Substance Abuse

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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 PracticeJohn R. Knight,
MDHarvard Medical SchoolChildrens 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 QuestionsHEADS

• H Home
• E Education
• A Activities, Affect
• Ambition. Anger
• D Drugs
• S 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 2ASSESS

• Is there a problem?
• If so, what is the problem?
• What is the adolescents view of the problem?

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CRAFFT Questions

• C Have you ever ridden in a CAR driven by
  someone (including yourself) who was high or
  had been using alcohol or drugs?
• R Do you ever use alcohol or drugs to RELAX,
  change your mood, feel better about yourself, or
  fit in?
• A Do you ever use alcohol/drugs while you are by
  yourself, ALONE?
• F Do your FAMILY or FRIENDS ever tell you that
  you should cut down on your drinking or drug
  use?
• F Do you ever FORGET things you did while using
  alcohol or drugs?
• T 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
use of alcohol, drugs
recovery, treatment
occasional use social setting
tolerance withdrawal
Regular Use
Abuse
continued use despite harm preoccupation, loss
of control
negative consequences associated with use
Problem Use
(Source Knight, 1997)
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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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TraditionalInterviewing Style

• Sgt. Friday
• Closed questions
• How much?
• How often?
• Distant, professional
• Just the facts...

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More ProductiveInterviewing Style

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

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What Makes a Teenager Change?
Reward?
X
Yelling and threatening?
Punishment?
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Stages of ChangeProchaska and DiClemente
Determination
Action
Precontemplation
Termination
Contemplation
Maintenance
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 3ADVISE 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
Emphasis on personal RESPONSIBILITY to change
R
A
Clear ADVICE to change
M
A MENU of alternatives
E
EMPATHY as a counseling style
S
Facilitate SELF-EFFICACY (Optimism)
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Feedback

• State the FACTS in adolescents own words (Youve
  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

• Youre 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 thats
  happened, Im 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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MenuA Hierarchy of Change Options

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

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MenuTreatment Options

• 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 adolescents 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 teenagers 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