Screening and Handoff to Counseling for PCPs

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Adolescent Substance Use Screening and Referral

SHANNON MOUNTAIN-RAY: Hello, and welcome to today’s presentation for screening and referral for adolescents who use substances. I’m Shannon Mountain-Ray, Director of Integrated Care for the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. 

Today, we’ll focus on discussing the importance of using a valid and reliable screening tool. We’ll discuss the Screening to Brief Intervention, otherwise known as the STBI, and describe recommended interventions based on those screening results. 

One question we often find ourselves asking is, do health care providers really need a structured tool for substance use screening? Do we really have a good sense of what’s going on? And do our own questions allow us to have the most accurate information? 

In a study that our team did, we asked many participating primary care providers what their perception of adolescent substance use was in their communities. Some of the responses were things like, “It’s a very small city. I wouldn’t think that kids are really using drugs and alcohol.” 

Another provider said, “If patients are drinking, it’s like stupid high school kids who go out and have a couple of beers on the weekend here and there. It’s not like chronic alcohol problems.” And when discussing the idea of screening, this primary care provider said “There hasn’t been much agreement among the physicians in my practice about the need for a screening tool on adolescent drug and alcohol use.” 

What we actually know is medical providers really do benefit from a structured, valid, and reliable screening tool. This was a study that was done comparing medical providers’ impressions with what was actually happening using a diagnostic interview. 

So what we see here is a good number of providers were actually able to identify whether or not there was any use. Just over 60% were able to identify that their patients were using on some level. Often in those situations, it was because the patient disclosed their use. 

But when we get into the other areas of any problem, any disorder, or severe substance use disorder, the providers were not as accurate. So just over 1% were able to identify whether or not there was any problem related to substance use. 1% were able to identify whether there was any disorder. And none of them were able to identify whether or not there was a severe substance use disorder. 

So that leads us to understand that we do need a valid and reliable tool in order to accurately screen for adolescent substance use. So for today’s topic, we’re going to be introducing the Screening to Brief Intervention, otherwise known as the STBI. The STBI is a valid and reliable screening tool. It has been validated for adolescent patients ages 12 to 17. 

The STBI consist of frequency questions for different substances and focuses on use in the past year. This is actually a summary slide of what the STBI looks like. When you’re actually utilizing the STBI, you want to ask these frequency questions for each individual substance that’s bulleted on this slide. 

So for example, you would ask, in the past year, how many times have you used tobacco or nicotine? And we give some examples in parentheses. And the patient would identify whether or not they’ve used never, once or twice, monthly, or weekly. And then you would move on to ask the same frequency questions for alcohol, marijuana, and get a sense of that. 

If the patient actually answers never to all three of those, you can stop the screen at that point. As you may know, the most widely used substances by far amongst adolescents are tobacco, nicotine, alcohol, and marijuana. Very few patients who are using substances are not also using those substances. So if they answer never to all three questions, in order to save yourself a little bit of time you can stop the screen at that point. 

However, if they answer– if they indicate any frequency– once or twice, monthly, or weekly for any of those top three substances– then you’ll want to move on to ask about the other substances listed below. So prescription drugs, illegal drugs, inhalants, herbs, or synthetic drugs. 

You use the frequency to assess risk. So what we know is the sensitivity and specificity of the STBI is very high for identifying any substance use and also for identifying a severe substance use disorder. 

So previously, we have classifications of substance use disorders in the DSM-4 and the DSM-4-TR that were focused on areas of “abuse,” quote, unquote, and dependence. But in May of 2013, the DSM-5 was released, and the DSM-5 combines the DSM-4 categories and actually creates a single disorder measured on a continuum from mild to severe. So it’s mild, moderate, or severe substance use disorder. 

And each specific substance is addressed as a separate substance use disorder. So for example, it might be a mild alcohol use disorder and a severe opioid use disorder. So each substance that they use, if they meet criteria for a substance use disorder, is then identified as mild, moderate, or severe based on the number of criteria that they indicate. 

