Children Suffer From Parental Substance Abuse

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(No Transcript)
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Learning Objectives

• You will be able to
• Describe the substance use continuum
• Cite data on the effectiveness ofscreening and
  brief intervention
• Conduct screening, intervention, and referral for
  women of reproductive age

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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


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Standard Drink
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At-Risk Drinking

• Per Week Per OccasionMen gt14 drinks gt4 drinks
• Women gt7 drinks gt3 drinks
• Elders gt7 drinks gt1 drink
• Pregnant Any Any

(NIAAA Physicians Guide, 1995)
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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


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Rationale for Generalist Care

• Risky and problematic substance use is common in
  our settings
• Most affected people receive no intervention or
  treatment
• Early identification and intervention can prevent
  adverse effects, improve other health outcomes,
  and save money

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Generalist Care for Substance Use Related
Disorders
Screen if positive, perform brief assessment
Abstinence or low-risk use
At-risk use or abuse
Dependence
Refer to treatment
Prevention message
Brief intervention



Motivational Interviewing
Follow-Up
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Evidence on Screening

• Screening instruments are often tested by
  concurrent validity
• Screen is compared to a gold standard criterion
  measure
• Gold standard is usually a lengthy diagnostic
  interview

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Definition of Screening

• Procedure to recognizeindividuals with a
  disorder or at-risk for a disorderbefore obvious
  manifestationsof the disorder are apparent.
• Examples
• Cancer and depression

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Choose Screens By ...

• Number of items
• Method of administration
• Substances covered
• Accuracy by age group, gender, pregnancy status,
  ethnic group

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AUDIT

• 10 questions - multiple choice
• Administered in writing
• Alcohol only
• Screens for at-risk drinking, abuse, and
  dependence
• Accurate across many cultures/nations
• Sens 51 - 97 Spec 78 - 96

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CAGE

• 4 yes/no questions (1 yes positive)
• Administered by interview
• Alcohol only
• Screens for abuse and dependence
• Add quantity and frequency questions to screen
  for at-risk drinking
• Sens 43 - 94 Spec 78 - 96

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CRAFFT

• 6 yes/no questions (2 yeses positive)
• Administered by interview
• Alcohol and drugs
• Validated for adolescents
• Sens 92 Spec 82

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Two-Item Conjoint Screen

• 2 yes/no questions (1 yes positive)
• Administered by interview
• Covers alcohol and drugs
• Screens for abuse and dependence
• Add quantity and frequency questions to screen
  for at-risk use
• Sens 81 Spec 81

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TWEAK

• 5 questions
• Administered by interview
• Covers alcohol only
• Screens for abuse and dependence for pregnant
  women
• Sens 59 - 87 Spec 72 - 94

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TWEAK

• Tolerance
• Worry
• Eye-Opener
• Amnesia
• K (C)ut down

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Q/F Questions on Alcohol

• How many days a week do you drink some alcohol?
• How much do you typically drink when you do
  drink?
• Whats the most youve had to drink at one time
  in the past 3 months?

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Other Questions to Consider

• Have you ever tried or experimented with-
  Marijuana? - Inhalants?- Cocaine? - Pills?-
  Shooting Up? - Any other drugs?
• Days per week, usual quantity, maximum
• Have you ever gotten any help for an alcohol or
  drug problem?

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Transitions to Screening

• Routine questions
• Tie into pt's/client's concern.
• Questions on preventive health
• Family medical or social history
• Diet history
• Leisure activities
• Stresses and ways of coping

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Sample Adult Screening Protocol

• Transition Stresses and ways of coping
• Do you drink alcohol?
• Have you ever experimented with any drugs?
• Ask TWEAK questions
• Ask Q/F questions on alcohol
• Usually takes less than one minute

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Non-Verbal Cues

• Interpret significant changes in a patient's/
  client's non-verbal cues as a positive screen for
  abuse or dependence
• Eye contact
• Fluidity and tone of speech
• Posture
• Movements
• Affect

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For Especially Sensitive Situations

• Ask about friends first
• Ask about prior use first
• Make normalizing statements before asking
  questions

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Screen Results and Actions

• Abstinence (ask why) Prevention message
• Low-risk drinker Prevention message
• At-risk drinker or Briefdrug user with
  other- interventionwise negative screen
• Positive screen for abuse Briefor
  dependence assessment

