overview: screening brief intervention and referral to treatment

OVERVIEW: SCREENING BRIEF INTERVENTION AND REFERRAL TO TREATMENT

Holly Hagle, PhD

Director of the Northeast ATTC

OBJECTIVES FOR THIS WORKSHOP

1.Compare and contrast alcohol and other drug (AOD) use as it relates to the continuum of use, abuse, and dependency.

2. Describe the principles of screening, brief intervention, and referral to treatment (SBIRT) process.

3. Review the stages of change and Motivational Interviewing (MI) strategies and their implication for the intervention process.

4. Examine the elements of effective brief interventions.

5. Examine SBIRT for at risk individuals.2

SBIRT AN EFFECTIVE APPROACH

ScreeningBrief InterventionReferralTreatment

3

Intro to SBIRT

Source: SBIRT Oregon Residency Program, 2012

ALCOHOL AND US Annual cost of alcohol related injuries: $130 billion(1)

Substance abuse is strongly associated with health problems, disability, death, accident, injury, social disruption, crime and violence (1)

30% of trauma center admissions are intoxicated (1)

24.255 of high school students have 5 or more drinks in a row on at least 1 day during a month (2)

49% of men who identified as homosexual ages 25-29, reported binge drinking (3)

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Sources: 1.H. Gill Cryer, MD, Chief of Trauma, UCLA Medical Center2.CDC study - http://www.cdc.gov/hiv/youth/3.CDC studyhttp://www.cdc.gov/mmwr/preview/mmwrhtml/ss6014a1.htm?s_c

id=ss6014a1_e

ALCOHOL AND US National data indicates that the rate of STD among female heavy

drinkers was 7.3% (highest for women 18-25 years old) (1) 79,000 deaths were attributable to excessive alcohol use in the US (2) Excessive alcohol use is the third leading life-style related cause of

death for the US (2)

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Sources: 1. CDC - http://www.cdc.gov/ncbddd/fasd/research-preventing.html 2. CDC - http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm

DRUG USE AND US Injection drug users (IDUs) account for more than 60 percent

of all new hepatitis C virus (HCV) infections in the United States. (1)

Fifty to eighty percent of new IDUs are infected within 6 to 12 months of initial injection. (1)

Of an estimated 15.9 million people who inject drugs worldwide, up to 3 million are infected with HIV (2)

20.8% of students reported use of marijuana at least one time in the last month (3)

Ecstasy use in the past year (from 6 percent in 2008 to 10 percent in 2010).

Marijuana use among teens increased by a disturbing 22 percent (from 32 percent in 2008 to 39 percent in 2010).

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Sources: 1.CDC- U.S. Centers for Disease Control and Prevention - http://www.thebodypro.com/content/art22608.html2.Mathers, B. et al. (2008) http://www.unodc.org/documents/frontpage/Facts_about_drug_use_and_the_spread_of_HIV.pdf3.CDC - http://www.cdc.gov/hiv/youth/4. Join together online - http://www.drugfree.org/join-together/addiction/national-study-confirms-teen-drug-use-trending-in-wrong-direction

SCOPE OF THE PROBLEM Alcohol and/ drugs are a factor in:

60-70% of homicides

40% of suicides

40-50% of fatal motor vehicle crashes

60% of fatal burn injuries

60% of drownings

40% of fatal falls

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Source: Virginia department of Health, Division of Injury and Violence Prevention, retrieved from http://www.vahealth.org/Injury/data/reports/documents/2008/pdf/Alcohol%20and%20Injury%20Report.pdf

WHY SBIRT?

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment servicesFor persons with substance use disordersThose who are at risk of developing these disorders

Primary care, mental health, AOD and other community settings provide opportunities for intervention with at-risk substance users

Before more severe consequences occur

Source: The Pacific Southwest Addiction Technology Transfer Center - SBIRT webinar slides March 2010

SBIRT EFFECTIVENESS Rates of illicit drug use dropped by 67.7 percent six

months after patients using illicit drugs had received help through a SBIRT program.

