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OVERVIEW OF BRIEF
INTERVENTION FOR
RISKY SUBSTANCE
USE IN PRIMARY CARE

Prepared by
CASAColumbia®
February 2014
Outline
• Introduction

• Three Key Steps
− Engage
− Motivate
− Plan
• Sample Videos

© CASAColumbia 2014

2
INTRODUCTION

© CASAColumbia 2014

3
Addiction & Risky Use
For background
information on addiction
Addiction Medicine:
Closing the Gap
between Science and
Prac...
Addiction & Risky Use
For information on screening,
diagnosis, treatment planning
& management
Overview of Addiction
Medic...
Addiction & Risky Use
• Approach comprehensively across substances

• Address tobacco/nicotine, alcohol & other drugs
• Ma...
Addiction & Risky Use
• Addiction: disease requiring treatment

• Risky use:
− Substance use that threatens health & safet...
Addiction & Risky Use
All patients with addiction
should receive treatment
All patients who are risky users
should receive...
Brief Intervention for Risky Use
• Medical approach to
reduce risky use
• Evidence-based from
research studies

• Effectiv...
Brief Intervention for Risky Use
• 5-10 minutes as effective as 20 minutes4

• Tobacco/nicotine quit rate 3X as likely5
• ...
Common Frameworks
• 5A Approach: developed for tobacco/nicotine
cessation8
• FRAMES: developed for reducing alcohol use9-1...
Comprehensive Approach
for tobacco/nicotine, alcohol & other drugs

• Risky use of multiple substances occurs often
• Comp...
THREE KEY STEPS

© CASAColumbia 2014

13
Brief Intervention: Key Steps
1. Engage

2. Motivate
3. Plan

© CASAColumbia 2014

14
1. Engage
Assess to determine baseline & readiness

• Inquire about
current patterns of
substance use
• Determine patient
...
1. Engage
Explore the potential for change

• Discuss impact of
substance use on
goals
• Develop a discrepancy
between sub...
1. Engage
Tips for speaking with patients

• Establish rapport & ask permission to discuss
• Use nonjudgmental, empathic l...
1. Engage
Sample language to use with patients

• “Would you mind taking a few
minutes to talk with me about
your use of t...
2. Motivate
Offer personalized advice & feedback

Well delivered advice is associated with improved
patient satisfaction12...
2. Motivate
Tips to motivate patients to change

• Emphasize
confidence in ability
to change
• Assure continued
support th...
2. Motivate
Tips to communicate effectively with patients

• Tailor to patient level of health
literacy
• Provide small am...
2. Motivate
Sample language to use with patients

• “You seem to think that your smoking of tobacco
& marijuana has been m...
2. Motivate
Promote self-efficacy & empower patients

• Use reflective
listening,
summaries &
affirmations11
• Review
stre...
2. Motivate
Tips to encourage patients to change

• Validate
frustrations but
remain optimistic
• Summarize to
reinforce &...
2. Motivate
Sample language to use with patients

• “It seems like the support from your family was
very helpful when you ...
3. Plan
Select methods & goals collaboratively

• Create goals
aligned with
readiness to
change
• Assist patients to
ident...
3. Plan
Select methods & goals collaboratively

• Focus on attainable, measureable, timely goals
• Help anticipate potenti...
3. Plan
Tips on selecting goals with patients

• Recommend ideal
change but accept
less if patients resist
• Change strate...
3. Plan
Tips to work collaboratively with patients

• Avoid argumentation
which can be counterproductive & create
defensiv...
3. Plan
Sample language to use with patients

• “What changes do you think you can make with
your drinking & your use of p...
3. Plan
Sample language to use with patients

• “What problems do you expect in making this
change?”
• “How do you think y...
3. Plan
Offer support & follow-up care

• Follow up initially
within one month or
less
• Reinforce previous
steps at follo...
3. Plan
Offer support & follow-up care

• Acknowledge efforts & experiences
• Offer continued support irrespective of succ...
3. Plan
Discuss various options for support

• Follow-ups by phone, office visit, or
HIPAA-compliant email

• Self-help ma...
SAMPLE VIDEOS

© CASAColumbia 2014

35
Video Example for Adolescent
Adolescent Patient14 (4min 26sec)

www.youtube.com/watch?v=fX90j4jD9Sc

From University of Ma...
Video Example for Adult
Adult Patient15 (6min 37sec)

www.youtube.com/watch?v=ebsqETBWEdQ

From University of Maryland, Ba...
References
1. CASAColumbia. Addiction medicine: closing the gap between science and practice. 2012 Jun.
http://www.casacol...
References
12. Hollis JF, et al. Implementing tobacco interventions in the real world of managed care. Tob Control. 2000;9...
Acknowledgements
• Margot Cohen contributed much of the research
and writing for these materials.
• The following subject-...
Ending Addiction
Changes Everything

www.casacolumbia.org

Copyright © 2013 by CASAColumbia®. All rights reserved.
May not...
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Overview of Brief Intervention for Risky Substance Use in Primary Care

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These materials provide an overview of the major elements required for delivering a brief intervention for risky use within the primary care setting.

