An Initiative for the State of Maryland

1. An Initiative for the State of Maryland For Counselors, Intake Workers and Screeners, Social Workers, and Therapists Dr. Peter Cohen, Medical Director Maryland Alcohol and Drug Abuse Administration (ADAA) And a Special Thanks to Michael Greenberg and Shin Haeng Lee, who were instrumental in developing this training module Adolescent SBIRTScreening, Brief Intervention, and Referral to Treatment for Alcohol and Other Substance Abuse

2. The Problem and Challenge in Maryland • Goals for Maryland • Adolescent Substance Use Diagnoses • What is SBIRT and Why Use It? • Screening and the CRAFFT • Brief Intervention • Referral to Treatment Topics

3. BY 12TH GRADE, THE MAJORITY OF ADOLESCENTS HAVE USED ALCOHOL OR ANOTHER DRUG • 12th Graders in the Last Year • 63% have used alcohol • 34.9% have used marijuana (Maryland State Department of Education, 2008) The Problem in Maryland

4. BY 12TH GRADE, THE MAJORITY OF ADOLESCENTS HAVE USED ALCOHOL OR ANOTHER DRUG • Alcohol Abuse • 33% have been a passenger with a drunk driver • 16% drove under influence • 11% were absent from school due to alcohol or drunk at school • There are Similar Trends for Other Drugs… • (Maryland State Department of Education, 2008) The Problem

5. A Common Teen MISCONCEPTION • Only 40% of high school seniors believe marijuana, beer, liquor, cigarettes are dangerous Communication Issues • About 33% of using 12th graders can talk about their drug/alcohol use problem with an adult TAKE HOME POINT There is WIDE SPREAD substance abuse by teens at risk. Most NEED TO TALK TO AN ADULT but most do not. The Problem

6. Changes in school attendance and grades • Unusual flare-ups or outbreaks of temper • Poor physical appearance (often becomes slovenly) • Furtive behavior regarding drugs (especially when in possession) • Wearing of sunglasses at inappropriate times to hide dilated or constructed pupils • Long-sleeved shirts worn consistently to hide needle marks (if injecting drugs) • Association with known drug abusers * Note: Some of these changes may occur in normal adolescents or may result from other problems Maryland Healthy Kids EPSDT Manual 2006 13 Common Indicators of Adolescent Drug & Alcohol Abuse*

7. Borrowing money from students to purchase drugs • Stealing small items from the school or home • Hiding a stash in odd places; e.g., closets, storage areas • Attempting to appear inconspicuous in manner and appearance to mask usage • Withdrawal from responsibility • Change in a. overall attitude (school, home, family, friends, job) b. behavior, oppositional, poor social skills c. mood (depression, irritability, low self-esteem, grandiosity) * Note: Some of these changes may occur in normal adolescents or may result from other problems. Maryland Healthy Kids EPSDT Manual 2006 13 Common Indicators of Adolescent Drug & Alcohol Abuse*

8. The Governor’s Deliverable Unit • Expand Access to Substance Abuse Treatment in Maryland 25% by 2012 The ADAA’s GOAL • Increase Referral Rates of Adolescents with Substance Abuse Problems: From Primary Care Practitioners, Nurses, Counselors and Therapists Evaluation and Treatment Programs GOALS OF PROGRAM

9. Develop brief SBIRT training programs for practitioners • For medical & counseling professionals • Provide continuing medical education credits online or in person • The training program • Practice of basic screen interviewing that incorporates motivational interviewing skills • Effective use of the CRAFFT as the screening instrument • Demonstration videos that highlight effective screening of an adolescent in the office setting ADAA Objectives

10. DIAGNOSIS

11. Diagnostic Confusion: Abuse Vs. Dependence • Criteria not designed specifically for teens • Current use does not predict chronic abuse or dependence • Length of stay & medical necessity criteria affect the validity of diagnosis • Not easily translated into treatment plans • Diagnostic Orphans General Problems with DSM SUD Diagnosis Applied to Adolescents

12. At Least 13% Are Diagnostic Orphans Definition 1. Do Not Meet Enough DSM Criteria For Abuse Or Dependence 2. But The Teenager Has Substantial D&A Problems There is a Great Crossover with Other Psychiatric Symptoms That… • Persist after detoxification • Precede substance abuse • Exist beyond what would normally be expected • Exist in first-degree relatives General Problems with SUD Diagnosis of Adolescents