The DSM-5 criteria for substance use disorders includes 11 different areas. So everything from tolerance and withdrawal to persistent desire or unsuccessful efforts to cut down or quit, failure to fulfill major role obligations, recurrent use, and physically hazardous situations, et cetera. 

When we are talking with a patient and asking them about these 11 different criteria, based on the number that they endorse will indicate whether or not they meet criteria for a mild, moderate, or severe substance use disorder. So as you can see on the right-hand side of this slide, a 0 to 1 endorsement is no substance use disorder diagnosis. 2 to 3 indicate a mild substance use disorder, 4 to 5 a moderate substance use disorder, and 6 or more a severe substance use disorder. 

So when we think about substance use, we can think about it on a continuum or a pyramid with no use being down at the bottom. So hopefully, most kids that are being screened fall into that bottom category. 

And in the middle category, no substance use disorder. So there may be some level of substance use, but they don’t meet criteria for a substance use disorder. And then some may fit into the category of mild to moderate substance use disorder, and then even fewer may fit into the category of severe substance use disorder. 

When we take a look at the frequency questions, there is an algorithm that helps us decide exactly what we should do based on the screening results. And so as you can see, for each frequency answer there is a corresponding intervention, including in situations where someone reports that they have not used any substance. 

So some of the intervention goals include, for example, if a patient doesn’t report any substance use, the provider can provide positive reinforcement to help delay initiation. Research has shown that some intervention providing positive reinforcement can not only delay initiation, but also can reduce the frequency and the quantity of which someone may use. 

If there is substance use but no substance use disorder, the intervention could be giving brief advice and encouraging cessation of all use. If they meet criteria for a mild or moderate substance use disorder, it might be a motivational intervention, again, to encourage cessation, or at minimum, reduce use. 

And then a severe substance use disorder, which is a more intensive motivational intervention to stop or reduce use of risky behaviors. In these situations, patients may require a higher level of care. And adolescents with nicotine, alcohol, opioid, or cannabis use disorders may also benefit from medications. 

One thing to consider as you’re identifying what the appropriate intervention is is confidentiality. So it’s always best to interview the adolescent without parents or caregivers present when possible, and expressing that information can remain confidential unless safety is at risk. However, sometimes that can be a gray area. 

So we recommend checking state laws and guidelines regarding when confidentiality must be broken. What identify– what qualifies as a safety risk? And when confidentiality must be broken, discuss it first with the patient. Try out the words to use and avoid revealing small details unless they’re absolutely necessary. 

So we often try to have conversations with the patients and let them know why we have to share the information that we have to share, what we will share, and if possible, explore with the patient their thoughts and feelings about that. When these kinds of interventions are done well and thoughtful and in collaboration with the patient, often not only do they seem to go smoothly, but they can also actually help to deepen the clinical relationship that you have with these patients. 

So again, when we’re thinking about no use, what we are recommending is positive reinforcement for their safe choices around alcohol and drugs. When you’re providing positive reinforcement, the best options are to give positive feedback, very specific, clear, positive feedback. And frame it as a decision if appropriate, that they are making a choice to not use substances. 

And for younger kids, you can include a norms correction. So you can help them understand that quote, unquote, “not every kid” is using drugs and alcohol. Or any other questions or incorrect or inaccurate information they may have. 

So we’re going to talk about Sarah. Sarah’s a 16-year-old girl with no past year use of any substance. She meets with her primary care provider who says to her, “You’ve made a very good decision not to drink or use drugs, and I hope you keep it up. When kids do use, they can put themselves at risk like getting injured or even having unwanted sex.” So again, very clear, positive praise, framed it as a decision, and also shared some important information about what some of the risks of adolescent substance use might be. 

One of the other things that we would suggest strongly is doing– is including car safety as a part of this brief intervention. So teens should not drive even after a single drink or use of any substance. Often, teens don’t notice the early effects of alcohol and other substances, which can affect their ability to drive. 

