1. An Initiative for the State of Maryland For Counselors, Intake Workers and Screeners, Social Workers, and Therapists Dr. Peter Cohen, Medical Director Maryland Alcohol and Drug Abuse Administration (ADAA) And a Special Thanks to Michael Greenberg and Shin Haeng Lee, who were instrumental in developing this training module

2.  The Problem and Challenge in Maryland  Goals for Maryland  Adolescent Substance Use Diagnoses  What is SBIRT and Why Use It?  Screening and the CRAFFT  Brief Intervention  Referral to Treatment

3. BY 12 TH GRADE, THE MAJORITY OF ADOLESCENTS HAVE USED ALCOHOL OR ANOTHER DRUG  12 th Graders in the Last Year  63% have used alcohol  34.9% have used marijuana (Maryland State Department of Education, 2008)

4. BY 12TH GRADE, THE MAJORITY OF ADOLESCENTS HAVE USED ALCOHOL OR ANOTHER DRUG  Alcohol Abuse 33% have been a passenger with a drunk driver 16% drove under influence 11% were absent from school due to alcohol or drunk at school  There are Similar Trends for Other Drugs…  (Maryland State Department of Education, 2008)

5. A Common Teen MISCONCEPTION Only 40% of high school seniors believe marijuana, beer, liquor, cigarettes are dangerous Communication Issues About 33% of using 12 th graders can talk about their drug/alcohol use problem with an adult TAKE HOME POINT There is WIDE SPREAD substance abuse by teens at risk. Most NEED TO TALK TO AN ADULT but most do not.

6. 13 COMMON INDICATORS OF ADOLESCENT DRUG & ALCOHOL ABUSE* 1.Changes in school attendance and grades 2.Unusual flare-ups or outbreaks of temper 3.Poor physical appearance (often becomes slovenly) 4.Furtive behavior regarding drugs (especially when in possession) 5.Wearing of sunglasses at inappropriate times to hide dilated or constructed pupils 6.Long-sleeved shirts worn consistently to hide needle marks (if injecting drugs) 7.Association with known drug abusers * Note: Some of these changes may occur in normal adolescents or may result from other problems Maryland Healthy Kids EPSDT Manual 2006

7. 13 COMMON INDICATORS OF ADOLESCENT DRUG & ALCOHOL ABUSE* 8. Borrowing money from students to purchase drugs 9. Stealing small items from the school or home 10. Hiding a stash in odd places; e.g., closets, storage areas 11. Attempting to appear inconspicuous in manner and appearance to mask usage 12. Withdrawal from responsibility 13. Change in a. overall attitude (school, home, family, friends, job) b. behavior, oppositional, poor social skills c. mood (depression, irritability, low self-esteem, grandiosity) * Note: Some of these changes may occur in normal adolescents or may result from other problems. Maryland Healthy Kids EPSDT Manual 2006

8. The Governor’s Deliverable Unit  Expand Access to Substance Abuse Treatment in Maryland 25% by 2012 The ADAA’s GOAL  Increase Referral Rates of Adolescents with Substance Abuse Problems: From Primary Care Practitioners, Nurses, Counselors and Therapists  Evaluation and Treatment Programs

9.  Develop brief SBIRT training programs for practitioners  For medical & counseling professionals  Provide continuing medical education credits online or in person  The training program  Practice of basic screen interviewing that incorporates motivational interviewing skills  Effective use of the CRAFFT as the screening instrument  Demonstration videos that highlight effective screening of an adolescent in the office setting

10. DIAGNOSIS

11.  Diagnostic Confusion: Abuse Vs. Dependence  Criteria not designed specifically for teens  Current use does not predict chronic abuse or dependence  Length of stay & medical necessity criteria affect the validity of diagnosis  Not easily translated into treatment plans  Diagnostic Orphans

12. At Least 13% Are Diagnostic Orphans Definition 1. Do Not Meet Enough DSM Criteria For Abuse Or Dependence 2. But The Teenager Has Substantial D&A Problems There is a Great Crossover with Other Psychiatric Symptoms That… Persist after detoxification Precede substance abuse Exist beyond what would normally be expected Exist in first-degree relatives

