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Prevention and
Early Intervention in
Substance Use
AMFDA Annual Meeting 2017
Sheila Specker, MD
Associate Professor
Department of Psychiatry
Disclosure:
I have no conflict of interest
Funding from NIAAA, NIDA, Conrad Hilton Foundation
>90%
BEGAN
SMOKING,
DRINKING OR
USING OTHER
DRUGS BEFORE
AGE 18
Prevention
Primary :
• Prevent disease or injury before it ever occurs.
– preventing, altering unhealthy or unsafe behaviors that can lead
to disease or injury, and increasing resistance to disease or injury
should exposure occur.
Secondary:
• Reduce the impact
– detecting, treating disease ASAP to halt or slow its progress,
encouraging personal strategies to prevent recurrence
Tertiary:
• Soften the impact of an ongoing illness
– Manage chronic diseases, permanent impairments, improve
quality of life
Addiction Medicine Fellowship
PEI Program Requirements
IV.A.2.a).(1) Patient Care
• Competence in comprehensive assessment, dx,
treatment...along continuum of care including early
intervention
• Competence providing care….with diversity in
age..
• Proficiency in screening, brief intervention, and
motivational interviewing
Addiction Medicine Fellowship
PEI Program Requirements
IV.A.2.b).(1) Medical Knowledge
•
Demonstrate expertise in …..prevention, screening, brief
intervention and referral….
– medical model of addiction including changes in brain
structures
– epidemiology...and the genetic and environmental
influences…
– impact in diverse populations….neonates, children,
adolescents, families…
– prevention, including identification of risk and
protective factors
– screening, brief intervention strategies appropriate to
risk level
– MAT and psychosocial interventions to diverse ... age
Addiction Medicine Fellowship
PEI Program Requirements
II.C. Other program personnel
• Clinicians available such that fellow receive
training in SUD’s across the lifespan
Conrad Hilton SBIRT Addiction
Fellowship “Next Gen” 2015-2016
• Project: Prevention, Early Intervention (Brian
Grahan, MD, PhD)
– Screening of all adolescents presenting to
or current patient of fellow child psychiatry
clinic, U of MN
Conrad Hilton SBIRT Addiction
Fellowship Grant 2015-2016
Goal:
• Identify youth with risk behaviors for
substance use and SUD
• Establish systematic method of screening
• Educate providers (child fellows, child
faculty) on screening, BI
Principle #1:
Improvement Requires Change
Every system is perfectly designed to achieve exactly the
results it gets
Understand the System
Procedures, resources and routines needed to perform a specific
activity
✓ You need to:
✓ Know your customers (patients/residents/staff)
✓ Understand system failures and identify what is wrong
✓ Figure out which step needs fixing
Principle #2:
No One Wants More Work
Sustainability = simplicity
✓ Most people seek the path of least resistance
✓ Anticipate work-arounds
✓ Reliable change requires simpler work flow
✓ Simplification is hard
Aim
Screen X% of
child/adolescent
psychiatry patients for
substance use using a
standardized tool by
[DATE], 2016
S2BI
In the past year, how many times have you used:
• Tobacco?
• Alcohol?
• Marijuana?
STOP if all “Never.”
Otherwise, CONTINUE
• Prescription drugs that were not prescribed for you?
• Illegal Drugs?
• Inhalants
• Herbs or synthetic drugs (such as salvia, “K2”, or bath salts)?
never
1-2x
monthly
weekly
CRAFFT
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, feel better about yourself, or
fit in?
A
Do you ever use alcohol or drugs while you are by yourself, ALONE?
F
Do you 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?
0=no risk
1-2 low risk
3-4 moderate risk
5-6 high risk
Adolescent Screening Team: Round 1
• Addiction medicine fellow
• Chief fellow, child/adolescent psychiatry
• Medical director, child/adolescent psychiatry
clinic
• Child/adolescent psychiatry fellows
Initial Status
Chart review of documented substance use status among
child/adolescent fellows’ patients in 1 month period
(n=115)
Clinical
impression
No use
Any use
Problem use
No comment
43
8
2
62
• ≥ 9% of patients 12+ yrs old use substances
• 54% of fellows’ patients use status unknown
• No standard questions, template
Plan
• Chief child/adolescent psychiatry fellows willing to
try standardized screening tool
• No champions: “I already ask about it”
– Addiction fellow available for POC consult?
• Child fellows prospectively review patient panel
for 1 month and estimate substance use
• Child fellows use CRAFFT during interview, return
results to addiction fellow
Results: Feedback
“It confirmed what I already knew.”
