Overview of Brief Intervention for Risky Substance Use in Primary Care

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


3

Addiction & Risky Use
For background
information on addiction
Addiction Medicine:
Closing the Gap
between Science and
Practice1


4

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)

5

• Approach comprehensively across substances

• Address tobacco/nicotine, alcohol & other drugs
• Manage co-occurring disorders

dopamine
transporters


6

• 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


7

All patients with addiction
should receive treatment
All patients who are risky users
should receive a brief intervention


8

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


9

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


10

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


11

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


12

THREE KEY STEPS


13

Brief Intervention: Key Steps
1. Engage

2. Motivate
3. Plan


14

1. Engage
Assess to determine baseline & readiness

• Inquire about
current patterns of
substance use
• Determine patient
perception of
substance use8
• Identify personal
values & goals10

15

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

16

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


17

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?”


18

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


19

2. Motivate
Tips to motivate patients to change

• Emphasize
confidence in ability
to change
• Assure continued
support throughout
process


20

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


21

2. Motivate

• “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


22

2. Motivate
Promote self-efficacy & empower patients

• Use reflective
listening,
summaries &
affirmations11
• Review
strengths &
past successes


23

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

24

2. Motivate

• “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].”


25

3. Plan
Select methods & goals collaboratively

• Create goals
aligned with
readiness to
change
• Assist patients to
identify personal
goals & preferences
among methods

26

3. Plan
Select methods & goals collaboratively

• Focus on attainable, measureable, timely goals
• Help anticipate potential challenges & barriers
• Brainstorm on methods to overcome problems


27

3. Plan
Tips on selecting goals with patients

• Recommend ideal
change but accept
less if patients resist
• Change strategies
when patients resist


28

3. Plan
Tips to work collaboratively with patients

• Avoid argumentation
which can be counterproductive & create
defensiveness
• Collaborate to
increase patient
control/agency13


29

3. Plan

• “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?”


30

3. Plan

• “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.”


31

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

32

3. Plan
Offer support & follow-up care

• Acknowledge efforts & experiences
• Offer continued support irrespective of success


33

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


34

SAMPLE VIDEOS


35

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

www.youtube.com/watch?v=fX90j4jD9Sc

From University of Maryland, Baltimore

36

Video Example for Adult
Adult Patient15 (6min 37sec)

www.youtube.com/watch?v=ebsqETBWEdQ

From University of Maryland, Baltimore

37

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.


38

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


39

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.


40

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®.

Overview of Brief Intervention for Risky Substance Use in Primary Care

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