OVERVIEW OF BRIEF INTERVENTION FOR RISKY SUBSTANCE USE IN PRIMARY CARE. Prepared by CASAColumbia

OVERVIEW OF BRIEF INTERVENTION FOR RISKY SUBSTANCE USE IN PRIMARY CARE Prepared by CASAColumbia February 2014

Outline Introduction Three Key Steps Engage Motivate Plan Sample Videos 2

INTRODUCTION 3

Addiction & Risky Use For background information on addiction Addiction Medicine: Closing the Gap between Science and Practice 1 4

Addiction & Risky Use For information on screening, diagnosis, treatment planning & management Overview of Addiction Medicine for Primary Care 2 (62 Slides) Overview of Addiction Medicine for Primary Care: Supplement 3 (30 Pages) 5

Addiction & Risky Use Approach comprehensively across substances Address tobacco/nicotine, alcohol & other drugs Manage co-occurring disorders dopamine transporters 6

Addiction & Risky Use 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 Care 2 7

Addiction & Risky Use All patients with addiction should receive treatment All patients who are risky users should receive a brief intervention 8

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 9

Brief Intervention for Risky Use 5-10 minutes as effective as 20 minutes 4 Tobacco/nicotine quit rate 3X as likely 5 Average drinks per week reduced by 13-34% 6 60% of patients reduce illicit drug use 7 10

Common Frameworks 5A Approach: developed for tobacco/nicotine cessation 8 FRAMES: developed for reducing alcohol use 9-10 Motivational Interviewing: developed for reducing alcohol use 11 All of the above share similar concepts which are summarized in this presentation 11

Comprehensive Approach for tobacco/nicotine, alcohol & other drugs Risky use of multiple substances occurs often Comprehensively addressing tobacco/nicotine, alcohol & other drugs may help prevent replacement of one substance with another 12

THREE KEY STEPS 13

Brief Intervention: Key Steps 1. Engage 2. Motivate 3. Plan 14

1. Engage Assess to determine baseline & readiness Inquire about current patterns of substance use Determine patient perception of substance use 8 Identify personal values & goals 10 15

1. Engage Explore the potential for change Discuss impact of substance use on goals Develop a discrepancy between substance use & achieving goals Elicit need & perceived ability to change 16

1. Engage Tips for speaking with patients Establish rapport & ask permission to discuss Use nonjudgmental, empathic language & tone Ask open-ended questions from general to specific 11 Listen reflectively: repeat, rephrase, paraphrase 17

1. Engage Sample language to use with patients 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? 18

2. Motivate Offer personalized advice & feedback Well delivered advice is associated with improved patient satisfaction 12 Provide clear, specific, personalized feedback Include risks & consequences of use Express concern & recommend explicit changes Support patient self-determination & autonomy 8 19

2. Motivate Tips to motivate patients to change Emphasize confidence in ability to change Assure continued support throughout process 20

2. Motivate Tips to communicate effectively with patients Tailor to patient level of health literacy Provide small amounts of feedback at a time 10 Use empathic style for more cooperation & less resistance 21

2. Motivate Sample language to use with patients 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 22

2. Motivate Promote self-efficacy & empower patients Use reflective listening, summaries & affirmations 11 Review strengths & past successes 23

2. Motivate Tips to encourage patients to change Validate frustrations but remain optimistic Summarize to reinforce & to show that you listen Prepare patients for next steps 24

2. Motivate Sample language to use with patients 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]. 25

3. Plan Select methods & goals collaboratively Create goals aligned with readiness to change Assist patients to identify personal goals & preferences among methods 26

3. Plan Select methods & goals collaboratively Focus on attainable, measureable, timely goals Help anticipate potential challenges & barriers Brainstorm on methods to overcome problems 27

3. Plan Tips on selecting goals with patients Recommend ideal change but accept less if patients resist Change strategies when patients resist 28

3. Plan Tips to work collaboratively with patients Avoid argumentation which can be counterproductive & create defensiveness Collaborate to increase patient control/agency 13 29

3. Plan Sample language to use with patients 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? 30

3. Plan Sample language to use with patients 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. 31

3. Plan Offer support & follow-up care Follow up initially within one month or less Reinforce previous steps at follow-up visits Reassess & update plan based on current status 32

3. Plan Offer support & follow-up care Acknowledge efforts & experiences Offer continued support irrespective of success 33

3. Plan Discuss various options for support Follow-ups by phone, office visit, or HIPAA-compliant email Self-help materials printed or online Guidance to obtain social support 34

SAMPLE VIDEOS 35

Video Example for Adolescent Adolescent Patient 14 (4min 26sec) www.youtube.com/watch?v=fx90j4jd9sc From University of Maryland, Baltimore 36

Video Example for Adult Adult Patient 15 (6min 37sec) www.youtube.com/watch?v=ebsqetbwedq From University of Maryland, Baltimore 37

References 1. 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. 38

References 12. 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 39

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. 40