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Prevention Messages

• Brief
• Relevant information
• Culturally appropriate
• Reinforcing

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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


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Definition of Assessment

• A process intended to identify precisely a
  patients category of substance use on the
  continuum

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Assessment Tools

• Alcohol levels and drug tests
• Tests for excessive alcohol use - liver function
  tests, blood counts
• Physical examination
• Collateral report
• Self-report

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Self-Report

• Interview is usually the most accurate source of
  information
• Accurate assessment is usually possible even with
  minimization
• Appropriate assessment techniques can build
  rapport

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Brief Assessment Interview

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

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Later Consequences

• Cirrhosis, cardiomyopathy, AIDS, chronic
  pancreatitis, CAD, cancer
• Severe neuropsychiatric disorders
• Family dissolution, social isolation
• Unemployment, homelessness
• Incarceration
• Oral cancers and tooth loss

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Earlier Consequences
Identify problem before irreversible consequences

• Psychological
• Family
• Friends
• Biomedical

• Work
• Legal
• Financial

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Early Consequences Psychological

• Earliest category of consequences
• Dysphoria, depression, or anxiety
• Irritability, mood swings, hostility
• Paranoia, psychosis
• Any psychiatric symptom can be related to
  intoxication, overdose, or withdrawal

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Early ConsequencesFamily

• Marital/family dysfunction
• Childhood behavior/school problems
• Mental health problems and somatic symptoms among
  family members

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Early ConsequencesFriends

• Alienation and loss of old friends
• Gravitation toward others who use substances
  heavily

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Early ConsequencesBiomedical

• Gastritis, peptic ulcer, pancreatitis, vague
  abdominal pain, diarrhea
• Hypertension
• Weight gain for alcohol
• Weight loss for cocaine and amphetamines
• Sleep and sexual dysfunction
• Unplanned pregnancies, unwanted sexual advances,
  STD's
• Periodontal disease

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Early ConsequencesInjuries

• Assaults
• Domestic violence/family violence
• Other interpersonal violence
• Motor vehicle related
• Motor vehicle crashes
• Pedestrian motor vehicle crashes
• Falls
• Fires
• Swimming/boating related
• Suicide attempts
• Injuries in the home
• Repeated injury events

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Early ConsequencesWork/School

• Frequent lateness and absences
• Requests for work excuses
• Decline in performance
• Frequent job changes

Preservation of function for highly
motivatedindividuals, such as many health care
professionals
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Early ConsequencesLegal

• Domestic and other violence
• Arrests for disturbing the peace
• DWIs / DUIs
• Arrests for possession and dealing
• Burglary, robbery

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Early ConsequencesFinancial

• Spending more than one can afford on obtaining
  substances
• Financial strain
• Indebtedness
• Selling possessions

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Brief Assessment Interview

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

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Brief Assessment Interview (continued)

• Loss of control
• Setting rules about substance use
• Having difficulty adhering to rules
• Physical dependence
• Withdrawal symptoms
• Substance use to avoid withdrawal
• Tolerance

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Brief Assessment Interview (continued)

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

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Brief Assessment Interview (continued)

• How many days a week do you drink some alcohol?
• How much do you typically drink at one time when
  you do drink?
• Whats the most youve had to drink at one time
  in the past 3 months?
• Take responses at face value

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Other Important Concerns

• Cultural Competence
• Dual Diagnosis

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Cultural Competence Review

• Increased concern for cultural competence among
  all health care disciplines.
• Impetus concern for adequacy of services for
  members of minority groups.
• Flexible changing process.
• Each person is unique within their culture.

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Dual Diagnosis

• Co-existing substance use disorder and another
  psychiatric disorder
• Identify primary and secondary disorder, if
  possible
• If SUD may be primary, and if psychiatric
  symptoms are not pressing, try abstinence without
  medications

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Conventional Explanatory Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
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Another Possible Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
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Another Possible Model (continued)
PsychologicalDisorder
Stressful Circumstances
Substance Use Disorder
Cycle can start anywhere
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Evidence on Brief Interventions

• Intervention - up to 15 minutes of dialogue with
  up to 3 follow-up sessions
• Feedback
• Responsibility
• Advice

• Menu
• Empathy
• Self-efficacy

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Evidence on Brief Interventions (continued)