13. Not Necessary for Adolescents: Tolerance, Withdrawal Relief of withdrawal symptoms when using substance (Withdrawal) Occupational/social/recreational activities given up or reduced Larger amounts taken than originally intended Awareness of problems related to substance abuse Increased amounts are needed to achieve the same effect (Tolerance) Diminished effect with use of the same amount of the substance (Tolerance) Persistent desire to cut down or control use Unsuccessful efforts to cut down or control use Personal problems (social and interpersonal) due to use Investment of time in substance-related activity is considerable Longer duration of use than initially intended Symptoms of withdrawal occur (Withdrawal) DEPENDENCE = “ROLAID PUPILS” The Remaining Signs & Symptoms Can Qualify For Adolescent Substance Dependence

14. “HELP” Hazardous circumstances do not deter SA Evasion of obligations due to SA Legal difficulties caused by SA Problems (social and interpersonal) develop Robinson DJ. Mnemonics & More, 2001 Abuse = “HELP”

15. SUBSTANCE ABUSE Lifestyle and function is disrupted without learning from consequences and subsequent change of behavior Substance Abuse and Dependence: What’s the Difference?

16. Substance Dependence Lifestyle and function become primarily defined as Acquiring chemicals Reducing craving Avoiding withdrawal Overcoming tolerance Increasing losing of control of use (using too much, can’t cut down, giving up everything for the chemical) Substance Abuse and Dependence: What’s the Difference?

17. You can be dependent without signs of major abuse (eg. “the functional alcoholic”) BUT Abuse usually accompanies dependence Substance Abuse and Dependence: What’s the Difference?

18. Screening • Brief Intervention • Referral to Treatment The 3 Tasks of SBIRT

19. IT WORKS • Brief Intervention & Motivational Enhancement: The most effective treatment modalities • Confrontational counseling & educational lectures: More common but least effective (Miller & Wilbourne 2002) Why Use SBIRT?

20. Screening

21. General Effective Interviewing Techniques • Always Start On A Positive Note: Ask about the teen’s interests, talents & goals for the next year • Show Your Interest in the teen’s meeting those goals • Ask Permission to discuss use of D&A • Then Screen

22. While Screening, Pay Attention Put down the chart when you are listening Take notes after the interview is over • Give Praise, or State Your Worry and Interest in Helping The Teenager Achieve His or Her Goals • In Other Words…Use Motivational Interviewing General Effective Interviewing Techniques

23. Express Empathy & Acceptance: Listening Rather Than Telling Work with Ambivalence Develop DiscrepancyBetween Drug Use & Fulfilling One’s Goals Avoid Arguing Roll with Resistance Expect it: Be Empathic & Reflective Support Self-Efficacy: What would you like to do about it?” Using Motivational Interviewing:“Change Talk”

24. What is a Valid and Reliable Screening Tool for Adolescents?CRAFFT • Helps you determine • Whether to proceed with an office intervention • or • 2. Refer the teenager for specialized treatment

25. A substance usescreening instrument that is • valid & reliable • sensitive & specific • quick & effective • It is the center point of your screening, but… • It is only as good as your interviewing technique, such as the use empathy & reflective listening • Specifically designed for adolescents by John Knight MD* Why use crafft? *Click Here to Go To the Center for Adolescent Substance Abuse Research (CeASAR)Website

26. STEP 1:Three Basic Opening Questions • STEP 2:Six CRAFFT Screening Questions Do You Have 5 Minutes? Massachusetts Department of Public Health, Bureau of Substance Abuse Services, 2009 The Two Steps of Substance Abuse Screening for Teenagers

27. The Teenager fills out the PAPER or COMPUTER-BASED CRAFFT QUESTIONNAIRE OR • The Primary Care Provider ASKS the questions during visit OR • Another Provider in the Practice ASKS the questions Methods of CRAFFT Delivery

28. Which Method Should I Use In My Practice? Whatever… • Respects The Teen’s Privacy & Confidentiality • Is Time-effective • Is Cost-effective • Fits Your Style of Patient Care Methods of CRAFFT Delivery

29. After Establishing Rapport STEP 1: Prevention or Further Screening? Ask the teenager these 3 basic opening questions • During the past 12 months, did you: • Drink any alcohol (more than a few sips)? • Smoke any marijuana or hashish? • Use anything else to get high? How to Use CRAFFT

30. STEP 1: Three Opening Questions • During the past 12 months, did you: • Drink any alcohol (more than a few sips)? • Smoke any marijuana or hashish? • Use anything else to get high? The Teenager Answers “NO” to All 3 Opening Questions Ask ONLY the FIRST CRAFFT question: Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs?

