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TRANSCRIPT
Brett R. Harris, DrPH
University at Albany School of Public Health
Screening, Brief Intervention, and Referral to Treatment: An Overview
Source: Center for Social Innovation
Source: National Institute for Alcohol Abuse and Alcoholism. Alcohol screening and brief intervention for youth: A practitioner’s guide.
National Institutes of Health. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf (2)
*34% of US high school students have never had a drink in their lifetimes (1)
Source: Conrad N. Hilton Foundation
Source: Center for Social Innovation
Negative Consequences of Use
• Adolescent substance use is associated with…
– Risky sexual behavior, STDs, pregnancy (3-5)
– Motor vehicle accidents, other accidents, and injuries (5,6)
– Chronic diseases (4)
– Substance dependence and cognitive impairment (6,8)
– Depression (1)
– Fights (1)
– Criminal and delinquent behavior (7)
– Poor school performance, school misconduct, and dropout (9)
Source: Conrad N. Hilton Foundation
Substance Use Services
• Historically, the focus has been on
– Prevention: prevent abstainers from initiating use
– Treatment: provide substance abuse treatment for those with
substance use disorders (SUDs) with the goal of abstinence
• What about for everyone else?
– Most who drink or use drugs do not have an SUD and do not seek
treatment
– Can benefit from early intervention outside of substance abuse
treatment settings to reduce risky use before more severe problems
occur
What is SBIRT?
An evidence-based prevention and early intervention model to
address the full spectrum of substance use
• Screening
• Brief Intervention
• Referral to Treatment
• Goal: Identification of at-risk substance users in non-
substance abuse treatment settings and provision of
appropriate services
Source: Conrad N. Hilton Foundation infographic
Research Support for Adolescent SBIRT
• Research with adolescents found that SBIRT…– Increased identification of risky alcohol and drug use (10)
– Decreased intention to use (11,12)
– Reduced alcohol and drug use (11,13)
– Prevented initiation of alcohol and drug use among abstainers (12)
– Reduced drinking and driving (14)
• Youth are satisfied with services, plan to follow through with advice,
and are honest when reporting their use (12,13)
• SBIRT is recommended by the American Academy of Pediatrics (15)
Screening
Health/Social AssessmentsMAYSI-2
Now what?
How do you interpret responses to these questions?
Benefits of Standardized Tools
• Provide an evidence-based algorithm for provision of
appropriate services
• Takes the guessing game out of identifying problem
substance use
– Use of standardized screening tools results in higher detection
of problem substance use and is a best practice (16)
– Use of “informal screening” or larger health assessments such
as the MAYSI-2 does not provide these features
Relying on Clinical Impressions (17)
Leads to failure to identify and address problem use
• Of the 86 adolescents exhibiting abuse or dependence, providers
classified…
– 24.4% with no use, 50% with minimal use, 15.1% with problem use, 10.5% with
abuse, and 0% with dependence
Adolescent
Diagnostic
Interview
Clinical
Impressions
Problem use 100+ 18
Substance abuse 50 10
Substance dependence 36 0
Identification of problem use by clinical impressions versus diagnostic interview
Learning to Use Standardized
Tools
• Using a standardized tool does not guarantee identification
and intervention with risky users
– It is important to understand how to score them and provide the
appropriate intervention based on screening score
– EXAMPLE: In a sample of youth in which 14% scored + on the
CRAFFT, pediatricians only identified 5% with problem use based
on clinical impressions (16)
• Of the 5%, almost 20% were not recommended for intervention
CRAFFT Screening Tool(18)
• The CRAFFT is a validated screening tool for use with adolescent
patients
• Because it screens for both alcohol and other drug problems
simultaneously, it is especially handy for providers
• CRAFFT consists of
Part A: 3 prescreening questions and
Part B: 6 items (Car, Relax, Alone, Forget, Friends, Trouble)
Scoring Algorithm
• A positive CRAFFT means the adolescent should be assessed for
alcohol/drug abuse or dependence
CRAFFT Part A: 3 Opening
QuestionsDuring the Past 12 months, did you:
1. Drink any alcohol (more than a few sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high? (“Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”.)
If adolescents answer:
• NO to all, ask the CAR question in Part B, then STOP
• YES to ANY, ask all of Part B
1. C - Have you ever ridden in a CAR driven by someone (including yourself) who was
“high” or had been using alcohol or drugs?
