I MPROVING A DOLESCENT H EALTH : F ACILITATING C HANGE FOR E XCELLENCE IN SBIRT I NFORMATIONAL W EBINAR O CTOBER 30 TH 2:30PM ET
C ALL L OGISTICS • We recommend calling in on your telephone , but your computer is also an option • Remember to enter your Audio PIN so others can hear you • Please mute your line when you are not speaking since we will have lines open throughout the call This button should be clicked if you’re calling in by telephone. Here’s your audio PIN
H OW TO A SK A Q UESTION Prefer to write? Type into the question box and click “send.” On the phone? “ Raise your hand ” and we will open up your lines for you to ask your question to the group.
T ODAY ’ S P RESENTERS Sharon Levy, MD, MPH Molly Molloy, MSW Pam Pietruszewski, MA Director, Adolescent Director of Behavioral Health, Integrated Health Substance Use and Southwest Montana Consultant, Addiction Program at Community Health Center National Council for Boston Children’s Hospital, Behavioral Health Associate Professor in Pediatrics, Harvard Medical School
A GENDA • Why SBIRT? • Change Package Concepts & Lessons Learned from the Field • Questions & Answers
H EALTH CARE IS AN OPPORTUNITY TO TALK ABOUT SUBSTANCE USE HEALTH RISKS 1 in 10 reported a binge 4 in 10 high school aged reported in the last 3 months Presenting for general primary past-year alcohol use care; unpublished data from the AYAM clinic
H EALTH CARE IS AN OPPORTUNITY TO TALK ABOUT SUBSTANCE USE HEALTH RISKS 3 in 10 report past-year About 1.5 in 10 report using Presenting for general marijuana use marijuana monthly or more primary care; unpublished data from the AYAM clinic
A LCOHOL • Black outs • Unintentional injuries • Memory loss
M ARIJUANA • Hallucinations (27%) • Paranoia/Anxiety (33.6%) • Any psychotic symptom (42.9%) Levy S, Weitzman, ER. Acute mental health symptoms in adolescent marijuana users. JAMA Pediatrics . 2018 Dec 17;doi 10.1001/jamapediatrics.2018
C LINICAL INSTINCTS UNDERESTIMATE SUBSTANCE USE PROBLEMS Medical Provider Impressions Sensitivity Specificity Any use .63 (.58, .69 CI) .81 (.76, .85 CI) Any problem .14 (.10, .20 CI) 1.0 (.99, 1.0 CI) Any disorder .10 (.04, .17 CI) 1.0 (.99, 1.0 CI) Wilson CR, Sherritt L, Gates E, Knight JR. Are Dependence 0.0 1.0 clinical impressions of adolescent substance use accurate ? Pediatrics , Comparison of Provider Impressions with Diagnostic Interview 2004;114:536-540
There are no visible signs of substance use or even early problems Practicing physician “If [patients] are drinking, it’s like stupid high school kids who go out and have a couple beers on a weekend here and there…it’s not like chronic alcohol problems.”
Did I mention that I was suspended because I showed up drunk to a team dinner?
Adults Don’t Use the Same Code… Occasionally = once or twice a year
Occasionally = Only Fridays and Saturdays
H OW YOU ASK MATTERS Official GOP Presidential Job Performance Poll How would you rate President Trump’s job performance so far? Great Good Okay Other
S2BI S2BI: Screening to Brief Intervention In the past year, how many times have you used: Never Once or Twice Tobacco/Nicotine? Monthly (such as cigarettes, e-cigarettes, “vapes”) Weekly or more
S2BI S2BI: Screening to Brief Intervention In the past year, how many times have you used: Never Once or Twice Alcohol? Monthly Weekly or more
S2BI S2BI: Screening to Brief Intervention In the past year, how many times have you used: Never Once or Twice Marijuana? (smoked, vaped, edibles) Monthly Weekly or more
S2BI In the past year, how many times have you used No substance use No substance use disorder (SUD) Mild/Moderate SUD Severe SUD
S ENSITIVITY /S PECIFICITY OF S2BI CIDI-SAM interview vs screen frequency item for detecting a substance use disorder Criterion Screen Prevalence Sensitivity Specificity Standard Dx Frequency N (%) (95% CI) (95% CI) Any Use Once or twice 90 (42.3) 1 [Reference] 84 (76-89) Mild/Moderate 41 (19.2) 90 (77, 96) 94 (89, 96) > Monthly use SUD Severe SUD > Weekly use 19 (8.9) 100 (na) 94 (90, 96) Levy, S., Weiss, R., Sherritt, L., Ziemnik, R., Spalding, A., Van Hook, S., & Shrier, L. A. (2014). An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels. JAMA Pediatrics . Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25070067