“It helped because I didn’t have to spend time asking [about use]
when I got time alone with the patient. I could get right to the
point.”
“The car question was new... I now use that into my practice. The
rest... it didn’t help much.”
“If a patient is using, then I usually warn them about my staff’s
response. I focus on maintaining rapport, and they tend to
come down hard.”
Results/Conclusions
• Only 1 of 7 fellows reported any quantitative data
• Need frequent in-person contact with addiction
provider
• Medical assistants reliably screen using
standardized tools
• Parental presence skews adolescents responses
• Computerized screening ?
Adolescent Screening Team: Round 2
• Addiction medicine fellow
• Program director, child/adolescent psychiatry
fellowship
• Medical director, child/adolescent psychiatry clinic
• Clinic manager, outpatient psychiatry clinics
• Consulting physician, pediatric addiction medicine
• Child/adolescent psychiatry fellows
• Front desk & intake staff representative
• Medical assistant
Barriers
• No quality improvement culture/expertise on
staff
• Minimal informatics support
• High staff turnover
• Substance use low priority in child/adolescent
fellowship
Obstacle to Prevention Efforts:
Understanding the System
Procedures, resources and routines needed to perform a specific
activity
You need to:



Know your customers (patients/residents/staff)
Understand system failures and identify what
is wrong
Figure out which step needs fixing
Conrad N. Hilton Foundation’s Youth Substance Use
Prevention and Early Intervention Strategic Initiative:
Impacting Youth Substance Use, Health, and
Wellbeing
Setting by Number of Grantees and Organizations (as of
June 30, 2015)
Number of Grantees
Community
School/SBHC
Health care
Community behavioral health
Criminal Justice
3
8
6
2
2
Number of Sites
130
129
123
29
9
Conrad N. Hilton MPower Project
University of Minnesota
Enroll youth with mild-mod SU and
parents in SBIRT study in pediatric
health clinics and high schools
–Kaiser: health clinics
–UMN : high schools
–Same intervention
Conrad N. Hilton MPower Project
University of Minnesota
• Goals:
–Develop and use new screening tool for SU and
MH
–Develop manual
–Comparison of 2 brief interventions:
•Single session psychoeducation with teen
alone
•4 sessions: teen alone, parent alone, teen
alone, teen + parent
•Follow up intervals to 6 months
Conrad N. Hilton MPower Project
University of Minnesota
Single session:
• CORE: Personal strengths, life stressors, social
support
• FLEX:
–If teen requests alternate topic to discuss
–If high stress/cognitive emotional regulation needs
–If need for increased decision making skills
–If alcohol/other drug use
Conrad N. Hilton MPower Project
University of Minnesota
4 sessions:
• Session 1 (teen alone): coping with life stressors
• Session 2 (parent alone): parenting teens
• Session 3 (teen alone): addresses risk factors,
including SU and decision making skills
• Session 4 (parent + teen): family communication,
drug education: “getting on the same page”
Conrad N. Hilton Project
University of Minnesota
•Enroll 150 parent- teen dyads
•Identified through school system
•Teen with “mild-mod” substance use
–Used a substance once/last 6 months
and/or
–Sxs of depression, anxiety, PTSD, ADHD,
ED
Conrad N. Hilton Project
University of Minnesota
• Exclusion:
– Received SU treatment
– Mental health interfering
– Non-English speaking
• Must have both parent/teen involvement
Conrad N. Hilton Project
University of Minnesota
Hypothesis: either program helps the
teen to:
1. Make healthier choices
2. Improve family relationships
3. Reduce alcohol/other drug use
Addiction Fellow Prevention/Early Intervention
Learning
• Didactics, webinars, seminars
(knowledge)
• Many excellent resources on line:
https://www.addictionmedicinefoundation.org/wpcontent/uploads/2016/06/Web-version-of-recs-from-Yale-Meeting-on-PEI10-22-15_updtd_6.22.16.pdf
https://www.addictionmedicinefoundation.org/wpcontent/uploads/2016/08/Compendium-June-20162-updtd-July-2016.pdf.
Addiction Fellow Prevention/
Early Intervention Learning
Team: “buy in”
• Can’t do it alone!
• Faculty, fellow, case manager, SW,
nurse
“Hands on”
• Know your system
• Guidance
Addiction Fellowship
Challenges to Training in Prevention
•
•
•
•
Identifying a specific need area
Faculty with expertise
Most of trainees days busy
Unfamiliarity – where to start?
Summary
• Start small and think ahead a few steps
• Test changes
• Continuous improvement often requires a few
cycles
Thank you!
Sheila Specker, MD
[email protected]