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Overview of Brief Intervention for Risky Substance Use in Primary Care

  1. 1. OVERVIEW OF BRIEF INTERVENTION FOR RISKY SUBSTANCE USE IN PRIMARY CARE Prepared by CASAColumbia® February 2014
  2. 2. Outline • Introduction • Three Key Steps − Engage − Motivate − Plan • Sample Videos © CASAColumbia 2014 2
  3. 3. INTRODUCTION © CASAColumbia 2014 3
  4. 4. Addiction & Risky Use For background information on addiction Addiction Medicine: Closing the Gap between Science and Practice1 © CASAColumbia 2014 4
  5. 5. 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) © CASAColumbia 2014 5
  6. 6. Addiction & Risky Use • Approach comprehensively across substances • Address tobacco/nicotine, alcohol & other drugs • Manage co-occurring disorders dopamine transporters © CASAColumbia 2014 6
  7. 7. 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 © CASAColumbia 2014 7
  8. 8. Addiction & Risky Use All patients with addiction should receive treatment All patients who are risky users should receive a brief intervention © CASAColumbia 2014 8
  9. 9. 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 © CASAColumbia 2014 9
  10. 10. 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 © CASAColumbia 2014 10
  11. 11. 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 © CASAColumbia 2014 11
  12. 12. Comprehensive Approach for tobacco/nicotine, alcohol & other drugs • Risky use of multiple substances occurs often • Comprehensively addressing tobacco/nicotine, alcohol & other drugs may help prevent replacement of one substance with another © CASAColumbia 2014 12
  13. 13. THREE KEY STEPS © CASAColumbia 2014 13
  14. 14. Brief Intervention: Key Steps 1. Engage 2. Motivate 3. Plan © CASAColumbia 2014 14
  15. 15. 1. Engage Assess to determine baseline & readiness • Inquire about current patterns of substance use • Determine patient perception of substance use8 • Identify personal values & goals10 © CASAColumbia 2014 15
  16. 16. 1. Engage Explore the potential for change • Discuss impact of substance use on goals • Develop a discrepancy between substance use & achieving goals • Elicit need & perceived ability to change © CASAColumbia 2014 16
  17. 17. 1. Engage Tips for speaking with patients • Establish rapport & ask permission to discuss • Use nonjudgmental, empathic language & tone • Ask open-ended questions from general to specific11 • Listen reflectively: repeat, rephrase, paraphrase © CASAColumbia 2014 17
  18. 18. 1. Engage Sample language to use with patients • “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?” © CASAColumbia 2014 18
  19. 19. 2. Motivate Offer personalized advice & feedback 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 © CASAColumbia 2014 19
  20. 20. 2. Motivate Tips to motivate patients to change • Emphasize confidence in ability to change • Assure continued support throughout process © CASAColumbia 2014 20
  21. 21. 2. Motivate Tips to communicate effectively with patients • Tailor to patient level of health literacy • Provide small amounts of feedback at a time10 • Use empathic style for more cooperation & less resistance © CASAColumbia 2014 21
  22. 22. 2. Motivate Sample language to use with patients • “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 © CASAColumbia 2014 22
  23. 23. 2. Motivate Promote self-efficacy & empower patients • Use reflective listening, summaries & affirmations11 • Review strengths & past successes © CASAColumbia 2014 23
  24. 24. 2. Motivate Tips to encourage patients to change • Validate frustrations but remain optimistic • Summarize to reinforce & to show that you listen • Prepare patients for next steps © CASAColumbia 2014 24
  25. 25. 2. Motivate Sample language to use with patients • “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].” © CASAColumbia 2014 25
  26. 26. 3. Plan Select methods & goals collaboratively • Create goals aligned with readiness to change • Assist patients to identify personal goals & preferences among methods © CASAColumbia 2014 26
  27. 27. 3. Plan Select methods & goals collaboratively • Focus on attainable, measureable, timely goals • Help anticipate potential challenges & barriers • Brainstorm on methods to overcome problems © CASAColumbia 2014 27
  28. 28. 3. Plan Tips on selecting goals with patients • Recommend ideal change but accept less if patients resist • Change strategies when patients resist © CASAColumbia 2014 28
  29. 29. 3. Plan Tips to work collaboratively with patients • Avoid argumentation which can be counterproductive & create defensiveness • Collaborate to increase patient control/agency13 © CASAColumbia 2014 29
  30. 30. 3. Plan Sample language to use with patients • “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?” © CASAColumbia 2014 30
  31. 31. 3. Plan Sample language to use with patients • “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.” © CASAColumbia 2014 31
  32. 32. 3. Plan Offer support & follow-up care • Follow up initially within one month or less • Reinforce previous steps at follow-up visits • Reassess & update plan based on current status © CASAColumbia 2014 32
  33. 33. 3. Plan Offer support & follow-up care • Acknowledge efforts & experiences • Offer continued support irrespective of success © CASAColumbia 2014 33
  34. 34. 3. Plan Discuss various options for support • Follow-ups by phone, office visit, or HIPAA-compliant email • Self-help materials printed or online • Guidance to obtain social support © CASAColumbia 2014 34
  35. 35. SAMPLE VIDEOS © CASAColumbia 2014 35
  36. 36. Video Example for Adolescent Adolescent Patient14 (4min 26sec) www.youtube.com/watch?v=fX90j4jD9Sc From University of Maryland, Baltimore © CASAColumbia 2014 36
  37. 37. Video Example for Adult Adult Patient15 (6min 37sec) www.youtube.com/watch?v=ebsqETBWEdQ From University of Maryland, Baltimore © CASAColumbia 2014 37
  38. 38. References 1. 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. © CASAColumbia 2014 38
  39. 39. References 12. 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 © CASAColumbia 2014 39
  40. 40. 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. © CASAColumbia 2014 40
  41. 41. Ending Addiction Changes Everything www.casacolumbia.org Copyright © 2013 by CASAColumbia®. All rights reserved. May not be used or reproduced without the express written permission of CASAColumbia®.

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