Heavy alcohol use dropped by 38.6 percent. Illicit drug users receiving brief treatment or referral

to specialty treatment also reported other quality of life improvements: 29.3 percent reported feeling generally healthier 31.2 percent reported experiencing fewer emotional

problems 15.4 percent reported improved employment status 64.3 percent reported fewer arrests 45.8 percent who were homeless reported no longer being

homeless Madras, B.K., Compton, W.M., Avula, D. Stegbauer, T., Stein, J.B., Clark, H.W., Drug and Alcohol Dependence Volume 99, Issues 1–3, 1 January 2009, Pages 280–295.

SBIRT EFFECTIVENESS

Study - Moyer et al, 2002; Whitlock et al, 2004; Bertholet et al, 2005; Ppt. Source – SBIRT Oregon Residency Program, 2012

WHY SBIRT?

Source – SBIRT Oregon Residency Program, 2012

LET’S LOOK AT THE CONTINUUM OF USE

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Use

SCREENING

8%5%

78% Healthy

Dependent

9%

Harmful

Risky

Source – SBIRT Oregon Residency Program, 2012

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The Drinkers’ Pyramid

3-7 % alcohol dependent or harmful users

40% abstainers

35- 40% low-risk drinkers

10- 15% hazardous, at-risk users

Source: World Health Organization (WHO)

WHAT IS A LOW-RISK LIMIT?

No more than two standard drinks a day

Do not drink at least two days of the week

NIAAA Guidelines

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There are times when even one or two drinks can be too much:

When operating machinery When driving When taking certain medicines If you have certain medical conditions If you cannot control your drinking If you are pregnant

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WHAT IS A LOW-RISK LIMIT?

AT RISK DRINKING

Men: more than 14 drinks per week or consuming more than 4 drinks per occasion

Women (and anyone age 65+): more than 7 drinks per week or consuming more than 3 drinks per occasion

Drinking: more than 2 standard drinks per day w/o abstaining for at least 2 days per week

NIAAA Guidelines

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Source: NIAAA Guidelines

Abuse

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Substance Abuse vs. Substance Dependence

Substance Abuse: the misuse of an illicit drug, prescription drug or over-the-counter medication.

Substance abuse often involves a pattern of harmful drug use for mood altering purposes.

A person diagnosed with substance abuse is not considered to be addicted or dependent (otherwise the diagnosis would be substance dependence).

DEFINITIONS: DRINKING EPISODES

A drinking “binge” is a pattern of drinking that brings blood alcohol concentrations (BAC) to 0.08 or above.

Typical adult males: 5 or more drinks in over a 2 hour period

Typical adult females: 3 or more

For some individuals, the number of drinks needed to reach “binge” level BAC is lower

University of Oklahoma “Police Notebook” BAC Calculator www.ou.edu/oupd/bac.htm 23

Addiction

CHEMICAL DEPENDENCY According to the National Epidemiologic Survey on

Alcohol and Related Conditions

8.5 percent of adults in the United States meet the criteria for an alcohol use disorder

2 percent of adults met the criteria for a drug use disorder

1.1 percent of adults met the criteria for both

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26

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STEREOTYPE

LINCOLN ON ALCOHOLISM

“In my judgment such of us who have never fallen victim (of alcoholism) have been spared more by the absence of appetite than from any mental or moral superiority over those who have.” (remarks to the Springfield, Illinois Washingtonian

Society, February, 1842)

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Addiction is Manageable

Recovery HappensAddiction is Manageable and, with treatment, has good outcomes.

….all this bad news!

Is there no hope?

Of course there is hope! Recovery is all around us.

“No known cure” doesn’t mean not “untreatable.” We don’t cure diabetes, we manage it with proper diet, blood sugar monitoring and other acts of discipline.

RECOVERY

Recovery from alcoholism and drug addiction is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. (SAMHSA/CSAT)

WHY DON’T WE SCREEN AND INTERVENE?

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DON’T ASK-DON’T TELL?

Alcohol and Drug Abuse problems are often unidentified

In a study of 241 trauma surgeons, only 29% reported screening most patients for alcohol problems*

In a study of 7,371 primary care patients, only 29% of patients reported being asked about their use of alcohol or drugs in the past year**

(*Danielson et al., 1999; **D’Amico et al., 2005) 35

QUESTION TO THE GROUP

What barriers get in the way of screening?36

WHY WE DON’T SCREEN & INTERVENE: BARRIERS

Lack of awareness and knowledge about tools for screening

Discomfort with initiating discussion about substance- use/misuse

Sense of not having enough time for carrying out interventions

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WHY WE DON’T SCREEN & INTERVENE: BARRIERS

Healthcare negative attitudes toward substance abusers

Pessimism about the efficacy of treatment

Fear of losing or alienating patients

Lack of simple guidelines/procedures for brief intervention

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WHY WE DON’T SCREEN & INTERVENE: BARRIERS

Uncertainty about referral resources

Limited or no insurance company reimbursement for the screening for alcohol and other drug use.

