overview of brief intervention for risky substance use in primary care

February 2014

OVERVIEW OF BRIEF INTERVENTION FOR RISKY SUBSTANCE

USE IN PRIMARY CARE

Prepared byCASAColumbia®

© CASAColumbia 2014

Outline

• Introduction

• Three Key Steps

− Engage

− Motivate

− Plan

• Sample Videos

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INTRODUCTION


Addiction & Risky Use

For background information on addiction Addiction Medicine: Closing the Gap between Science and Practice1

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http://www.casacolumbia.org/addiction-research/reports/addiction-medicine








For information on screening, diagnosis, treatment planning & management

Overview of Addiction Medicine for Primary Care2 (62 Slides)

Overview of Addiction Medicine for Primary Care: Supplement3 (30 Pages)

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http://bit.ly/Mdi6fo


http://bit.ly/1eQNfRS





• Approach comprehensively across substances

• Address tobacco/nicotine, alcohol & other drugs

• Manage co-occurring disorders

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dopamine transporters



• Addiction: disease requiring treatment

• Risky use:

− Substance use that threatens health & safety

− Does not meet addiction criteria

Diagnostic criteria can be found here: Overview of Addiction Medicine for Primary Care2

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All patients with addiction

should receive treatment

All patients who are risky users

should receive a brief intervention

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Brief Intervention for Risky Use

• Medical approach to reduce risky use

• Evidence-based from research studies

• Effective for risky use involving tobacco/nicotine, alcohol & other drugs

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Brief Intervention for Risky Use

• 5-10 minutes as effective as 20 minutes4

• Tobacco/nicotine quit rate 3X as likely5

• Average drinks per week reduced by 13-34%6

• 60% of patients reduce illicit drug use7

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Common Frameworks

• 5A Approach: developed for tobacco/nicotine cessation8

• FRAMES: developed for reducing alcohol use9-10

• Motivational Interviewing: developed for reducing alcohol use11

• All of the above share similar concepts which are summarized in this presentation

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Comprehensive Approachfor tobacco/nicotine, alcohol & other drugs

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• Risky use of multiple substances occurs often

• Comprehensively addressing tobacco/nicotine, alcohol & other drugs may help prevent replacement of one substance with another


THREE KEY STEPS


Brief Intervention: Key Steps

1. Engage

2. Motivate

3. Plan

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1. EngageAssess to determine baseline & readiness

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• Inquire about current patterns of substance use

• Determine patient perception of substance use8

• Identify personal values & goals10


1. EngageExplore the potential for change

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• Discuss impact of substance use on goals

• Develop a discrepancy between substance use & achieving goals

• Elicit need & perceived ability to change


1. EngageTips for speaking with patients

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• Establish rapport & ask permission to discuss

• Use nonjudgmental, empathic language & tone

• Ask open-ended questions from general to specific11

• Listen reflectively: repeat, rephrase, paraphrase


1. EngageSample language to use with patients

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• “Would you mind taking a few minutes to talk with me about your use of tobacco/nicotine, alcohol & other drugs?”

• “Tell me more about how your substance use has affected your life?”


2. MotivateOffer personalized advice & feedback

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Well delivered advice is associated with improved patient satisfaction12

• Provide clear, specific, personalized feedback

• Include risks & consequences of use

• Express concern & recommend explicit changes

• Support patient self-determination & autonomy8


2. MotivateTips to motivate patients to change

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• Emphasize confidence in ability to change

• Assure continued support throughout process


2. MotivateTips to communicate effectively with patients

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• Tailor to patient level of health literacy

• Provide small amounts of feedback at a time10

• Use empathic style for more cooperation & less resistance


2. MotivateSample language to use with patients

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• “You seem to think that your smoking of tobacco & marijuana has been making your asthma worse. I agree that smoking less will reduce asthma symptoms.”

• “I think you should...” rather than “You should...”8


2. MotivatePromote self-efficacy & empower patients

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• Use reflective listening, summaries & affirmations11

• Review strengths & past successes


2. MotivateTips to encourage patients to change

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• Validate frustrations but remain optimistic

• Summarize to reinforce & to show that you listen

• Prepare patients for next steps


2. MotivateSample language to use with patients

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• “It seems like the support from your family was very helpful when you cut back on meth & cocaine use last year. Your family support can help again now as you try to quit both completely.”

• “This is what I heard you say [summarize].”


