MVP/PREFERRED CARE GUIDELINE

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1 MVP/PREFERRED CARE GUIDELINE MVP/Preferred Care Clinical Guideline Overview Screening Adolescents for Alcohol and Substance Abuse in Primary Care MVP Health Care/ Preferred Care, as part of its continuing Quality Improvement Program, developed a guideline outlining recommendations for screening adolescents for alcohol and substance abuse in the primary care setting. Consider the following statistics from the 2005 national Youth Risk Behavior Survey: 28.5% of students had ridden in a car in the month prior to the survey with someone who had been drinking 25.6% of students had their first alcoholic drink before age % of students had tried marijuana before age 13 In conjunction with the guideline MVP/Preferred Care has developed an initiative to assist providers in screening. MVP adopted the CRAFFT screening tool developed by John Knight, MD of the Center for Adolescent Substance Abuse Research, Children s Hospital Boston. As part of its Youth Health Initiative, MVP makes tools available to providers free of charge including: a screening tool to record the adolescents answers to the CRAFFT questions an informational sheet to hand to the teen after the screening is performed a resource sheet listing Substance Abuse Clinicians available for consultation Risky Teen Behaviors brochure that physicians can distribute to parents an exam room poster (8.5 X 11 in.) with the CRAFFT questions These materials can be requested by calling or The guideline is not intended to replace the role of clinical judgment by the physician in the management of this, or any other disease entity. It is an educational guideline to assist in the delivery of good medical care. All treatment decisions are ultimately up to the physician. Approval(s) and Review/Revision(s) Approval: Clinical Quality Improvement Committee 11/20/07 Quality Improvement Committee 12/10/07 Integration Date: 12/10/07 Prior Approval Date: Quality Improvement Committee: 01/06

2 GOALS OF SCREENING To identify a current or potential problem with substance use that may otherwise go undetected To help the adolescent identify the consequences of alcohol and substance use and motivate them to refrain from use If appropriate, to refer the adolescent to a substance abuse professional for further evaluation and treatment RECOMMENDATIONS FOR SCREENING Physicians should routinely interview their adolescent patients about their use of alcohol and other drugs and use by family members and friends All adolescents should be screened annually beginning around age 12 using a structured questionnaire Adolescents presenting with trauma, significant behavior changes or sudden medical problems (e.g. GI disturbance) should be screened Adolescents presenting with frequent colds, sinusitis or eye problems should be screened High-risk individuals who screen negative should be followed-up within 6 months College students are at high-risk for binge drinking and should be screened and counseled during school physicals. Binge drinking can lead to alcohol poisoning and death. THE SCREENING PROCESS The screening process should take no more than 2-3 minutes Parents should be asked to leave the room so adolescents are more comfortable sharing information about use The screening tool should be simple to administer and score, allowing for various types of practitioners to use it CRAFFT Questionnaire The CRAFFT test is a brief and efficient tool for determining which adolescents need further assessment and treatment for substance use disorders. It was developed by John Knight, MD of the Center for Adolescent Substance Abuse Research, Children s Hospital Boston. The tool is designed to be the age-appropriate substitute to the CAGE questionnaire. Clinicians can have a high degree of confidence based on the test s high negative predictive value that those adolescents who report fewer than 2 yes answers do not need to be referred to substance abuse treatment specialists. An adolescent who responds yes to 2 or more questions has an 80% chance of having a serious problem, a greater than 50% chance of having an alcohol- or drug-related disorder, and a 25% chance of being alcohol or drug dependent. The questions are shown below:

