, just as in feedback. We do this to provide the patient with the opportunity to generate their own possible options and plans for changing their behavior, which is far more likely to lead to actual change than if we set forth options and a plan for them initially.

  • “What do you think you will do?”
  • “What changes are you thinking about making?”
  • “What do you see as your options?”

Although they may respond in myriad ways, the things patients say will likely boil down to only a handful of options, a “menu”:

  • Manage drinking (cut down)
  • Eliminate drinking (quit)
  • Never drink and drive (risk reduction)
  • Seek help (refer to treatment)
  • Utterly nothing (no change)

And your role becomes that of an advisor trying to help them develop and commit to plans and actions to make their menu choices happen.

  • “If you wanted to change. . .”
  • “If the time were right . . .”
  • “How would you do it?”

While doing that, there are a few important strategies to remember:

  • Ask permission
    • “Would it be OK if I shared my concerns with you?”
  • Remain patient-centered
    • Help identify options and elicit commitments from patients without telling what to do
  • Allow for disagreement
    • “This may or may not be helpful to you but I’ve found that its useful for many people in situations that seem similar to yours.”
  • Elicit their reaction
    • “I understand you to be saying that…. What do you think?”
    • “Something that might be helpful would be to… What do you think?”

Abstinence/Harm Reduction

Abstinence vs Harm ReductionHelping patients is not always about getting them to STOP what they are doing.

Sometimes it is just as important to help our patients take smaller steps that reduce the harm they may be causing.

That is, although in certain circumstances we may want the patient to stop using a substance, including alcohol, altogether, this may not be a reasonable goal. In fact, sometimes attempting to get a patient to become abstinent can drive them away from getting the help they need. Starting with harm reduction and moving toward abstinence can be a great way to  help your patient. Remember, if you can get them to say yes to some small behavior, you are well on your way to larger changes.

Your Patient and The Boiling Frog

frogIn a way, your patient is exactly like the opposite of the old story of the frog in boiling water. If you toss the frog into already boiling water, he’ll jump out. If you put him in water and slowly warm him up, he will stay right there. Our patients are often already in boiling water and they don’t even know it. We want to pull them out but they may jump right back in. However, if we slowly help them turn the water down, by taking small steps to reduce the harm they may be doing to themselves and others, then they may hop right on out of that boiling water on their own and with your help.

Generate Options: The First Step Need Not Be Abstinence

In generating a menu of options to the patient, recall that not all change goals in the brief intervention process end in abstinence from substance use.  In fact, there are a variety of different types of goals related to harm reduction, including, but certainly not limited to:

  • Cut back on frequency of use;
  • Cut back on quantity of use at each instance of use;
  • Talk to friends/family about options raised by the brief intervention process;
  • Make the decision to avoid driving or other risk behaviors on days when you choose to drink;
  • Drink a full glass of water between each alcoholic drink that you consume.

Summary

When we learn that our patients are using substances, we naturally want to help patients understand and change their substance use in order to reduce our patients risks and improve their health.

SOC FRAMES MI

Those changes may involve stopping use altogether, that is, becoming abstinent, or target smaller changes that are more readily adoptable by our patients, such as moderation or other harm reduction.

Brief interventions are a first step we can take to help patients initiate change in their substance use behaviors.

A good place to start with a brief intervention is to understand the patient’s stage of change: have they thought about changing? Where are they in relation to changing?

With a particular stage of change in mind, we can then use FRAMES to help build a change plan with patient.

Throughout the process, motivational interviewing, or MI, can help us understand, connect with, and foster change among our patients.

MI flowchart


Introduction to Referral to Treatment (RT)

We have presented SBIRT as a best-practice approach to substance use and abuse in the primary care setting; much of the previous content has focused on the SBI components, but there will be situations in which a patient is in need of more substantial treatment than what is offered through the SBI protocol, which in turn leads to the RT (referral to treatment) component of the whole process (SBIRT).

RT really is a BI!

follow up

The referral to treatment component of SBIRT uses the same skills and strategies as the Brief Intervention component. Basically, the only thing that changes is the objective: rather than fostering a harm reduction or abstinence change, we are initiating a change in behavior that involves going to another provider or source of support.

Behavioral change is behavioral change, and supporting a patient to accept and follow through on our referral involves the same strategies.

Stage of Change: Is our patient ready for a referral? That is, regardless of what we may thing, does our patient think he or she needs to go? How can we support this acceptance?

FRAMES: How can we build, with our patient’s help, a plan that increase the liklihood of followthrough?

Motivational Interviewing (MI): And, throughout this process, we can incorporate the objectives and strategies, the overall MI approach to patient-provider interaction, to foster this change: that is, to get them to engage in the referral.

confirmation

RT Patient Follow Through is a Key Indicator of SBIRT

Referral to specialized treatment is provided to those patients who are identified as needing more extensive treatment than offered by the SBIRT program. The effectiveness of the referral to specialty treatment process is a strong measure of SBIRT success and involves a proactive and collaborative effort between SBIRT providers and those providing specialty treatment to ensure access to the appropriate level of care.


The ABCs of Effective Referral to Treatment

When is it Appropriate to Refer a Patient to Treatment?