2. R - Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
3. A - Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. F - Do you ever FORGET things you did while using alcohol or drugs?
5. F - Do your FAMILY or FRIENDS ever tell you that you should cut-down on your drinking
or drug use?
6. T - Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CRAFFT Part B: 6 Questions
CRAFFT Scoring (15)
Each “Yes” is added to produce the screening score
• Reports no use in Part A = “Low Risk: Abstinence”
– Provide praise and encouragement for making healthy choices
– Give guidance to avoid riding in a car with someone who has been
drinking or using drugs
• Reports use in Part A; scores 0-1 = “Moderate Risk: CRAFFT-
Negative”– Provide brief advice to stop using substances
– Provide education on the health effects of substance use and the
effects it might have on their achievements and personalities
CRAFFT Scoring (15)
• CRAFFT score ≥ 2 = “High Risk: CRAFFT-Positive”
– Assess for risk or presence of addiction and the conviction they have for
making behavior changes
– Discuss history of use, patterns of increasing use, whether they have
made quit attempts, and whether they have experienced any negative
consequences from their use
– Consider scheduling a follow up appointment and/or providing a referral
to treatment, especially for scores 5-6 (very high risk)
• Yes to Car question = “Driving Risk”
– Encourage a commitment to avoid future driving or riding risks
Brief Intervention
• Engage
• Explore pros and cons
• Provide feedback
• Explore readiness to change
• Negotiate an action plan
• Summarize
Use OARS motivational interviewing techniques
• Open-ended questions, affirmations, reflective listening, summaries
Before we go further, I’d like to learn a little more about you.
Brief Intervention –Youth & Adolescents
What is a typical day like for you?What’s the most important thing in your life right now?Would you mind taking a few minutes to talk about your [X] use? Where does your [X] use fit in?
1. Engagement
I’d like to understand more about your use of “X”. What do you enjoy about “X”?What is not as “good” about your use of “X”?
2. Pros & ConsExplore Pros and ConsUse reflective listening
What else?So on the one hand you said <PROS>, and on the other hand <CONS>.
Reinforce positives
What are your thoughts?
3. Feedback
Ask permission
I have some information on low‐risk guidelines for drinking, would you mind if I shared them with you?
Provide information
We know that drinking•3 or more drinks in 2hrs ...(binge drinking)
•...drinking ‘X’ alcoholic drinks and/or use of illicit drugs can put you at risk for illness and injury. It can also cause health problems like [insert medical information].
What are your thoughts on that?
Elicit Response
4. Readiness to Change This Readiness Ruler is like the Pain
Scale we use in the hospital.On a scale from 1‐10, with one being not ready at all and 10 being completely ready,How ready are you to change your [X] use?
Readiness ruler
Reinforce positivesYou marked . That’s great. That
% ready to make ameans you’rechange.Why did you choose that number and not a lower one like a ‘1 or 2?’
Envision change
1 2 3 4 5 6 7 8 9 10
What are some options/steps that will work for you?
5. Negotiate an Action Plan
Those are great ideas! Is it okay for me to write down your plan, your own prescription for change, to keep with you as a reminder?
Write down action plan
Envision a future
Will you summarize the steps you will take to change your [X] use?
Explore Challenges
I’ve written down your plan, a prescription for change, to keep with you as a reminder.
Draw on past successes
Benefits of Change
What do you think you can do to stayCreate action plan
healthy and safe?What will help you to reduce the things you don’t like about using [X, Y,Z]?
Tell me about a time when you overcame challenges in the past.What kinds of resources did you call upon then?
Identify strengths & supports
Which of those are available to you now?
6. Summarize
“Let me summarize what we’ve been discussing and you let me know if there’s anything else you want to add or change.....”
Reinforce resilience & resourcesProvide handoutsGive action plan
Thank the adolescentReview the action plan.
Set up Follow‐up if needed Give Referrals if Appropriate:‐Outpatient Counseling‐NA/AA‐Primary Care‐Mental Health‐Handouts/Information
Providing Multiple BI Sessions
Adolescents who agree to make a behavioral change
should be given a follow-up appointment to discuss the
results of their efforts and should be praised for any
progress they made, no matter how small.
