Janice Pringle, PhD

1. Screening, Brief Intervention, and Referral To Treatment (SBIRT) for Adolescents With Substance Use and Abuse Janice Pringle, PhD

2. LearningObjectives • Describe substance use disorder (SUD) and screening in adolescents. • Identify and learn to address social, familial, and cultural variables that impact adolescent substance use. • Understand the physiologic, developmental, and behavioral effects of substances commonly used by adolescents. • Recognize the impact, setting, and pattern of use on adolescent substance use. • Identify common co-morbid psychiatric and medical conditions found in the adolescent substance user and the effect of substance use on these disorders. • Learn how to use SBIRT (Screening Brief Intervention and Referral to Treatment) in your position.

3. Substance Use in Adolescence 5% of youth aged 12-17 and 15% of those 18-20 years of age meet DSM-IV criteria for alcohol use disorders. • Kaye, D.L., Current Opinions in Peds. (2004)

4. DSM- IV Abuse vs. Dependence

5. Medical and Psychiatric Harmof High Risk Drinking

6. Harms Associated withSubstance Use in Adolescence • Higher risk for developing a SUD • Involved in three leading causes of death in adolescence • Motor vehicle accidents, homicide, and suicide • School failure/dropout • Involvement in criminal activity • Illness: Human immunodeficiency virus (HIV), Sexually Transmitted Infections (STIs), Hepatitis-C(HEP-C) • Teen pregnancy • Kaye, D.L., Current Opinions in Peds. (2004)

7. Substance Use Changes as Adolescence Age • Johnston et al. Monitoring the Future 1975-2009. 2010; Volume 1

8. Changes Faced in Adolescence • Living arrangements • Educational settings • Work settings • Dating and sexual behavior • Marrying and forming a family • Driving autonomy (obtaining license) • Criminal liability • Financial responsibility Pediatrics. 2008 April; 121(Suppl 4): S290–S310.

9. Normative Behavioral Development Development of self-regulation leads to the: • Ability to control and plan one’s behavior and resist impulses to engage in behavior that results in negative consequences. • Decrease in the likelihood of adolescents engaging in risk-taking behavior, which is considered a social function in the developmental period. • Reduction of disinhibited behavior in childhood and minimizes the likelihood of SUD in adolescence. Pediatrics. 2008 April; 121(Suppl 4): S290–S310.

10. Normative Cognitive Development Executive Function Strategic, supervisory, and self-monitoring aspects of cognition. Decision Making Complex process involved in selecting an action among different options. Working Memory Constellation of interrelated cognitive processes that result in one’s ability to hold temporarily and to manipulate information. Pediatrics. 2008 April; 121(Suppl 4): S290–S310.

11. Normative Social and Emotional Development in Adolescents • Family relationships • Peer relationships • Romantic relationships and sexuality • Emotional changes and mental health problems Pediatrics. 2008 April; 121(Suppl 4): S290–S310.

12. Neurobiological Changes in the Adolescent Brain The brain continues to develop throughout adolescence into young adulthood: • Fine neuro-anatomical changes result in neural signals transmitting more rapidly and permitting greater capacity for more complex, higher-order reasoning, and processing. • Adolescence is a period of continued neuroplasticity which brings with it a period of vulnerability to neuro-toxic processes, including those attributable to heavy alcohol exposure. Pediatrics. 2008 April; 121(Suppl 4): S290–S310.

13. Neurobiological Changes in the Adolescent Brain Dopamine is key! • Disturbed dopamine circuitry in the adult pre-frontal cortex and limbic system potentiates the addiction process. • Normal adolescent development indicates changes in dopamine activity in these key regions. • Dopamine agonists have been shown to help with alcohol-abusing and nicotine-dependent adolescents. Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2).

14. Risk Factor Domains forAdolescent Substance Abuse • Constitutional predisposition • Environmental factors • Life events American Family Physician. 2008 Feb 1;77(3):331-336

15. Risk Factor: Constitutional Predisposition • Genetic risk • Novelty seeking and risk-taking • Aggression • Psychopathology Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2).

16. Risk Factor: Environmental Factors • Studies of twin pairs show significant heritability of tobacco, alcohol, drug, and marijuana use later in life. • Exposure to parental SUDs during adolescence is predictive of development of SUDs. • Substance use before age 18 is associated with an eightfold greater likelihood of developing substance dependence in adulthood. Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2). American Family Physician. 2008 Feb 1;77(3):331-336

17. Risk Factor: Life Events • Self-medicating in an attempt to reduce the emotional toll of trauma. • Exposure to violence or victimization by physical or sexual assault. Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2).