S2BI S ENSITIVITY /S PECIFICITY DSM-5 Moderate or Severe Substance Use Disorder diagnosis Criterion Sensitivity Specificity Standard Dx (95% CI) (95% CI) Alcohol Use 100% 93.6% Disorder Cannabis Use 95.3% 91.6% Disorder
Rates of substance use disclosure and positive CRAFFT screening results Routine clinical Anonymous p value screening (N=5,971) research interviewing (N=525) n (%) n (%) Reported past year alcohol, 598 (10.0%) 158 (30.1%) <.001 marijuana, or other drug use on the CRAFFT prescreen Screened positive for a substance use 246 (4.1%) 92 (17.5%) <.001 problem (CRAFFT score ≥ 2) Gryczynski J, Mitchell SG, Schwartz RP, et al. Disclosure of Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research Interviews. J Adolesc Heal . 2019;64(4):541-543. doi:10.1016/j.jadohealth.2018.10.009
P RIMARY C ARE P EDIATRICS Substance Use Screens documented for patients >12 2018: 21 (1.8%) July-August 2019: 212 Monitoring the Future Study & Village Pediatrics: Trends in Prevalence of Various Drugs in 2018 60% 50% 53% 40% 8th Graders 38% 37% Percent 36% 30% 32% 10th Graders 28% 27% 24% 20% 12th Graders 19% 18% 17% 16% 15% 10% Monitoring the 11% Village Pediatrics (avg. Future 16 year 9% age: 16 years) olds 0% Alcohol- Past Year Marijuana- Past Year Any Vaping- Past Year Cigarettes- Lifetime Substance 23
Screening may encourage counseling Table 1 –Rates of alcohol counseling by screening status Counseled for Alcohol -value TOTAL Use 273 (70.0%) 238 (87.2%) Asked about alcohol 117 (30.0%) 60 (51.3%) Not asked about alcohol Lunstead J. NIAAA screening and counseling brief report. Journal of Adolescent Health. 2019. In press.
Screening may encourage counseling Table 1 –Rates of alcohol counseling by screening status Counseled for Alcohol -value TOTAL Use 273 (70.0%) 238 (87.2%) Asked about alcohol 117 (30.0%) 60 (51.3%) Not asked about alcohol Lunstead J. NIAAA screening and counseling brief report. Journal of Adolescent Health. 2019. In press.
AAP SBIRT G UIDELINES Use validated screening tool to identify risk level and appropriate intervention Substance use Abstinence Severe substance without a disorder Mild/moderate use disorder substance use Positive disorder reinforcement Brief Health Brief Intervention Advice Referral to Treatment Levy SJ, Williams JF. Substance use screening, brief intervention, and referral to treatment. Pediatrics , 2016; 138 (1):e20161211.
M ENTAL H EALTH C ARE U SE O VER 3 Y EARS AFTER A DOLESCENT SBIRT 1 y Postindex 3 y Postindex SBIRT Usual Care P SBIRT Usual Care P (N=1255) (N=616) (N=1255) (N=616) n % n % n % n % Use − − Primary care visit 315 25.1 163 26.5 1036 82.5 520 84.4 • − − Substance use visit 5 0.4 1 0.2 26 2.1 23 3.7 • − − Psychiatry visit 66 5.3 39 6.3 235 18.7 128 20.8 • Comorbidity Sterling S, Kline- − − Mental health diagnosis 85 6.8 57 9.3 341 27.2 189 30.7 • Simon AH, Jones A, Hartman L, Saba K, Weisner − C, Parthasarathy Substance use 11 0.9 6 1.0 83 6.6 66 10.7 *** • S. Health Care diagnosis Use Over 3 Years After Adolescent − SBIRT. Pediatr. Chronic conditions 68 5.4 48 7.8 *** 396 31.6 201 32.6 • 2019 May.
I NTRODUCING ! The change package is available to the public for free at: ySBIRT.org
T HE DISTANCE BETWEEN THEORY AND PRACTICE …
… IS FURTHER IN PRACTICE THAN IN THEORY
Guidelines help to change behavior 2013 2008 2009 2010 2011 2012 2007 2014 2015
Second survey Third survey administered administered 2007 ‘08 ‘14 ‘12 ‘13 ‘15 ‘16 ‘10 ‘11 2017 ‘09 200 200 200 201 201 201 201 201 201 7 8 9 0 1 2 3 4 First survey administered
A NNUAL SCREENING RATES 1) American Academy of Pediatrics. Periodic Survey of Fellows #31: Practices and Attitudes Toward Adolescent Drug Screening. Elk Grove Village, IL: American Academy of Pediatrics, Division of Child Health Research; 1997. 2) Harris et al. Results of a statewide survey of adolescent substance use screening rates and practices in primary care. Subst Abus. 2012;33(4):321-326. 3) Levy et al. Screening Adolescents for Alcohol Use: Tracking Practice Trends of Massachusetts Pediatricians. J Addict Med . 2017;11(6):427-434. 4) Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.
V ALID S CREENING T OOL U SE Levy et al, JAM . Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.
R ESPONSE TO P OSITIVE S CREEN Levy et al, JAM. Screening Adolescents for Alcohol or Other Substance use in Massachusetts, in press.
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