3 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, feel better about yourself, or fit in? Do you ever use alcohol or drugs while you are by yourself, ALONE? Do you ever FORGET things you did while using alcohol or drugs? Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you gotten into TROUBLE while you were using alcohol or drugs? When screening you may want to consider the following: Adding a timeframe (e.g. the past six months) to the questions to assess the adolescent s current situation Following up no responses with open-ended questions such as When was your last drink? Responding to the Adolescent s Answers Any yes response to a CRAFFT question should be considered as reason for concern and should be followed-up with further questioning and education. Brief office interventions have been shown to reduce substance use for 12 months following the intervention in individuals who are not dependent. These interventions typically last 5 to 10 minutes and can take place over several visits. If a Primary Care Physician (PCP) has a long-term trusting relationship with the adolescent this can be advantageous in influencing his/her behavior. The five components of a brief intervention are shown below with tips specific to adolescent screening for alcohol and substance use. Assessment and direct feedback Assess the adolescent s use with a screening tool such as the CRAFFT Express concerns regarding the adolescent s substance use as it relates to their health. Ask the adolescent to consider the link between usage and the problems (s)he is having. Negotiation and goal-setting Work with the adolescent to set a goal for reducing consumption. A written contract may be useful. Writing the goal on a prescription pad may also help the adolescent to take it seriously. Behavioral Modification Help the adolescent to identify situations in which (s)he is likely to use substances. Ask the patient to think of his/her environment (school, friends, family) and what triggers use. Assist the patient in developing coping skills for managing/ avoiding trigger situations. Self-help-directed bibliotherapy Provide the adolescent with written information on alcohol/ substance use and behavioral modification exercises. Examples of behavioral modification exercises include homework assignments to cut back on drinking or instructing the adolescent to not ride in a car with anyone who has been drinking. Follow-up and reinforcement Establish a follow-up plan with the adolescent to track their progress. This could be in the form of a follow-up visit or telephone call.

4 A brief office intervention may be considered if the following: Substance abuse problems appear to be mild to moderate Current consumption patterns will likely lead to adverse consequences Continued consumption will exacerbate an illness or interfere with medication The adolescent is not open to the suggestion of additional evaluation and treatment by a specialist WHERE TO REFER MVP will assist PCPs in matching their patients to the appropriate provider in their area. To locate an appropriate provider please call the MVP Behavioral Health Access Center at between the hours of 8:30 am and 5:00. Providers in Vermont should call PrimariLink at during these same hours. Referrals for outpatient substance abuse treatment are generated when calling. Board-certified psychiatrists who are medical directors for MVP and PrimariLink are also available by telephone to answer questions primary care physicians may have. OTHER CONSIDERATIONS Confidentiality Practitioners should be familiar with state and federal regulations regarding confidentiality of substance abuse treatment. Some regulations are outlined below: In New York and Vermont: The practitioner must ask permission of a child over age 12 to disclose any information regarding substance use to the parent except in cases of an emergency. Title 42 of the Federal Regulations governing confidentiality of patient records binds all disclosures for alcoholism and substance abuse treatment. Information can only be released when a patient signs a written authorization that includes designation of who should receive the information and what information should be disclosed. Any information received pertaining to a patient s use or abuse of alcohol and drugs (e.g. substance abuse treatment records) cannot be re-disclosed to another party, without additional authorization from the patient. According to HIPAA and NY and Vermont regulations, calls to the MVP Access Center or PrimariLink for the purpose of obtaining treatment do not require formal consent from the patient. For more information contact your state s alcohol and substance abuse treatment regulatory agency.

5 Bibliography 1. American Academy of Pediatrics, Committee on Substance Abuse. Indications for management and referral of patients involved in substnace abuse. Pediatrics. 2000; 106 (1): Substance Abuse and Mental Health Services Administration (SAMHSA). Screening and assessing adolescents for substance use disorders. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment; p Vermont Department of Health Division of Alcohol & Drug Abuse Programs. Guidelines for the development of Vermont's adolescent treatment system. Available at Accessed October 7, Fleming, M and Manwell, LB. Brief intervention in primary care settings: a primary treatment method for at-risk problem, and dependent drinkers. Alcohol Research & Health. 1999; 23(2): Knight HR, Sherritt, L, Shrier, LA, Harris, SK, Change, G. Validity of the CRAFFT substance abuse screening test amnog adolescent clinic patients. Arch Pediatr Adolesc Med. 2002; 156: American Academy of Pediatrics, Committee on Substance Abuse. Alcohol use and abuse: a pediatric concern. Pediatrics. 2001; 108 (1):

6 PATIENT FLOW DIAGRAM Administer CRAFFT Screen No Yes Answers 1 Yes Answer Positive Screen (2+ Yes ) Congratulate adolescent and encourage them to continue healthy behaviors If adolescent is high-risk re-screen in 6 months Help adolescent identify consequences of use Motivate them to refrain from use Obtain more complete alcohol and substance use history Brief Office Intervention Schedule follow-up focused visit for education / counseling Refer to specialist for further evaluation. Call: The MVP Schenectady Behavioral Health Access Center at or PrimariLink at (for providers in Vermont) or The Preferred Care Behavioral Health Line at Continued follow-up and relapse prevention

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