13. Not Necessary for Adolescents: Tolerance, Withdrawal Relief of withdrawal symptoms when using substance (Withdrawal) Occupational/social/recreational activities given up or reduced Larger amounts taken than originally intended Awareness of problems related to substance abuse Increased amounts are needed to achieve the same effect (Tolerance) Diminished effect with use of the same amount of the substance (Tolerance) Persistent desire to cut down or control use Unsuccessful efforts to cut down or control use Personal problems (social and interpersonal) due to use Investment of time in substance-related activity is considerable Longer duration of use than initially intended Symptoms of withdrawal occur (Withdrawal) The Remaining Signs & Symptoms Can Qualify For Adolescent Substance Dependence

14. “HELP” Hazardous circumstances do not deter SA Evasion of obligations due to SA Legal difficulties caused by SA Problems (social and interpersonal) develop Robinson DJ. Mnemonics & More, 2001

15. SUBSTANCE ABUSE Lifestyle and function is disrupted without learning from consequences and subsequent change of behavior

16. Substance Dependence Lifestyle and function become primarily defined as 1.Acquiring chemicals 2.Reducing craving 3.Avoiding withdrawal 4.Overcoming tolerance 5.Increasing losing of control of use (using too much, can’t cut down, giving up everything for the chemical)

17. You can be dependent without signs of major abuse (eg. “the functional alcoholic”) BUT Abuse usually accompanies dependence

18.  Screening  Brief Intervention  Referral to Treatment

19. IT WORKS  Brief Intervention & Motivational Enhancement: The most effective treatment modalities  Confrontational counseling & educational lectures: More common but least effective (Miller & Wilbourne 2002)

20. Screening

21.  Always Start On A Positive Note: Ask about the teen’s interests, talents & goals for the next year  Show Your Interest in the teen’s meeting those goals  Ask Permission to discuss use of D&A  Then Screen

22.  While Screening, Pay Attention Put down the chart when you are listening Take notes after the interview is over  Give Praise, or State Your Worry and Interest in Helping The Teenager Achieve His or Her Goals  In Other Words…Use Motivational Interviewing

23. 1. Express Empathy & Acceptance: Listening Rather Than Telling Work with Ambivalence 2. Develop Discrepancy Between Drug Use & Fulfilling One’s Goals 2. Avoid Arguing 3. Roll with Resistance Expect it: Be Empathic & Reflective 5. Support Self-Efficacy: What would you like to do about it?”

24. Helps you determine 1.Whether to proceed with an office interventionor 2. Refer the teenager for specialized treatment

25. *Click Here to Go To the Center for Adolescent Substance Abuse Research (CeASAR) Website A substance use screening instrument that is valid & reliable sensitive & specific quick & effective It is the center point of your screening, but… It is only as good as your interviewing technique, such as the use empathy & reflective listening Specifically designed for adolescents by John Knight MD*

26.  STEP 1: Three Basic Opening Questions  STEP 2: Six CRAFFT Screening Questions Do You Have 5 Minutes? Massachusetts Department of Public Health, Bureau of Substance Abuse Services, 2009

27. The Teenager fills out the PAPER or COMPUTER- BASED CRAFFT QUESTIONNAIRE OR The Primary Care Provider ASKS the questions during visit OR Another Provider in the Practice ASKS the questions

28. Which Method Should I Use In My Practice? Whatever… Respects The Teen’s Privacy & Confidentiality Is Time-effective Is Cost-effective Fits Your Style of Patient Care

29. After Establishing Rapport STEP 1: Prevention or Further Screening? Ask the teenager these 3 basic opening questions  During 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?

30. STEP 1: Three Opening Questions During 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? The Teenager Answers “NO” to All 3 Opening Questions Ask ONLY the FIRST CRAFFT question: Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs?