31. When the Teen Answers “NO” to All 3 Opening Questions Ask the 1St CRAFFT Question Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs? “NO” ”YES” 1. Give praise & encouragement to remain abstinent, 2. Advise avoiding a ride with an intoxicated driver 3. Follow-up at next visit: How is it going? (Duration: 1-2 minutes) • Ask teen to agree to avoid • riding with a driver who • has used alcohol or drugs • 2. Follow-up at next visit: • Was the agreement upheld? • 3. If a risk still exists: • Involve the parents • (Duration: 1-2 minutes)

32. STEP 1: Ask the Three Opening Questions • During the past 12 months, did you: • Drink any alcohol (more than a few sips)? • Smoke any marijuana or hashish? • Use anything else to get high? The Teenager Answers “YES” to Any Opening Question Step 2: Ask The SIX CRAFFT Questions Each yes = 1

33. C Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs? R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A Do you ever use alcohol or drugs while you are by yourself, or 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? The Six CRAFFT Questions

34. STANDARD DRINKCARD

35. STANDARD RULER CARD How ready are you to change your tobacco/alcohol/drug use?

36. Brief Intervention

37. What Should I Do? YOUR INTERVENTION DEPENDS ON YOUR CLINICAL JUDGEMENT + YOUR RAPPORT WITH THE TEEN + THE CRAFFT SCORE

38. ADD UP all 6 CRAFFT questions • “YES” = 1 point • “NO” = 0 points • Get a score between 0-6 Scoring the Test: CRAFFT Scoring System

39. CounselorsSocial WorkersTherapists SBIRT Thanks to BNI Art Institute

40. Youth & Young Adult Health & Safety Needs Questionnaire: Click Here for Copy

41. SBIRT Interview Algorithm for Counselors & Therapists Click here to Download the BNI ART Institute Youth Intervention Algorithm and CRAFFT

42. Four basic elements of the sbirt interview • Promote Rapport and Trust: • Ask Permission, Address Privacy, and Engage • Provide Feedback • Enhance Motivation • Negotiate and Advise

43. Steps Dialogue • Ask Permission • Address Privacy • Engage • Hello, I am _______. Would you mind taking a few minutes to talk with me confidentially about your use of [X]? <<PAUSE and LISTEN>> • Before we start, could you tell me a little about a day in your life? 1. Promote rapport and trust

44. 1. Promote rapport and trust To Watch on YouTube: Click on the Picture

45. steps Dialogue • Ask how X fits in with life goals • Make connection (No arguing) • For alcohol, show NIAAA guidelines & norms for adults • From what I understand, you are using [insert screening data]… We know that drinking above certain levels, smoking and/or use of illicit drugs can cause problems, such as [insert medical info]…I am concerned about your use of [X]. • What goals do you have for yourself? (What is important to you?) • What connection (if any) do you see between your use of [X] and this ED visit? 2. Provide Feedback

46. steps • These are what we consider the upper limits of low risk drinking for adults. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines. From what you say, you are drinking above the adult guidelines. • If the patient sees a connection: reiterate what he or she has said • If the patient does not see a connection: make one using medical info Dialogue 2. Provide Feedback

47. 2. Provide Feedback To Watch on YouTube: Click on the Picture

48. steps Dialogue • Explore Pros and Cons • Use reflective listening • Help me to understand what you enjoy about [X]? <<PAUSE AND LISTEN>> • Now tell me what you enjoy less about [X] or regret about your use of [X] <<PAUSE AND LISTEN>> 3. Enhance Motivation

49. 3. Enhance Motivation To Watch on YouTube: Click on the Picture

50. steps Dialogue • Use responses to continue exploring pros & cons • On the one hand you said… • On the other hand you said…. • Ask CRAFFT questions, then sum up and restate in patient’s own words 4. Administer THE CRAFFT