CASE A: Caroline. You are an 18 year old woman coming in for a check-up prior to starting college. Your mother is in the waiting room.

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1 Adolescent Role Part 1 You are an 18 year old woman coming in for a check-up prior to starting college. Your mother is in the waiting room. If your PCP screens you for substance use in the past year: You have had alcohol at parties twice You have not used tobacco or marijuana If your PCP asks follow-up substance use questions: Each of the two times you had alcohol, you had about 6 drinks and felt drunk You have not driven when you have had alcohol you and your friends have a designated driver who doesn t drink If your PCP talks with you about your alcohol use: You don t want your mother to know You are not sure if you will not drink again You are sure that you will continue to not drink and drive and you will use a designated driver, although you do not anticipate needing to drive at all when at college. You think you can limit your drinking when at college, but you really don t know yet. What is your S2BI result? No use Once or twice Monthly or more Weekly or more What is your risk category? No use No SUD Mild/Moderate SUD Severe SUD What intervention did your PCP try with you? Positive Brief advice Assess, discuss, and Assess, discuss, make reinforcement to quit make a plan a plan, and refer

2 Part 2 In November, you return to your PCP s office together with your parents. In your first 10 weeks of school you have been brought to the Emergency Department 3 times for alcohol intoxication, most recently the day before Thanksgiving break. The school is now requiring that you have a medical evaluation prior to returning. If your PCP asks you about your alcohol use in college: You enjoy college parties and go to them every Friday and Saturday night. You usually drink until you are drunk, probably 6-8 drinks. You don t remember what happened on the nights you went to the ER. You blacked out and woke up in the ER. It was very scary and you don t want that to happen again. Your campus housing is in jeopardy and you might have to withdraw from school if you continue to have problems from drinking. If your PCP asks you about why you drink Drinking is an important social activity for you, especially on the weekends. You have always been high strung, and it feels really good to go out to a party and let everything go. All of your friends on campus drink and while you worry about being expelled from campus housing, you cannot imagine giving up drinking entirely. If your PCP asks you about the college s response to your drinking: You saw the college alcohol counselor after the first ER visit. The counselor advised you to cut back on your drinking and suggested that you count your beer bottle caps. You don t think it worked because you share pitchers of beer or have alcohol punch and never have beer bottle caps. If your PCP asks you what you plan on doing to avoid consequences: You don t think that quitting is reasonable but you plans on cutting down so that you do not get drunk again. You weren t really serious about cutting back before, but now you are, and you know you can limit yourself to 2 drinks. If your PCP and you discuss a plan to address your drinking You agree that your PCP will include a recommendation for ongoing counseling in your letter to the school. You discuss seeing another counselor at the student health service. You agree to have your parents come into the room to discuss the conversation you and your PCP had and what your plan is to improve the situation.

3 PCP Role Part 1 Caroline is an 18 year old woman presenting for an annual check-up. Her mother is in the waiting room. You use the S2BI screen. What is Caroline s S2BI result? No use Once or twice Monthly or more Weekly or more What is Caroline s risk category? No use No SUD Mild/Moderate SUD Severe SUD What intervention should you try with Caroline? Positive Brief advice Assess, discuss, and Assess, discuss, make reinforcement to quit make a plan a plan, and refer What would you say to her? Would you tell Caroline s mother about her substance use? Yes No Why or why not? If yes, what would you say?

4 Part 2 In November, Caroline returns to your office together with her parents. In her first 10 weeks of school she has been brought to the Emergency Department 3 times for alcohol intoxication, most recently the day before Thanksgiving break. The school is now requiring that she have a medical evaluation prior to returning. You do a brief assessment. How will you make a plan with Caroline? What is the plan? Would you talk with Caroline s parents about her alcohol use? Yes No Why or why not? If yes, what would you say?

5 Help for PCP Part 1 Provide brief advice to not drink for the sake of her health and development. Discuss the risks of driving/riding under the influence of alcohol, reinforce her decision to use a designated driver, and discuss the alternative of not drinking. Discuss how she will handle increased exposure to alcohol in college. Make a clear recommendation that she not drink in college.