Lack of education and training about the nature of addiction or addiction treatment

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WHY WE DON’T SCREEN & INTERVENE: OPPORTUNITIES

When AOD screening becomes more routine, you typically can expect: Greater patient and

family satisfaction

Better patient management and follow-up

40

WHY WE DON’T SCREEN & INTERVENE: OPPORTUNITIES

The concern shown by

healthcare providers, even

during brief intervention, can

provide patients with

significant motivation for

change or referral for further

assessment and treatment.

41

WHY WE DON’T SCREEN & INTERVENE: OPPORTUNITIES

The costs of AOD counseling

for patients in relation the

costs for AOD related

hospitalization are small, but

the value in terms of

prevention may be great.

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ROLE OF HEALTHCARE PROFESSION IN DRUG AND ALCOHOL USE–

WHAT CAN WE DO TO HELP?

1. Identify use, misuse, and problematic use; screen with simple direct methods

2. Connect use/misuse to health related issues

3. Encourage consumption reduction

4. Conduct a Brief Intervention

5. Refer for formal assessment

43

IDENTIFICATION OF USE, MISUSE, AND PROBLEMATIC USE:

HOW CAN WE APPROACH THIS PROCESS?

There are many screening tools that are brief and easy to use that can help to determine the involvement of a person with AOD.

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Goals of Screening

Identify both hazardous/harmful drinking or drug use and those likely to be dependent

Use as little patient/staff time as possible

Create a professional, helping atmosphere

Provide the patient information needed for an appropriate intervention

Use “teachable moments”

SBIRT AN EFFECTIVE APPROACH

ScreeningBrief InterventionReferralTreatment

46

SBIRT EFFECTIVENESS“Alcohol screening and counseling (is) one of the highest-ranking preventive services among the 25 effective services evaluated using standardized methods. Since current levels of delivery are the lowest of comparably ranked services, this service deserves special attention by clinicians and care delivery systems.”

- American Journal of Preventive Medicine

SBIRT EFFECTIVENESS

Rates of illicit drug use dropped by 67.7 percent six months after patients using illicit drugs had received help through an SBIRT program.

Heavy alcohol use dropped by 38.6 percent.

Madras, et.al. (2009)

Harris County (Texas) Hospital District Study: Patients reporting any days of heavy drinking dropped

from 70% at intake to 37% at 6-month follow-up Patients reporting any days of drug use dropped from

82% at intake to 33% at follow-up

Spence, et. al. InSight Project Research Group (2009)

SBIRT SAVES MONEY

Literature reports a 4 to 1 savings with SBIRT approach

2002 study published in the journal Alcoholism: Clinical and Experimental Research (Vol. 26, No. 1), researchers found that every dollar invested in an SBIRT-like approach saved $4.30 in future health care costs. These reduced costs are associated with changes in:

Alcohol useED visitsHospital daysLegal eventsMotor vehicle accidents

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SBIRT as a Response Option

Abstinence Infrequent use Problematic use Abuse D

ependence

Brief Intervention

AODA Treatment

Primary Prevention

LETS LOOK AT THE SCREENING INSTRUMENTS

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SCREENING

Involves the use of …

Alcohol and/or drug abuse screening tools

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SCREENING VS. ASSESSMENT

Screening: determining the possibility that a condition exists

Assessment: confirming the existence of a condition and its severity.

WE TAKE A LOOK AT MANY FACTORS

pattern(s) of use negative consequences context of use control of use/ motivation previous treatment

SCREENING TOOLS

CAGE3 question AUDIT3 question drug screen1 question binge drinking questionBAC

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C.A.G.E.

Please answer yes or no to each item that best describes how you

have felt and behaved over your whole life.

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you had an Eye-opener first thing in the morning to steady nerves or get rid of a hangover?