18. AdolescentPsychiatric Co-Morbidities Most adolescents with SUDs have co-morbid psychiatric conditions: • Mood disorders (depression and bipolar) • Anxiety disorders • Conduct disorders (attention-deficit/hyperactivity disorder) Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2).

19. Identify level of risk for hazardous and harmful substance use. Screening Brief Intervention Referral Treatment Provide education and foster motivation to change modifiable risk factors. Connect with recovery support services.

20. Evidence for Using SBIRT in Adolescence • Recommendations to provide SBIRT in adolescents in primary care are based on generalizations from adult research and other care settings. • Several studies have identified several screening instrumentswith sufficient sensitivity and specificity in underage drinkers. Clark, et al. Mayo Clin Proc. April 2010;85(4):380-391

21. Screening for SUD in Adolescents • Use a validated tool. • Self-administered screens (on paper or computer) have been shown to elicit more honest responses. • Careful and complete explanation of screening and subsequent assessment will promote more honest answers. Knight, et al. Arch Pediatr Adolesc Med. 2007;161(11):1035-1041.

22. SBIRT in Job Corps • All students are drug tested upon entry to program. • Those who test positive have 45 days to produce a negative test result. • A Trainee Employee Assistance Program (TEAP) Specialist should use SBIRT. • SBIRT should be used on students who use substances, but do not test positive. • Self-referral • Medical appointment identification/referral

23. SBIRT Components • A standardized screening tool • Feedback • Discussion of negative consequences • Motivation • Behavior change options • Agreed upon behavior change • Follow-up plan http://www.wiphl.com/uploads/media/SBIRT_Manual.pdf

24. Barriers to Screening • Time to conduct screening • Time to manage positive result • Availability of treatment resources • Lack of employee training and familiarity with screening tools S. Van Hook et al. Journal of Adolescent Health 2007;40.

25. Acceptable Adolescent Screening Tools • CRAFFT • Acceptable sensitivity and specificity • Broadened screening focus includes drugs • Easy format which include “yes or no” answers • AUDIT • Studied extensively with good outcomes • Score of 3 found acceptable sensitivity and specificity (vs. score of 8 for adults) • Abbreviated Methods • DSM-IV-TR – 2 item scale • One question frequency in past month • AUDIT-C Clark, et al. Mayo Clin Proc. April 2010;85(4):380-391

26. CRAFFT with Adolescents Through the interview, ask the adolescent these three questions. Drink any alcohol (more than a few sips)? (Do not count sips taken during family or religious events.) 2. Smoke any marijuana or hashish? 3. Use anything else to get high? If response is “No” to use questions, only ask “C” If response is “Yes” to use questions, ask all CRAFFT questions Adolescent SBIRT for Alcohol and Other Drug Use. Using the CRAFFT Screening Tool: Provider Guide Massachusetts Department of Public Health Bureau of Substance Abuse Services (2009)

27. CRAFFT- Scoring • One point for every positive response. • An overall score of two or more points warrants further diagnostic attention. • If screening indicates a high likelihood of an SUD, the interview should progress to a diagnostic evaluation. Gray, et al. Adolescent Medicine Clinics. 2006;Vol 17(2).

28. Addressing Screening Resultsin Adolescence Negative CRAFFT Screen (score of 0 or 1) • Score 0 = Reinforce safe behavior • Score 1 = Encourage through brief advice regarding the adverse health effects of substance use. Positive CRAFFT Screen (score of 2 or greater) • Adolescent is at high risk • Further questioning: “Tell me about your substance use.” “Have you had problems at school, home or with the law?” “Have you ever tried to quit?” • Rule out SUD Adolescent SBIRT for Alcohol and Other Drug Use. Using the CRAFFT Screening Tool: Provider Guide Massachusetts Department of Public Health Bureau of Substance Abuse Services (2009)

29. Definition of Brief Intervention Brief dialogues that assist patients in realizing negative consequences of substance use and attempts to motivate positive behavior change. Edwards et al., 2003

30. Components of a Brief Intervention:The FRAMES Model • Feedback • Responsibility • Advice • Menu of options • Empathy • Self efficacy (confidence for change) Edwards et al., 2003

31. Motivational Interviewing • Express Empathy • Develop Discrepancy • Roll with Resistance • Support Self-Efficacy Arkowitz & Miller, 2008

32. Motivational Interviewing (MI) and the Adolescent and Young Adult • Conducting MI with the adolescent is relatively new and only a few well-designed studies exist. • Of those studies, it is promising that motivational interviewing techniques have been shown to help reduce substance use in general. • There are some unique clinical challenges to MI with adolescents. Miller et.al. Motivational Interviewing, Chapter 21; Baer, et al. Motivation Interviewing with Adolescents and Young Adults.