RT first stepsYou should begin the RT process if:

  • A patient has screened as having the most severe levels of alcohol/drug use and/or has met the DSM diagnostic criteria for substance use disorder.

AND

  • Your patient is agreeable to participating in treatment.

Of course, if your patient meets the first criterion but is not “agreeable” then you should still use your  MI and brief intervention skills to raise the issue and attempt to bring about change in his or her stage of change. Giving your patient something to think about, planting the seed, that is, may be all you can do, but it is an important first step.

Referral to Treatment – Relevant Concepts and Components

  • A Patient diagnosed with SUD should be directly referred for acute treatment or to a SUD treatment program that will asses him/her to determine the appropriate level of care.
  • Such a patient should also be referred for treatment of other mental and physical health problems.
  • Treatment for all conditions should be integrated and coordinated.
  • Successful transitions to and from treatment and between levels of care are supported by active development of a working relationship with your community substance abuse treatment providers.

RT another providerIntroducing the Need for Referral

For patients who appear as though they will require a RT, an introduction to a need for referral can be integrated into the brief intervention component of your interaction.

We suggest the following four steps as means by which you can set the stage for RT.

  • Connect the patients screening results and current office visit to the need for specialized treatment.
  • Set the tone by displaying genuine interest with active listening.
  • Display a non-judgmental demeanor.
  • Explain your role and concern as patient’s healthcare provider.

Remove Referral Barriers

When you are working with a patient to refer him or her to treatment, it is vital that you assist the patient in accessing treatment.

overcome problemsIt is probable that your knowledge-base of treatment options and service providers is more substantial than the patient’s and that sharing this knowledge in order to provide an array of options will greatly facilitate this process.

  • Discuss a range of treatment options .
  • Identify programs and providers by name and have contact information available.
  • Assist the patient in making the first appointment by sitting with them while they make the initial call.
  • Call the insurance company with patient present to determine payment and next steps.
  • Prepare the patient to address insurance and payment for treatment by providing contact information for insurer and for any local authority overseeing access to treatment.

What’s Brief Treatment?

When handling referral to treatment, or ongoing treatment yourself, you may hear about something called “Brief Treatment.” Brief treatment is distinct from SBIRT’s brief interventions (BI) and is not the same as referral to treatment.

Brief treatment is a distinct level of care and is inherently different from both brief intervention and specialist treatment. Brief treatment is provided to those seeking or already engaged in treatment who acknowledge problems related to substance use. Brief treatment in relation to traditional or specialist treatment has increased intensity and is of shorter duration. It consists of a limited number of highly focused and structured clinical sessions with the purpose of eliminating hazardous and/or harmful substance use.

Generally, you will not be expected to determine whether a patient needs brief treatment or traditional specialty treatment. That will be determined by an addiction specialist after the patient receives further assessment.

The RT Nutshell

Will your patient benefit from referral to more specialized care? If so, which care? Will they take advantage of the referral?

In the end, RT is a behavior change: Knowing patient stage of change can help you foster the change, remove barriers, and facilitate the referral. Generating options, choosing from them, jointly developing a plan to implement them, and getting the patient to overtly endorse the plan “Yes, I will…” can make the difference between an referral offer that is accepted and acted upon and one that languishes.


RT Summary

Referral to treatment (RT) is an important part of patient care.

getting helpFacilitating the hand-off of a patient to more specialized care is the same whether the health issue is cardiovascular, dermatological, substance use related, or any number of other health care concerns that we encounter with our patients on a daily basis.

Acceptance and follow through on a referral is an important behavioral change on the part of the patient. He or she must choose to accept the offer of a referral and must be willing to take advantage of the specialized care. This can seem like a burden to patients, involving as it may, stigma, embarrassment, and self-doubt.

Facilitating a referral is the same as any brief intervention: understand the patient perspective, remove barriers, and support acceptance and self-efficacy. MI, FRAMES, and Stage of Change can help.


Course Summary

Substance abuse is prevalent and you can play an important role in reducing your patients’ risks.

By taking the relatively small steps necessary to implement SBIRT in your interactions with each and every one of your patients, each and every time you see them, you can markedly increase the likelihood that you will identify substance use and abuse and be able to do something about it.

A Reminder About Parents

Because Indiana code does not require you to notify parents but allows you to do so, each situation has to be handled on a case by case basis using your clinical judgement. In the end, you do not have to inform parents, but you may do so if, in your opinion, it will benefit the patient or is needed for other reasons such as seeking payment.

The ideal solution: help the patient see the value of involving his or her parent(s), a task well suited to the MI skills discussed in this course.

Are you ready? A quick self-assessment is next »

 


Next Steps

screen some patients

SBIRT is a proven best practice. It is effective. It is efficient. It is acceptable to a wide range of patients and has been implemented in quite diverse healthcare settings.

Future modules will provide more guidance on how to work through each of the SBIRT components, the S, the BI, and the RT, in greater detail.

In the interim, will you take a small step yourself and try to screen several patients even when you don’t think they are at risk? Such screening is simple, short, and painless for your and the patient, yet can make a substantive difference in your patients’ lives.


Thank you for completing this course.


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