If there is a yes answer to any of these questions please complete the

full AUDIT.

Ewing JA. (1984). Detecting alcoholism, the CAGE questionnaire. Journal of the American Medical Association, 252(14), 1905-1907.

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ALCOHOL USE DISORDERS TEST - AUDIT

Full AUDIT 10 question instrument

Brief 3 question version

Screens for hazardous drinking, harmful use and alcohol dependency

57

THE AUDIT – 3 QUESTION VERSION

Add the number for each question to get the total score for items 1, 2, & 3

A score of 4 or more for men and 3 or more for women is considered positive.

(Generally, the higher the score the more likely it is that the patient’s drinking is affecting his/her health and safety)

1. How often do you drink anything containing alcohol?

(0 )Never (1) Less than monthly (2) Monthly

(3) Weekly (4 ) 2-3 times a week (5) 4-6 times a week (6) Daily

2. How many drinks do you have on a typical day when you are drinking?

(0) 1 drink (1) 2 drinks (2) 3 drinks

(3) 4 drinks (4) 5-6 drinks (5) 7-9 drinks (6) 10 or more

3. How often do you have four or more drinks on one occasion?

(0) Never (1) Less than monthly (2) Monthly

(3 ) Weekly (4) 2-3 times a week (5) 4-6 times a week (6) Daily

Babur, T.F., Higgins-Biddle, J.C., Saunders, J.B., Maristela G. Monteiro, M.G. (2001). The alcohol use disorders identification test guidelines for use in primary care.

(2nd ed.). World Health Organization, Department of Mental Health and Substance Dependence.58

Domains Question

Number

Item Content

Hazardous Alcohol

Use

1

2

3

Frequency of drinking

Typical quantity

Frequency of heavy drinking

Dependence Symptoms 4

5

6

Impaired control over drinking

Increased salience of drinking

Morning drinking

Harmful Alcohol Use 7

8

9

10

Guilt after drinking

Blackouts

Alcohol-related injuries

Others concerned about drinking

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DOMAINS AND ITEM CONTENT OF THE FULL AUDIT

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INTERPRETATION OF AUDIT-

Score Degree of Problems 0-7 No Problems at this time

8-15 Hazardous & Harmful Alcohol Use

16-19 High Level of Alcohol Problems and Possible Dependence

20-40 Possible Alcohol Dependence

DRUG ABUSE SCREENING TEST (DAST)

DAST – 10 items used to screen for potential involvement in the use of drugs.

Three question pre-screen for drug use.

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THREE QUESTION PRE-SCREEN FOR DRUG USE

If there is a yes response to any item please use full DAST.

1. In the last year have you used drugs other than those required for medical reasons?

Yes No

2. In the last year, have you used prescription or other drugs more than you meant to?

Yes No

3. Which drug do you use most frequently? _________________________________

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ONE QUESTION SCREEN FOR BINGE DRINKING

When was the last time you had more than x (x=5 for men; x = 4 for women) drinks on 1 occasion?

Williams, R.H., Vinson, D.C. (2001). Validation of a single question screen for problem drinking. Journal of Family Practice 50(4), 307-312.

63

BRIEF INTERVENTION64

Brief interventions are those practices that aim to identify a real or potential alcohol or other drug (AOD) problem and to motivate an individual to do something about it.

THE BRIEF INTERVENTION:

Short dialogues between the medical provider and the patient that typically involve:FeedbackClient engagementSimple advice or brief counselingGoal-settingFollow-up

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Brief Negotiated InterviewFRAMES ApproachFLO – Feedback, Looking for Change, Options

5A’s – Ask, Advise, Assess, Assist, Arrange

WORLD HEALTH ORGANIZATION(AM J PUB HEALTH 1996)

“A cross-national trial of brief interventions with heavy drinkers”

• Multinational study in 10 countries (n=1,260)• Interventions included simple advice, brief and extended

counseling compared to control group• Results: Consumption decreased

– 21% with 5 minutes advice, 27% with 15 minutes compared to 7% controls

– Significant effect for all interventions

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ASSESSING READINESS: STAGES OF CHANGE

It’s important to assess for stage of change so you can determine the right kind of intervention.

Intervention matching individualizes the approach to Intervention matching individualizes the approach to readiness aspectsreadiness aspects

TThe model describes 5 stages of change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-287.

