Transcript ADOLESCENT SUBSTANCE USE: Screening & Assessment in

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
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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
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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
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Adolescent Questions
HEADS
H
E
A
D
S
Home
Education
Activities, Affect
Ambition. Anger
Drugs
Sex
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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.)
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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? ”
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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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CRAFFT Questions
C
R
A
F
F
T
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 things you did while using alcohol or
drugs?
Have you gotten into TROUBLE while you were using alcohol
or drugs?
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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
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Stages of Use
Abstinence
Secondary Abstinence
use of alcohol,
drugs
recovery,
treatment
Dependency
Experimentation
occasional use
“social” setting
tolerance
withdrawal
Regular Use
negative consequences
associated with use
Abuse
Problem Use
“continued use despite harm”
preoccupation, loss of control
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(Source: Knight, 1997)
Intervention Goals
•
•
•
•
•
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
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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
Precontemplation
Contemplation
Action
Maintenance
Termination
Relapse
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Stage Specific Strategies
• Precontemplation - raise doubt, increase awareness of
risks and problems
• Contemplation - acknowledge ambivalence, evoke
reasons to change, tip the balance
• Determination - help find best course of action
• Action - provide assistance in moving forward
• Maintenance - relapse prevention strategies, positive
reinforcement
• 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
FEEDBACK on personal risk or impairment
R
Emphasis on personal RESPONSIBILITY
to change
A
M
E
S
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
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Responsibility
• “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.”
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Advice
• State your concern. “Considering all
that’s happened, I’m worried that you
might have a real problem with drugs
and alcohol.”
• Give clear advice to change, and list the
menu of possible choices. “My advice is
that you stop using drugs and alcohol
completely for a while…”
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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
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Menu:
Treatment Options
•
•
•
•
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•
•
Outpatient Counseling
Psychiatric Consultation
Day Hospital Program
Half-way House
Therapeutic Community
Residential Treatment Center
12-Step Programs
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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
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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..”
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Summary
• 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
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