3. PlanSelect methods & goals collaboratively

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• Create goals aligned with readiness to change

• Assist patients to identify personal goals & preferences among methods


3. PlanSelect methods & goals collaboratively

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• Focus on attainable, measureable, timely goals

• Help anticipate potential challenges & barriers

• Brainstorm on methods to overcome problems


3. PlanTips on selecting goals with patients

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• Recommend ideal change but accept less if patients resist

• Change strategies when patients resist


3. PlanTips to work collaboratively with patients

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• Avoid argumentation which can be counter-productive & create defensiveness

• Collaborate to increase patient control/agency13


3. PlanSample language to use with patients

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• “What changes do you think you can make with your drinking & your use of painkillers?”

• “It sounds like limiting the alcohol & painkillers you keep at home might be a great first step. How do you feel about making that change? When do you think you would be able to make that change?”


3. PlanSample language to use with patients

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• “What problems do you expect in making this change?”

• “How do you think you could deal with them?”

• “I think you’ve chosen a great, realistic goal. If you have problems, remember that I am here to help you throughout this process.”


3. PlanOffer support & follow-up care

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• Follow up initially within one month or less

• Reinforce previous steps at follow-up visits

• Reassess & update plan based on current status


3. PlanOffer support & follow-up care

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• Acknowledge efforts & experiences

• Offer continued support irrespective of success


3. PlanDiscuss various options for support

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• Follow-ups by phone, office visit, or HIPAA-compliant email

• Self-help materials printed or online

• Guidance to obtain social support


SAMPLE VIDEOS


Video Example for Adolescent

Adolescent Patient14 (4min 26sec)

www.youtube.com/watch?v=fX90j4jD9Sc

From University of Maryland, Baltimore

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http://www.youtube.com/watch?v=fX90j4jD9Sc


Video Example for Adult

Adult Patient15 (6min 37sec)

www.youtube.com/watch?v=ebsqETBWEdQ

From University of Maryland, Baltimore

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http://www.youtube.com/watch?v=ebsqETBWEdQ


References1. CASAColumbia. Addiction medicine: closing the gap between science and practice. 2012 Jun. http://

www.casacolumbia.org/addiction-research/reports/addiction-medicine

2. CASAColumbia. Overview of addiction medicine for primary care. 2014 Feb. http://bit.ly/Mdi6fo

3. CASAColumbia. Overview of addiction medicine for primary care: supplement. 2014 Feb. http://bit.ly/1eQNfRS

4. Kaner EF, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004148.

5. Ong MK, et al. Primary care providers advising smokers to quit: comparing effectiveness between those with and without alcohol, drug, or mental disorders. Nicotine Tob Res. 2011 Dec;13(12):1193-201.

6. Whitlock EP, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004 Apr 6;140(7):557-68.

7. World Health Organization. The effectiveness of a brief intervention for illicit drugs linked to the ASSIST screening test in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomised controlled trial. 2008.

8. Whitlock EP, et al. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002 May;22(4):267-84.

9. Hester RK, et al. Handbook of Alcoholism Treatment Approaches. 2nd Edition. 1995.

10. Center for Substance Abuse Treatment: Substance Abuse and Mental Health Services Administration. Brief interventions and brief therapies for substance abuse. 1999.

11. Miller WR and Rollnick S. Motivational interviewing. 2nd Edition. 2002.

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References12. Hollis JF, et al. Implementing tobacco interventions in the real world of managed care. Tob Control. 2000;9 Suppl 1:I18-24.

13. Miller WR and Heather NH. Treating Addictive Behaviors. 2nd Edition. 1998.

14. University of Maryland, Baltimore MD3 SBIRT Medical Residency Training Initiative. SBIRT in pediatrics: teen alcohol use case - good doctor example - part ii: brief intervention. Accessed Nov 1, 2013. http://www.youtube.com/watch?v=fX90j4jD9Sc

15. University of Maryland, Baltimore MD3 SBIRT Medical Residency Training Initiative. SBIRT: Brief intervention: at risk alcohol use. Accessed Nov 1, 2013. http://www.youtube.com/watch?v=fX90j4jD9Sc

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Acknowledgements

• Margot Cohen contributed much of the research and writing for these materials.

• The following subject-matter experts served as external reviewers for these materials: Frances Levin, M.D., Edward Nunes, M.D., Richard Saitz, M.D., M.P.H.

• Funding was provided by The Joseph A. Califano, Jr. Institute for Applied Policy.

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overview of brief intervention for risky substance use in primary care

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