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3 TASKS OF A BRIEF INTERVENTIONFLO

Feedback

Listen and Understand

Options Explored

Source of information for slides 62-80,82,86: The Pacific Southwest Addiction Technology Transfer Center - SBIRT PDF 2010

TASK #1: FEEDBACK

Give the Patient Feedback Using:

o Rangeo Accurate Informationo Normal Rangeso Give their scoreo Elicit reaction

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EXAMPLE Range: “BAC can range from 0 (no alcohol

detected) to .4 (usually lethal)

Accurate Information: “.08 defines drunk driving (heavy drinking)

Normal: “Normal drinking range is .03-.05

Give their score: “Your level was…”

Elicit reaction: “What do you make of that?”72

FEEDBACK

Your job is to deliver the feedback

Let the patient decide where to go with it

73

FEEDBACK

Handling resistance…

• Look, I don’t have a drinking problem• My dad was an alcoholic; I’m not like him• I can quit anytime I want to• I don’t know why I had such a high BAC, I

hardly drank anything• As hard as I work, I have a right to drink and

relax 74

FEEDBACK

75

To avoid this…

Let Go!!!

FEEDBACK

Easy Ways to Let Go…

o I’d really like to hear your thoughts..

o I’d just like to give you some information..

o What you do is up to you.76

FEEDBACK

Finding a Hooko Ask about their concernso Be non-judgmentalo Watch for signs of discomfort with the status

quoo Always ask: “What role do you think

alcohol played in your injury?”o Let the patient decide what they want to doo Just bringing up the subject is helpful

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TASK #2: LISTEN AND UNDERSTAND

Listen to what the situation sounds like from the patient’s perspective

Show that you understand where they are coming from

Listen to assess readiness to change

78

LISTEN AND UNDERSTAND

Useful Tools to Promote Change

o Pros and Cons

o Importance/Readiness/Confidence Rulers

79

PROS AND CONSWhat do you like about drinking?

What do you see as the downside?

What else?

Summarize both pros and cons…“On the one hand you said…, on the

other hand you said…80

THE RULERS

Importance/Readiness/Confidence

81

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On a scale from 0 to 10, where 0 is not at all important and 10 is very important, how important is it to you to ______ your drinking right now?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Not at all Important Very Not at all Important Very ImportantImportant

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On a scale from 0 to 10, where 0 is not at all ready and 10 is very ready, how ready are you to ______ your drinking right now?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Not at all Ready Very ReadyNot at all Ready Very Ready

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On a scale from 0 to 10, where 0 is not at all confident and 10 is very confident, how confident are you right now that you can meet your goal of ________ ?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

Not at all Confident Very ConfidentNot at all Confident Very Confident

THE RULERS

For each ask…

“Why didn’t you give it a lower number?”

“What would it take to …”

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TASK #3: OPTIONS EXPLORED

o What do you think you will do?

o What changes are you thinking about making?

o What do you see as your options?

o Where do we go from here?

o What happens next?

86

OFFER A MENU OF OPTIONS

Manage your drinking (cut down to low-risk limits)

Stop drinking

Never drink and drive (reduce harm)

Nothing (no change)

Seek help (refer to treatment)

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EXPLORE PREVIOUS SUCCESSES

“Have you stopped/cut back drinking/drug use before?”

“How were you able to do it?”

“Who helped and supported you?”

“Have you made other kinds of changes in your life in the past?”

“How did you do that?” 88

THE ADVICE SANDWICH

Ask permission

Give Advice/Suggest Options

Ask for a response

89

CLOSING THE CONVERSATION- SEW

Summarize the patient’s statements in favor of change

Emphasize their strength and ability to change

What agreement was reached?

90

SPIRIT OF MOTIVATIONAL INTERVIEWING

Collaboration (vs. Confrontation) Meeting of aspirations Neither exhortation nor persuasion

Evocation (vs. Education) Drawing out Neither instilling nor installing

Autonomy (vs. Authority) Personal responsibility Neither imposition nor coercion

A GOOD OUTCOME FROM BI

Reduction or cessation of use (even temporary)

Starting to think about reducing

Agreeing to accept referral

92

IT MATTERS HOW YOU TALK TO THE PATIENT You are singing off key if you find yourself…

Challenging Warning Finger-wagging Shaming Labeling Confronting Being Sarcastic Moralizing Giving unwanted advice 93

Source – SBIRT Oregon Residency Program, 2012

REFERRAL TO TREATMENT95

SPECIALTY TREATMENT NEAR YOU

o Do you have a current listing of substance abuse treatment centers?

o Have you developed a referral relationship with them?

o Are you able to do a “warm handoff”?o Do you have information about 12-Step and

other recovery programs in your area?

