Adolescent SBIRT: What, Why, When, and How

1. Adolescent SBIRT: What, Why, When, and How Scott Caldwell October 28, 2008 Teleconference with Wisconsin Initiative to Promote Healthy Lifestyles

2. Adolescent SBIRT: Screening Brief Intervention Referral for Treatment

3. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists

4. BI as a Response Option Primary Prevention Brief Intervention AODA Treatment Abstinence Infrequent use Subclinical use AbuseDependence

5. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services

6. Unmet Adolescent Treatment Need (% of SUDs without any private/public treatment) Only 1 in 20 receive treatment Prevalence 82.4 to 90.1% 90.2 to 92.3% 92.4 to 94.2% 94.3 to 98.0% US Ave.= 92.2% Source: Dennis (2006)

7. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services • Primary care offers an “opportunistic” setting

8. Treatment Referral Sources: WI vs. US 100% 90% WI U.S. 80% 70% 60% 50% Low rate of referrals from health care 40% 30% 20% 10% 0% School Self/Family Other Referral Community Care Provider Other Health System Abuse Criminal Justice Agency Treatment Other Substance Source: Dennis (2006); Treatment Episode Data Set (TEDS) 1993-2003.

9. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services • Primary care offers an “opportunistic” setting • Expands service options

10. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services • Primary care offers an “opportunistic” setting • Expands service options • Low threshold for service engagement

11. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services • Primary care offers an “opportunistic” setting • Expands service options • Low threshold for service engagement • Congruent with aspects of adolescent development

12. How are MI principles consistent with adolescent development? • Express Empathy • Roll with Resistance • Avoid Argumentation • Support Self-efficacy • Develop Discrepancy -- relationship building -- respect for autonomy and individuation -- competency development -- supports planning ahead, anticipating risks

13. Why SBIRT with adolescents? • A large population of “subclinical” AOD users exists • Only 1 in 20 with clinical AOD involvement get services • Primary care offers an “opportunistic” setting • Expands service options • Low threshold for service engagement • Congruent with aspects of adolescent development • It seems to work

14. On-going meta-analysis of adult alcohol treatment outcome • Rank order of treatment efficacy (Cumulative Evidence Score) • Source:Miller & Wilbourne (2002)

15. #1 Brief Intervention #2 Motivational Enhancement + 280 + 173 • What does notwork: • Standard treatment • Confrontational counseling • Education • 130 • 190 • 343

16. Brief Intervention studies with adolescents • Aubrey (1998): AODA treatment * • Monti et al. (1999): hospital ED * • Breslin et al. (2002): 4-session treatment • McCambridge & Strang (2004): school * • Baer et al. (2004): homeless • Spirito et al. (2004): hospital ED * • Knight et al. (2005): primary care • Stein et al. (2006): juvenile detention * • Walker et al. (2006): school * • Monti et al. (2007): hospital ED* • Winters & Leitten (2007): school * • D’Amico et al. (2008): primary care* • Martin & Copeland (2008): community* * Randomized Clinical Trial

17. Summary of the teen BI research: • 1) Small but growing literature • 2) Teen outcomes: • AOD use • AOD consequences • self-efficacy • 2) Abstinence not typical • 3) Effects are rapid and durable • 4) High satisfaction ratings by teens • 5) May promote additional help-seeking

18. Uses of BI • Facilitate referral for AOD services • Bridge time while on waiting list • “Stand alone” approach

19. WIPHL Adolescent Protocol Components: • Screening

20. CRAFFT Questions C Have you ever ridden in a CAR driven by someone (including yourself) who had been using alcohol or drugs? R Do you ever use alcohol or drugs to RELAX, to feel better about yourself, or to fit in? A Do you ever drink alcohol of use drugs while you are by yourself (ALONE)? F Do you ever FORGET things you did while using alcohol or drugs? F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? T Have you ever gotten into TROUBLE while you were using alcohol or drugs? Score 0 - 6