31. Ask the 1 St CRAFFT Question CAR Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs? “NO” ”YES” 1. Give praise & encouragement to remain abstinent, 2. Advise avoiding a ride with an intoxicated driver 3. Follow-up at next visit: How is it going? (Duration: 1-2 minutes) 1.Ask teen to agree to avoid riding with a driver who has used alcohol or drugs 2. Follow-up at next visit: Was the agreement upheld? 3. If a risk still exists: Involve the parents (Duration: 1-2 minutes) When the Teen Answers “NO” to All 3 Opening Questions

32. Step 2: Ask The SIX CRAFFT Questions Each yes = 1 STEP 1: Ask the Three Opening Questions During 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? The Teenager Answers “YES” to Any Opening Question

33. C CAR C Have you ever ridden in a CAR driven by someone (or yourself) who was “high” or had been using alcohol or drugs? RELAX R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A ALONE A Do you ever use alcohol or drugs while you are by yourself, or ALONE? F FORGET F Do you ever FORGET things you did while using alcohol or drugs? F FAMILYFRIENDS F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? T TROUBLE T Have you ever gotten into TROUBLE while you were using alcohol or drugs?

35. How ready are you to change your tobacco/alcohol/drug use?

36. Brief Intervention

37. WHAT SHOULD I DO? YOUR INTERVENTION DEPENDS ON YOUR CLINICAL JUDGEMENT + YOUR RAPPORT WITH THE TEEN + THE CRAFFT SCORE

38.  ADD UP all 6 CRAFFT questions  “YES” = 1 point  “NO” = 0 points  Get a score between 0-6

39. Thanks to BNI Art Institute

40. Youth & Young Adult Health & Safety Needs Questionnaire: Click Here for Copy

41. SBIRT INTERVIEW ALGORITHM FOR COUNSELORS & THERAPISTS Click here to Download the BNI ART Institute Youth Intervention Algorithm and CRAFFT

42. 1.Promote Rapport and Trust: Ask Permission, Address Privacy, and Engage 2.Provide Feedback 3.Enhance Motivation 4.Negotiate and Advise

43. STEPSDIALOGUE 1. Ask Permission 2. Address Privacy 3. Engage  Hello, I am _______. Would you mind taking a few minutes to talk with me confidentially about your use of [X]? >  Before we start, could you tell me a little about a day in your life?

44. To Watch on YouTube: Click on the Picture

45. STEPS DIALOGUE 1. Ask how X fits in with life goals 2. Make connection (No arguing) 3. For alcohol, show NIAAA guidelines & norms for adults  From what I understand, you are using [insert screening data]… We know that drinking above certain levels, smoking and/or use of illicit drugs can cause problems, such as [insert medical info]…I am concerned about your use of [X].  What goals do you have for yourself? (What is important to you?)  What connection (if any) do you see between your use of [X] and this ED visit?

46. STEPS  These are what we consider the upper limits of low risk drinking for adults. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines. From what you say, you are drinking above the adult guidelines. 1. If the patient sees a connection: reiterate what he or she has said 2. If the patient does not see a connection: make one using medical info DIALOGUE

47. To Watch on YouTube: Click on the Picture

48. STEPS DIALOGUE 1. Explore Pros and Cons 2. Use reflective listening  Help me to understand what you enjoy about [X]? >  Now tell me what you enjoy less about [X] or regret about your use of [X] >

49. To Watch on YouTube: Click on the Picture

50. STEPS DIALOGUE 1. Use responses to continue exploring pros & cons  On the one hand you said…  On the other hand you said….  Ask CRAFFT questions, then sum up and restate in patient’s own words

51. To Watch Now: Click on the Picture

52. STEPS DIALOGUE 1. Elicit % ready to change (on the ruler) 2. Ask “Why not less?” 3. Reinforce Change Talk  So tell me, where does this leave you? [show readiness ruler] On a scale from 1-10, how ready are you to change any aspect of your use of [X]?  Why did you choose that number and not a lower one like a 1 or a 2? Other reasons for change?

53. To Watch on YouTube: Click on the Picture

54. STEPS DIALOGUE 1. Negotiate Goal: Elicit action plan (steps to be healthy) 2. Discuss benefits of change 3. Reinforce resilience  What do you think you can do to stay healthy and safe? [elicit action plan]  If you make these changes, what do you think might happen to you now and in the future?  Have you made changes before or have you accomplished goals you feel proud of? Who helped? Could you use these methods now?

