Substance Abuse

by

John R. Knight

reviewed by

Terrill D. Bravender Carolyn H. Frazer S. Jean Emans

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ADOLESCENT SUBSTANCE USE:

Screening & Assessment in Medical Office Practice John R. Knight, MD

Harvard Medical School Children’s Hospital, Boston

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Background

• • •

Substance abuse is a major national problem.

During the 1990s, use of alcohol and other drugs (AOD) among adolescents increased.

Pediatricians and other clinicians should screen every adolescent for AOD use as part of routine health care.

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Pediatricians should:

“be alert for signs and symptoms

suggestive of substance abuse, evaluate the nature and extent of alcohol and other drug use, and make an assessment as to whether additional counseling or referral may be needed.”

Source: Committee on Substance Abuse, American Academy of Pediatrics SUS

Role of the Clinician

Alcohol (and Drug) Use

• • •

Ask (Screening) Assess Advise & Assist (Intervention)

Source: National Institute on Alcohol Abuse and Alcoholism

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Step 1: ASK

“

Inquiry regarding the extent of tobacco, alcohol, and other drug use, as well as sexual activities, should be part of the routine history of every teenager presenting for periodic health care.”

Committee on Adolescence American Academy of Pediatrics SUS

Interviewing Guidelines

• • •

Begin by meeting family together Explain the ground rules of confidentiality

– –

All information confidential unless safety is at risk When confidentiality must be broken, adolescent is included in discussion of how to tell parents Interview adolescent without parents present SUS

H E A D S Adolescent Questions

HEADS

Home Education Activities, Affect Ambition. Anger Drugs Sex SUS

Transitional Strategy #1

• •

Begin with those topics which are easiest to discuss (home, school, activities, ambitions, etc.) Gradually transition to those topics which are more highly charged (tobacco, alcohol, Rx drugs, illicit drugs, sex, etc.) SUS

Transitional Strategy #2

• • •

Begin with generic statements about the behavior. Transition to questions about use by peers and friends.

Move on to questions about personal views and behavior.

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Transitional Strategy #2

• • •

“I know that many kids your age have started to experiment with alcohol.” “Have any of the kids in your school begun to drink? How about

your

friends?” “Have you ever thought about it? Have you tried drinking? What was the experience like for you? ” SUS

Step 2: ASSESS

• • •

Is there a problem?

If so, what is the problem?

What is the adolescent’s view of the problem?

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C R A F F T

CRAFFT Questions

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 , change your mood, feel better about yourself, or fit in?

Do you ever use alcohol/drugs while you are by yourself, ALONE ?

Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

Do you ever FORGET drugs?

things you did while using alcohol or Have you gotten into TROUBL E while you were using alcohol or drugs? SUS

CRAFFT Questions

– – – – – –

Brief Reliable Easy to administer Developmentally appropriate for adolescents Simple to score (each “yes” answer = 1 point) Clinically relevant

• •

1 “yes” answer = need for further assessment, brief intervention 2 or more “yes” answers = need for more intensive treatment SUS

Stages of Use

use of alcohol, Abstinence drugs Experimentation occasional use “social” setting Regular Use Secondary Abstinence recovery, treatment Dependency tolerance withdrawal Abuse negative consequences associated with use Problem Use “continued use despite harm” preoccupation, loss of control

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(Source: Knight, 1997)

Intervention Goals

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STAGE OF USE Abstinence Experimentation, Regular Use Problem Use Abuse, Dependency Secondary Abstinence

• • • • •

GOAL Positive Reinforcement Risk Reduction “Rescue Plan” Abstinence Test, CUT Specialized Treatment Follow-up, Support, Reinforcement SUS

Traditional Interviewing Style

“Sgt. Friday” • Closed questions • How much?

• How often?

• Distant, professional • Just the facts...

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More Productive Interviewing Style

• • • • •

“Lt. Colombo” Open-end questions Partnership Mutual discovery Problem solving Empathy

What Makes a Teenager Change?

Reward?

X Punishment?

Yelling and threatening?

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Stages of Change

Prochaska and DiClemente Determination Action Precontemplation Contemplation Maintenance Termination Relapse SUS

• • • • • •

Stage Specific Strategies

Precontemplation -

risks and problems raise doubt, increase awareness of

Contemplation -

acknowledge ambivalence, evoke reasons to change, tip the balance

Determination Action -

help find best course of action provide assistance in moving forward

Maintenance -

reinforcement relapse prevention strategies, positive

Relapse -

avoid demoralization, enhance movement back toward action, assist in learning process

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Step 3: ADVISE AND ASSIST

•

How can I best promote health and facilitate behavioral change?

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Brief Intervention:

(Miller & Sanchez) F R A M E S

FEEDBACK on personal risk or impairment Emphasis on personal RESPONSIBILITY to change Clear ADVICE to change A MENU of alternatives EMPATHY as a counseling style Facilitate SELF-EFFICACY (Optimism)

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• • • •

Feedback

State the FACTS in adolescents own words (“You’ve told me that…”) List health risk and problem behaviors, accidents, and injuries List impairments in school and work performance, troubled or broken relationships Relate concerns about immediate future, not distant possibilities SUS

Responsibility

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“You’re practically an adult. You will have to take responsibility for your own life now.” “I respect your right to make your own decisions. Neither your parents nor I can do things for you or to you. If you will allow us, we would like to work through this problem with you.” SUS

Advice

• •

State your concern. “

and alcohol

.”

Considering all that’s happened, I’m worried that you might have a real problem with drugs

Give clear advice to change, and list the menu of possible choices. “

completely for a while

…”

My advice is that you stop using drugs and alcohol

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Menu :

A Hierarchy of Change Options

• • • • • •

Abstinence Challenge Controlled Use Trial (CUT) Risk Reduction Problem Contemplation Referral or Consultation Always Follow Up SUS

Menu:

Treatment Options

• • • • • • •

Outpatient Counseling Psychiatric Consultation Day Hospital Program Half-way House Therapeutic Community Residential Treatment Center 12-Step Programs SUS

Empathy

• • • • •

Avoid anger and confrontation Work at true understanding See the world through an adolescent’s eyes Remember the feelings of your own teen years (not behavior) Give voice to compassion SUS

Self-Efficacy

• • • •

Adult predictions of failure and future trouble are common Be optimistic!

Refute negative attributions (“bad seed”) Make empowering statements “I believe you can do it..” SUS

Summary

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All adolescents should be screened for substance use.

The pattern of use must be viewed on a continuum.

Assess severity, what the teenager’s view of the problem is, and readiness to change.

If safety is at immediate risk, move toward structured treatment program.

Otherwise, target your intervention at moving from one stage of change to the next during each encounter Always follow-up SUS