overview of brief intervention for risky substance use in primary care
TRANSCRIPT
February 2014
OVERVIEW OF BRIEF INTERVENTION FOR RISKY SUBSTANCE
USE IN PRIMARY CARE
Prepared byCASAColumbia®
© CASAColumbia 2014
Outline
• Introduction• Three Key Steps
− Engage− Motivate− Plan
• Sample Videos
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INTRODUCTION
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Addiction & Risky Use
For background information on addiction Addiction Medicine: Closing the Gap between Science and Practice1
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Addiction & Risky Use
For information on screening, diagnosis, treatment planning & management
Overview of Addiction Medicine for Primary Care2 (62 Slides)
Overview of Addiction Medicine for Primary Care: Supplement3 (30 Pages)
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Addiction & Risky Use
• Approach comprehensively across substances• Address tobacco/nicotine, alcohol & other drugs• Manage co-occurring disorders
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dopamine transporters
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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 Care2
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Addiction & Risky Use
All patients with addiction
should receive treatment
All patients who are risky users
should receive a brief intervention
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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
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Brief Intervention for Risky Use
• 5-10 minutes as effective as 20 minutes4
• Tobacco/nicotine quit rate 3X as likely5
• Average drinks per week reduced by 13-34%6
• 60% of patients reduce illicit drug use7
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Common Frameworks
• 5A Approach: developed for tobacco/nicotine cessation8
• FRAMES: developed for reducing alcohol use9-10
• Motivational Interviewing: developed for reducing alcohol use11
• All of the above share similar concepts which are summarized in this presentation
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Comprehensive Approachfor tobacco/nicotine, alcohol & other drugs
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• Risky use of multiple substances occurs often• Comprehensively addressing tobacco/nicotine,
alcohol & other drugs may help prevent replacement of one substance with another
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THREE KEY STEPS
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Brief Intervention: Key Steps
1. Engage
2. Motivate
3. Plan
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1. EngageAssess to determine baseline & readiness
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• Inquire about current patterns of substance use
• Determine patient perception of substance use8
• Identify personal values & goals10
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1. EngageExplore the potential for change
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• Discuss impact of substance use on goals
• Develop a discrepancy between substance use & achieving goals
• Elicit need & perceived ability to change
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1. EngageTips for speaking with patients
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• Establish rapport & ask permission to discuss• Use nonjudgmental, empathic language & tone• Ask open-ended questions from general to
specific11
• Listen reflectively: repeat, rephrase, paraphrase
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1. EngageSample language to use with patients
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• “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?”
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2. MotivateOffer personalized advice & feedback
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Well delivered advice is associated with improved patient satisfaction12
• Provide clear, specific, personalized feedback• Include risks & consequences of use• Express concern & recommend explicit changes• Support patient self-determination & autonomy8
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2. MotivateTips to motivate patients to change
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• Emphasize confidence in ability to change
• Assure continued support throughout process
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2. MotivateTips to communicate effectively with patients
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• Tailor to patient level of health literacy
• Provide small amounts of feedback at a time10
• Use empathic style for more cooperation & less resistance
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2. MotivateSample language to use with patients
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• “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
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2. MotivatePromote self-efficacy & empower patients
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• Use reflective listening, summaries & affirmations11
• Review strengths & past successes
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2. MotivateTips to encourage patients to change
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• Validate frustrations but remain optimistic
• Summarize to reinforce & to show that you listen
• Prepare patients for next steps
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2. MotivateSample language to use with patients
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• “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].”
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3. PlanSelect methods & goals collaboratively
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• Create goals aligned with readiness to change
• Assist patients to identify personal goals & preferences among methods
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3. PlanSelect methods & goals collaboratively
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• Focus on attainable, measureable, timely goals• Help anticipate potential challenges & barriers• Brainstorm on methods to overcome problems
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3. PlanTips on selecting goals with patients
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• Recommend ideal change but accept less if patients resist
• Change strategies when patients resist
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3. PlanTips to work collaboratively with patients
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• Avoid argumentation which can be counter-productive & create defensiveness
• Collaborate to increase patient control/agency13
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3. PlanSample language to use with patients
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• “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?”
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3. PlanSample language to use with patients
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• “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.”
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3. PlanOffer support & follow-up care
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• Follow up initially within one month or less
• Reinforce previous steps at follow-up visits
• Reassess & update plan based on current status
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3. PlanOffer support & follow-up care
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• Acknowledge efforts & experiences• Offer continued support irrespective of success
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3. PlanDiscuss various options for support
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• Follow-ups by phone, office visit, or HIPAA-compliant email
• Self-help materials printed or online• Guidance to obtain social support
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SAMPLE VIDEOS
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Video Example for Adolescent
Adolescent Patient14 (4min 26sec)
www.youtube.com/watch?v=fX90j4jD9Sc
From University of Maryland, Baltimore
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Video Example for Adult
Adult Patient15 (6min 37sec)
www.youtube.com/watch?v=ebsqETBWEdQ
From University of Maryland, Baltimore
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References1. 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.
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References12. 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
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© CASAColumbia 2014
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.
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