Referral to Treatment
Small percentage of youth will need referral to alcohol or drug treatment• All sites should have at least one current referral
agreement with an accessible certified treatment provider and be familiar with …• The programs and services of the local treatment providers
• The referral procedure
Additional Resources
• Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide
– http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuideOrderForm.htm
• Adolescent SBIRT Learner’s Guide (see handouts)
• SBIRT: A Brief Clinical Training for Adolescent Providers
– http://hospitalsbirt.webs.com/adolescent-providers
• IRETA SBIRT for Youth Learning Community
– Nationwide learning community of individuals who have implemented SBIRT
or are interested in implementing SBIRT with youth populations
– http://my.ireta.org/SBIRTyouthLC
• Brief Negotiated Interview
– http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-brief-negotiated-interview-bni/
• American Academy of Pediatrics SBIRT Policy Statement 2016
– http://pediatrics.aappublications.org/content/early/2016/06/16/peds.2016-1210
Citations1. Centers for Disease Control and Prevention. Youth risk behavior survey. 2013. Available at
http://www.cdc.gov/healthyyouth/yrbs/factsheets/index.htm. Accessed on March 12, 2015.
2. National Institute for Alcohol Abuse and Alcoholism. Alcohol screening and brief intervention for youth: A practitioner’s guide. National
Institutes of Health. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf. Accessed on May
12, 2015
3. American Academy of Pediatrics. Policy statement – Alcohol use by youth and adolescents: A pediatric concern. Pediatrics.
2010;125:5 1078-1087.
4. Sterling S, Valkanoff T, Hinman A, Weisner C. Integrating substance use treatment into adolescent health care. Curr Psychiatry Rep.
2012;14:453-461.
5. Mertens JR, Flisher AJ, Fleming MF et al. Medical conditions of adolescents in alcohol and drug treatment: Comparison with matched
controls. J Adolesc Health. 2007;40:173-179.
6. Schweer LH. Pediatric SBIRT: Understanding the magnitude of the problem. Journal of Trauma Nursing. 2009;16:3 142-147.
7. Pacific Institute for Research and Evaluation (PIRE). Underage drinking in New York: The facts. Office of Juvenile Justice and
Delinquency Prevention; 2011.
8. Hingson RW, Heeren T, Winter MR. Age of alcohol-dependence onset: Associations with severity of dependence and seeking
treatment. Pediatrics. 2006;118:755-763.
9. Bryant AL, Schulenberg JE, O’Malley PM, Bachman JG, Johnston LD. How academic achievement, attitudes, and behaviors relate to
the course of substance use during adolescence: A 6-year, multiwave national longitudinal survey. Journal of Research on
Adolescents. 2003;13:3 361-397.
10. Knight JR, Harris SK, Sherrit L, Van Hook S, Lawrence L, Brooks T, Carey P, Kossach R, Kulig J. Prevalence of positive substance
abuse screen results among adolescent primary care patients. Arch Pediatr Adolesc Med. 2007;161:11 1035-1041.
Citations11. D’Amico EJ, Miles JNV, Stern SA, Meredith LS. Brief motivational interviewing for teens at risk of substance use consequences: A
randomized pilot study in a primary care clinic. J Subst Abuse. 2008;35: 53-61.
12. Grenard JL, Ames SL, Wiers RW, Thush C, Stacy AW, Sussman S. Brief intervention for substance use among at-risk adolescents: A
pilot study. J Adolesc Health. 2007;40:2 188-191.
13. Harris SK, Csemy L, Sherritt L, Starostova O, Van Hook S et al. Computer-facilitated substance use screening and brief advice for
teens in primary care: An international trial. Pediatrics. 2012;129:6.
14. Knight JR, Sherritt L, Van Hook S, Gates EC, Levy S, Chang G. Motivational interviewing for adolescent substance use: A pilot study.
J Adolesc Health. 2005;37:167-169.
15. American Academy of Pediatrics. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics.
2011;128:e1330-40.
16. Wilson CR, Sherrit L, Gates E, Knight JR. Are clinical impressions of adolescent substance use accurate? Pediatrics. 2004;114:5
e536-40.
17. Harris SK, Herr-Zaya K, Weinstein Z, et al. Results of a statewide survey of adolescent substance use screening rates and practices
in primary care. Subst Abuse. 2012;33:321-326.
18. The Center for Adolescent Substance Abuse Research. The CRAFFT screening tool. Available at http://www.ceasar-
boston.org/CRAFFT/index.php. Accessed on March 25, 2015.