• Several randomized controlled trials
• Subjects at-risk and problem drinkers
• Control subjects improved - screening and
  assessment can elicit behavior change
• Experimental subjects improved more
• Statistically significant differences in
• Self-reported Q/F
• Liver inflammation
• Attendance at work
• Days in hospitals

• Costs of health care, car crashes and criminal
  justice

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Evidence on Brief Interventions (continued)

• Per subject
• Costs savings in health care,car crashes,
  criminal justice 1146
• Cost of screening/intervention 250
• Net cost savings 946

Fleming et al, Medical Care, 2000.
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Evidence on Treatment

• Consider SUDs as chronic relapsing and remitting
  conditions
• Abstinence is not the sole criterion for
  evaluating effectiveness of treatment
• Other criteria for effectiveness are less
  substance use, better function, improved quality
  and duration of life

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Evidence on Treatment (continued)

• Effective for those who commonly receive them
• Inpatient outpatient alcohol treatment
• Naltrexone for alcohol dependence (short-term)
• Opioid maintenance treatment
• Long-term residential drug treatment

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BI/Referral - Principles

• Feedback
• Responsibility
• Advice
• Menu of options
• Empathy
• Self-efficacy

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BI/Referral - Steps

• Feedback
• Education
• Recommendation
• Negotiation
• Secure agreement
• Set follow-up

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Feedback

• Summarize negative consequences
• Describe relevant risks
• Raise concern about substance use
• Seek reaction
• Listen and acknowledge
• Explain how their use compares to norms

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Education

• Educate about how substance use is linked to
  consequence or risk
• Assess prior knowledge and
• culturally linked perceptions
• Assess interest in information
• Convey information
• Assess understanding

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Initial Recommendations

• For at-risk use or abuse
• For family history abstinence
• For family history low-risk use
• For pregnancy abstinence
• For dependence
• Abstinence
• Referral to specialist/treatment

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Negotiation

• Listen and acknowledge response
• If recommendation is resisted
• Ask about interest in change
• Suggest further change if risks or consequences
  will continue
• Identify and help remove barriers to change
• Accept decision support any change

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Secure Agreement

• Ensure specificity and concreteness
• Record agreement for client/pt and practitioner
• Express optimism and support
• Suggest use of drinking or substance using diary
• Give warning about withdrawal symptoms

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Set Follow-Up

• Suggest follow-up at one month
• Offer follow-up sooner
• Emphasize desire for follow-up regardless of
  progress
• Reassure about lack of anger and judgment if
  pt/client has difficulty
• Make statement of partnership

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Follow-Up

• Assess progress after intervention
• Reassess if necessary consequences, dependence,
  Q/F
• Make recommendation
• Negotiate
• Secure agreement set follow-up

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At Follow-Up, If No Better

• Use motivational interviewing, OR
• for dependence
• Recommend referral, continue discussing over time
• For abuse or at-risk use
• Continue discussing over time
• Consider specialized assessment or consultation

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Watch for Dual Diagnosis

• Continuation of symptoms despite decreased use
• Unmasking of new psychiatric symptoms

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Documentation

• Advantages
• Reminder to attendto issue in future
• Useful informationfor colleagues
• Documents qualityof care
• May facilitate reimbursement

• Disadvantages
• Colleagues/staff may be judgmental
• Breaches of confidentiality
• Legal, economic, and social ramifications
• Insurance issues

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Documentation (continued)

• Possible Ramifications
• Subpoena
• Insurance applications
• Child custody decisions
• Mandatory or optional reporting of pregnant
  substance users may lead to imprisonment and/or
  forced treatment in some states

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Principles of Documentation

• Practitioner owns record patient/client owns
  information
• Written permission required to release records
  (except when life is at risk)
• Federal confidentiality law
• Must have specific permission to release
  information on substance abuse, mental health,
  HIV/AIDS, and STDs
• Must include effective and expiration dates and
  purpose of information release

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Implementation

• Training alone is minimally effective in changing
  practitioner behavior
• Bolster training with

• Directives
• Peer consensus
• Incentives
• Reminders

• Team approaches
• Systemization
• CQI

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Summary

• All generalist health professionals should
  screen, intervene, and refer
• Intervene and refer using FRAMES FERNSS
• Follow-up
• Document with care
• Consider implementation issues