96

SBIRT IN VARIOUS SETTINGS

Universal SBIRT – Where can you use SBIRT?

97

LET’S USE SBIRT98

ROLE PLAYS RELEVANT TO THE SITES (LARGE AND SMALL GROUP DISCUSSIONS)

Setting: Develop scenario relevant to the your primary worksite or the target population you work with (community health clinic, school, hospital, EAP, Jail, ER, Others???)

Example scenario – Age Gender Other descriptive features (cultural, marital status, stressors,

etc.) Circumstances leading to the interview AUDIT score 8-15 or DAST 3-5 Use BI Observation Sheet as a guide (role play)

THANKS FOR YOUR ATTENTION

Questions?

Holly Hagle, PhDDirector, Northeast

Addiction Technology Transferholly@ireta.org

100

101

SELECTED REFERENCES

Babur, Thomas et al., (2001) AUDIT: The Alcohol Use Disorders Identification Test – Guidelines for Use in Primary Care. World Health Organization, Department of Mental Health and Substance Dependence, Second Edition.

Babur, Thomas and Higgins-Biddle, John C. (2001) Brief Intervention For Hazardous and Harmful Drinking: A Manual for Use in Primary Care. World Health Organization, Department of Mental Health and Substance Dependence.

D’Amico, E. J., Miles, J. N. V., Stern, S. A., & Meredith, L. S. (2008). Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment, 35, 53-61.

Dennis, M. ( 2006, April). The current renaissance of adolescent treatment. Talk given at Project Fresh Light Partnership Meeting, Madison, WI. Retrieved from: www.chestnut.org/LI/Posters/1-The_Current_Renaissance_of_Adolescent_Treatment_4-17-06.pps.

102

Selected References (cont.)

Knight, J. R. (2006, March). Adolescent substance abuse: New strategies for early identification and intervention in primary medical care. Presentation to the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore, MD.

Knight, J. R., Sherritt, L., Shrier, L. A., Harris, & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatric and Adolescent Medicine, 156, 607-614.

Knight, J. R., Sherritt, L., Van Hook, S., Gates, E. C., Levy, S. & Chang, G. (2005). Motivational interviewing for adolescent substance use: A pilot study. Journal of Adolescent Health, 37, 167-169.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (Second edition). New York: Guilford Press.

Miller, W. R., & Wilbourne, P. L. (2002). Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97(3), 265-277.

103

Monti, P. M., Colby, S. M., & O’Leary, T. A. (Eds.). (2001). Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions. New York: Guilford Press.

O’Leary Tevyaw, T., & Monti, P. M. (2004). Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications, and evaluations. Addiction, 99(Suppl. 2), 63-75.

Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical therapy toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-287

Stern, S. A., Meredith, L. S., Gholson, J., Gore, P., & D’Amico, E. J. (2007). Project CHAT: A brief motivational substance abuse intervention for teens in primary care. Journal of Substance Abuse Treatment, 32, 153-165.

.

Selected References (cont.)

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Substance Abuse Tool Box: Information for Primary Care Providers, (2004). Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services,2nd Edition White, W., & Kurtz, E., (2006). Recovery, Linking Addiction Treatment & Communities of Recovery: A Primer For Addiction Counselors and Recovery Coaches. IRETA, Pittsburgh, PA.

Source: SAMHSA webinar (2011) Health Care Reform: Implications for Behavioral Health Providers http://www.youtube.com/watch?v=D0z1T3CRh_8

Winters, K. C. (2005). Expanding treatment options for drug-abusing adolescents using brief intervention. Retrieved from: www.tresearch.org/ resources/specials/2005Jan_AdolescentTx.pdf.

Understanding Drug Abuse and Addiction: What Science Says. National Institute on Drug Abuse (NIDA). National Institute of Health.

Selected References (cont.)