6 Part 2 Ask Caroline to tell you about her drinking in college. Validate her feelings and acknowledge that only she can decide if drinking is worth the risk. Provide her with some information about the prevalence of college drinking in general (not 100% - not everybody drinks and certainly not everybody drinks to excess as she has) and help her to identify friends who don t drink and social activities she likes that don t involve drinking. Ask Caroline for her own reasons to stop drinking. Talk about whether she thinks drinking has helped her to relieve stress, or has added stress in jeopardizing her residency at school. Point out that the cognitive and emotional effects of alcohol may make school work harder for her and make her feel worse. What are your concerns about drinking? Why might you want to stop drinking? Tell me more.when was the last time that happened? Reflect back what Caroline tells you about her reasons to stop drinking It sounds like you like to drink at parties, and, at the same time, you end up in some pretty frightening situations when you drink. Is that what you mean? Did I get it right? Elicit her knowledge about the problems that can arise from drinking, provide corrections and additions as you summarize and affirm What does a blackout mean about the drinking? It sounds like you know a lot about the negative effects of drinking on the brain. As you said, a blackout means that you drank enough to poison your brain cells. Affirm her change language and summarize her reasons for not drinking As you pointed out, kids often get themselves into trouble when they black out. It sounds as if you have had some frightening experiences. Given your experiences, it makes sense that you might be considering not drinking.as you said, you have a lot to lose if you continue to drink. You might not be able to remain in campus housing and, as a result, might have to withdraw from school. You have told me how important school is to you, so I can see how that s a pretty big deal. Give clear advice, while acknowledging agency. Discuss the risks of cutting down instead of stopping. As your PCP, I recommend that you stop drinking completely. How can you work toward not drinking? What might happen if you cut down instead of stop completely? Ask questions to empower Caroline to develop a plan. Encourage her to make use of resources available at her college and to come back to see you when she is home from break. Caroline may benefit from ongoing support around stress management AND drinking. How do you think you can take care of yourself in the future? It sounds like you have made a very important decision to limit your drinking. What sorts of things will help you to follow your plan? What have you tried? What has/hasn t worked? What can you do differently? If you don t want to see the college alcohol counselor, what other resources can your school provide? What s available in the community? Discuss what information will go back to the school. Since the school is asking for recommendations, you and Caroline can agree that you will include a recommendation for ongoing counseling. Ask Caroline for permission to discuss the plan with her parents. If she is resistant, remind her that they already know about her drinking from the school, they are in the waiting room, and they will probably be reassured that she is taking the problem seriously and has a plan. Practice what you will say together with Caroline before her parents come into the room.

7 Case Objectives Upon completion of this activity, participants will be able to Use a brief screen to identify a young adult who needs assessment for problematic substance use Provide brief advice to a young adult going to college Conduct a brief motivational intervention to help a college student with problematic substance use to develop a plan to reduce or cease use Teaching Points Brief substance use frequency screens can be used to identify a young adult s substance use risk level A young adult reporting substance use at least monthly needs further assessment for problematic substance use, specifically o Use of substances other than tobacco, alcohol, and marijuana o Problems associated with use (e.g., with the CRAFFT questions) o Driving/Riding under the influence PCPs can use Motivational Interviewing (MI) to help a young adult with problematic substance use to recognize problems associated with use, express ambivalence about use, and develop a plan to reduce or cease use With a young adult who has problematic substance use concerning for a mild or moderate substance use disorder, the PCP can o Ask questions to elicit the young adult s own knowledge about problems and motivations to change o Use reflective listening to demonstrate that understanding of the young adult s perspective o Provide accurate information and advice in the context of a conversation, rather than a lecture o Recognize the young adult s strengths and affirm statements and decisions that support behavior change o Give advice, but not directives o Empower the young adult to develop a plan o Involve the young adult s parents, with permission o Communicate with college staff to create a comprehensive care plan PCPs can screen for, further assess, and discuss substance use in young adults within the context of a primary care visit. PCPs can conduct a brief motivational intervention for problematic substance use and help older adolescents/young adults to develop a plan.