21. CRAFFT: Predictive ValueSource: Knight et al. (2006) Dx Abuse or Dependence CRAFFT score

22. WIPHL Adolescent Protocol Components: • Screening • Opening

23. Hi, my name is _____________ and I am a Health Educator in the clinic here. I’m wondering if it would be okay if I took about 10 minutes of your time to discuss the results of the screen you just completed. Can I first tell you about the purpose of this conversation?I would like to talk with you about your responses on the alcohol/drug screen and find out more about your experiences with alcohol or other drugs. I’m not going to lecture you or tell you what to do about alcohol and drugs; you’re in charge of you and only you can make those decisions. I just want to think with you about your use and how it fits into your life. Would this be okay?

24. WIPHL Adolescent Protocol Components: • Screening • Opening • Explore pros & cons

25. Continuing to drink alcohol

26. WIPHL Adolescent Protocol Components: • Screening • Opening • Explore pros & cons • Explore readiness to change

27. On a scale from 0 to 10, where 0 is not at all ready and 10 is very ready, how ready are you for ______ marijuana use right now?

28. WIPHL Adolescent Protocol Components: • Screening • Opening • Explore pros & cons • Explore readiness to change • Develop change plan

29. WIPHL Adolescent Protocol Components: • Screening • Opening • Explore pros & cons • Explore readiness to change • Develop change plan • Confidence ruler

30. On a scale from 0 to 10, where 0 is not at all confident and 10 is very confident, how confident are you right now that you can meet your goal of ________ ?

31. WIPHL Adolescent Protocol Components: • Screening • Opening • Explore pros & cons • Explore readiness to change • Develop change plan • Confidence ruler • Closing

32. Implementation Considerations: • Parental notification of program • Screening best practices • Confidentiality • Responding to suicidality and other mental health concerns • Clinic capacity and willingness to support referral to treatment recommendation

33. Implementation Copies of the Clinic Guide and Checklist for Adolescent Expansion can be found on our website: www.WIPHL.com in the QI Toolbox under the About Us tab Questions? Contact: Jessica Wipperfurth (implementation) Mia Croyle (clinical protocols)

34. Selected References • D’Amico, E. J., Miles, J. N. V., Stern, S. A., & Meredith, L. S. (2008). Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment, 35, 53-61. • Dennis, M. ( 2006, April). The current renaissance of adolescent treatment. Talk given at Project Fresh Light Partnership Meeting, Madison, WI. Retrieved from: www.chestnut.org/LI/Posters/1-The_Current_Renaissance_of_Adolescent_Treatment_4-17-06.pps • Knight, J. R. (2006, March). Adolescent substance abuse: New strategies for early identification and intervention in primary medical care. Presentation to the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore, MD. • Knight, J. R., Sherritt, L., Shrier, L. A., Harris, & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatric and Adolescent Medicine, 156, 607-614. • Knight, J. R., Sherritt, L., Van Hook, S., Gates, E. C., Levy, S. & Chang, G. (2005). Motivational interviewing for adolescent substance use: A pilot study. Journal of Adolescent Health, 37, 167-169.

35. Selected References (cont.) • Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing • people for change (Second edition). New York: Guilford Press. • Miller, W. R., & Wilbourne, P. L. (2002). Mesa Grande: A methodological • analysis of clinical trials of treatments for alcohol use disorders. Addiction, • 97(3), 265-277. • Monti, P. M., Colby, S. M., & O’Leary, T. A. (Eds.). (2001). Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions. New York: Guilford Press. • O’Leary Tevyaw, T., & Monti, P. M. (2004). Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications, and evaluations. Addiction, 99(Suppl. 2), 63-75. • Stern, S. A., Meredith, L. S., Gholson, J., Gore, P., & D’Amico, E. J. (2007). Project CHAT: A brief motivational substance abuse intervention for teens in primary care. Journal of Substance Abuse Treatment, 32, 153-165. • Winters, K. C. (2005). Expanding treatment options for drug-abusing adolescents using brief intervention. Retrieved from: www.tresearch.org/ resources/specials/2005Jan_AdolescentTx.pdf