33. MI and the Adolescent and Young Adult Your ability to influence resistance is less effective if the following exist for the adolescent: • A history of controlling interactions with adults • Previous exposure to exaggerated drug education messages • A sense of invulnerability • Coercion by justice systems • A need to establish identity • The adolescent has progressed to dependence Miller et.al. Motivational Interviewing, Chapter 21; Baer, et al. Motivation Interviewing with Adolescents and Young Adults.

34. Overcoming Resistance • Establish an alliance – this is most important. • Distinguish him/herself from other adults whose messages are more traditional by providing information that is different from the patients previous exposure. • Acknowledge and reflect doubts that the adolescent may have about the motivational interviewing session. • Gently launch into material and feedback with a warm, nonjudgmental tone (more effective than reflecting resistance). • Rapport and alliance will develop when the experience of the interview is different. Miller et.al. Motivational Interviewing, Chapter 21; Baer, et al. Motivation Interviewing with Adolescents and Young Adults.

35. Overcoming Resistance • Consider talking with the patient about their choices, behaviors, and risks rather than referring to the adolescent’s drug use as a “problem.” • Roll with resistance for the adolescent patient who will not communicate (i.e., “I dunno”). • Give structure by describing what is to be expected during the interview; how long it will take; and that you are curious about their thoughts, even if they disagree. • Close-ended questions can help as simple yes-no responses and orient the direction of the discussion. Miller et.al. Motivational Interviewing, Chapter 21; Baer, et al. Motivation Interviewing with Adolescents and Young Adults.

36. When is it Appropriate to Refer to Treatment? Screened as having the most severe levels of alcohol/drug use and/or met the DSM-IV diagnostic criteria. AND If your person is agreeable to participating in treatment.

37. Referral to Treatment in Job Corps • Student has the option of leaving the center on a medical separation with reinstatement rights (MSWR). • Treatment is in the community. • Students that seek treatment and produce a negative drug test within 6 months may return to the program.

38. Levels of Care in SUD Treatment INPATIENT • Medically Monitored Inpatient Detox • Medically Managed Inpatient Detox • Medically Managed Inpatient Residential OUTPATIENT • Outpatient • Intensive Outpatient • Partial Hospitalization • Halfway House • Medically Monitored Residential – Short term • Medically Monitored Residential – Long term • Medically Managed Residential • Methadone Maintenance Clinic • Self-help Groups

39. Case: Tiffany, Part I Tiffany is a healthy, social, and seemingly well-adjusted 16 year-old new student at Job Corps. She tests negative on her entry drug test. Tiffany says she drinks “once in a while” with friends “just like everyone else my age.” She promises never to drink and drive and states that she has never ridden in a car with someone who has been drinking or using drugs, as far as she knows. She has admitted to smoking marijuana once or twice this year. You administer the CRAFFT on Tiffany and she scores a 1 under “R” stating that she sometimes drinks to “fit in.”

40. Case: Tiffany, Part I • Explain the purpose of SUD disorder screening to Tiffany. • Disclose Tiffany’s result and obtain permission to discuss the concern further.

41. Case: Tiffany, Part 2 It’s a year later and Tiffany is now 17 years old. She is preparing to leave center for an advanced culinary training program. Tiffany was referred to TEAP after an alcohol violation. An RA recently caught Tiffany and her friends drinking in her dorm room and Tiffany had to go before a behavior review board. She is drinking on most weekends with her friends and admits to getting “wasted” on several occasions after drinking 5-7 drinks. Tiffany’s roommate told her that she was drinking too much and Tiffany said she was “tired of her nagging me.” You administer the CRAFFT on Tiffany and she scores a 2 under “F” (friends being concerned) and “T” for getting into trouble (referral to behavioral review board).

42. Case: Tiffany, Part 2 • How will your approach to Tiffany change compared to the last intervention? • Do you anticipate resistance with Tiffany and if so, how will you manage this?

43. Conclusions • Adolescents are vulnerable both physically and environmentally to harmful substance use. • Adolescent substance use is a strong predictor of adult substance misuse. • SBIRT can be effective in reducing long-term harms from substance misuse among adolescents. • Providers must be sensitive to the legal parameters for interacting with adolescents. • BI with adolescents requires effort to develop an alliance that is distinct from that which the adolescent shares with family and friends.