55. STEPS DIALOGUE 1. Summarize change steps/action plan 2. Offer resources (menu) 3. Prescription for change: Develop a plan 4. Provide handouts: agreement & info sheet 5. Refer: Make Primary Care f/u and other referrals to support carrying out plan; if CRAFFT >3, refer for further assessment and/or treatment.  This is what I’ve heard you say you want to change.  I’ve written down your plan— a prescription for change. Use it as an agreement between you and yourself.

56. To Watch on YouTube: Click on the Picture

59.  GOAL  EASY and EFFICIENT For Provider Use  ONE NUMBER to call to refer the child  Organized by:  County  The Counselor can help determine level of treatment needed

60. 1. Is the teenager intoxicated or is there any risk of withdrawal? 2. Are there any medical conditions or complications? 3. Are there any emotional or behavioral conditions? 4. How motivated or resistant is the teenager for evaluation or treatment? 5. How well can the teenager remain abstinent or control use? 6. How much support does the teenager have from the family, friends, and others? Based on the 6 Dimensions of ASAM PPC-2

61. Annotated Maryland Code § 20-102 A minor (<18) cannot refuse treatment for inpatient drug abuse or alcoholism treatment when a parent or guardian has given consent Parents must be informed about a treatment referral

62. Annotated Maryland Code § 20-102 Without the consent of or over the express objection of a minor: 1) the health professional of a hospital or public clinic may, but need not, 2) give a parent, guardian, or custodian of the minor or the spouse of the parent information about substance treatment needed by the minor or provided to the minor.

63. Annotated Maryland Code § 20-102 A minor has the same capacity as an adult to consent to: (1) Treatment for or advice about drug abuse (2) Treatment for or advice about alcoholism

64. Allegany - (301) 759-5050 Anne Arundel – (410) 222-6785 Baltimore County – (410) 887-3828 Baltimore City - (410) 637-1900 Calvert – (410) 535-5400 x 377 Caroline – (410) 479-1882 Carroll – (410) 848-6100 Cecil - (410) 996-5106 Charles- (301) 609-6600 Dorchester- (410) 228-7714 x 102 Frederick - (301) 600-3293 Garrett- (301) 334-7670 Harford- (410) 877-2340 Howard- (410) 313-6202 Kent - (410) 778-6404 Montgomery – (240) 217-1450 Prince George’s – (301) 883-7853 Queen Anne’s – (410) 758-1306 x309 Saint Mary’s – (301) 863-6661 * outpatient only Somerset – (443) 523-1790 x 1786 Talbot – (410) 819-5900 Washington – (240) 313-3314 Wicomico – (410) 742-3784 Worcester- (410) 632-1100 x 1024

65. Click Here to Download

67.  Substance abuse assessment at the annual preventative healthcare (“well”) visit  Must begin by age 11-12  Code and bill as part of the annual well visit ProcedureCPTMax Reimb NEW PT 12-1799384$98.07 18+99385$98.07 OLD PT 12-1799394$79.02 18+99395$80.00

68. http://sbirt.samhsa.gov/coding.htm PayerCodeDescriptionFee Schedule Commercia l Insurance CPT 99408 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT 99409 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51 Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $29.42 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69

69. Click Here to Download the Interview Scoring Sheet

70.  TEENAGE SUBSTANCE USE PROBLEMS ARE WIDESPREAD  CHILDREN AND TEENS AT RISK NEED TO BE ENCOURAGED TALK TO AN ADULT ABOUT THEIR SUBSTANCE USE  THE PRIMARY CARE PRACTITIONER’S OFFICE SHOULD BE CONSIDERED AS NATURAL PLACE FOR THIS DISCUSSION TO BEGIN  SBIRT and CRAFFT ARE  EASY  QUICK  EFFICIENT

71. Maryland State Department of Education. (2008, November 18). 2007 Maryland Adolescent Survey. Baltimore, Maryland, United States of America. Massachusetts Department of Public Health Bureau of Substance Abuse Services. (2009, March). Provider Guide: Adolescent Screening, Brief Intervention, and Referral to Treatment Using the CRAFFT Screening Tool. Boston, Massachusetts, United States of America. 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.