So one of the conversations can be around thinking about alternative and safe ways to getting home, being very explicit that you are suggesting that they not drive if they are under the influence of any substance. This includes alcohol, cannabis, opioids, sedatives, et cetera. 

But thinking about safe and alternative ways to get home, and give maybe some suggestions, or see if they can give you some suggestions like getting a ride from someone who hasn’t been using. Stay overnight and then go home the next morning. Call for a safe ride from parents. 

One really great resource is the Contract for Life. This was developed by the Students Against Destructive Decisions. The Contract for Life includes commitments on the part of a young person, as well as the parent or caring adult in their life around making safe choices specifically related to alcohol and drugs, and what they will do in the event that they cannot find a safe ride home. 

So for the young person, they really commit to trying to do everything in their power to make safe choices for themselves overall, and very specifically that they will not drive or ride in a car with someone who’s been using alcohol or drugs. They also agree to wear their seatbelt, and that in the event that they need a ride home or they don’t have a safe ride home that they will call and request a ride home or find an alternative way home. 

The parent or caring adult also agrees to make safe decisions for themselves, and they will also wear their seatbelt and will not drive under the influence of alcohol or drugs. And they agree to provide safe and sober transportation home in the event that the young person needs it. In addition to that, the parent or caring adult also agrees that they will defer discussions until everyone is in a calmer– in a calmer place and can have these discussions in a clear and caring manner. 

For young people who indicate that they’ve used substances a couple of times, we would recommend continuing on with a follow-up STBI questions, providing some brief advice, and considering a possible referral for evaluation or education related to substance use. So in these situations, again, we would recommend brief advice. 

So we would advise abstinence. There is no level of substance use that is safe for adolescents, so as a caring provider we suggest that they abstain from all substances. It doesn’t mean that they will, and they get to make their own choice, but at least they know where we stand on the topic. 

You can talk about health consequences related to use. Use a strengths-based approach and give an option for referral to, for example, a social worker for brief intervention such as education, planning, or support. 

Meet Marcus. He’s a 16-year-old boy who comes into the office after injuring his ankle at football practice. He reports that he’s used cannabis once or twice in the past year, but not at the time of his injury. 

His primary care provider says, I would recommend that for your sake– for your health that you quit smoking cannabis. It can affect your concentration and over time impact your mood and affect your performance on the football field. You’re such a good athlete. I would hate to see anything get in the way of your future. If you’re interested in learning a bit more about the effects of cannabis, we have someone on our team who knows a lot about this topic and would love to talk with you. 

In situations where a young person reports monthly use, again, can continue on with the follow-up STBI questions and refer to some level of treatment. Monthly use correlates directly to a mild to moderate substance use disorder, and early intervention is always better. So the earlier we can get someone into some level of treatment, usually outpatient treatment, depending on the level of substance use, the better. And the goal would be to stop– to abstain if at all possible, or at minimum reduce use and risky behaviors. 

So here’s Katie. She’s 17 years old and she comes into the office for a well child visit. She reports past year alcohol and cannabis use, but does not use any other substances and reports that she’s using alcohol on a monthly basis. 

So you’ve asked her the STBI questions, and you may go into a little bit of a further assessment. There are some structured assessments out there, or you could just ask. Tell me a little bit more about your alcohol use. Katie says that she started drinking at parties as a freshman, she now drinks about twice a month, and she’s drinking four to six shots, which is enough to get her drunk. 

You can ask about problems associated with her alcohol use. She reports that she was suspended for two weeks because she was drunk at the homecoming game and threw up in the bathroom. She believes her grades have dropped in part because she’s missed so much school and is having a lot of trouble catching up. She says her parents were very upset and grounded her, and she said she would stop drinking, but she continued to drink with friends. 

Have you ever had sexual contact after drinking? She reports that she’s had sex while drunk twice. Two days ago she had sex while drunk and did not use a condom. 

Have you ever tried to quit? Katie has never tried to quit before. She says she drinks less than her friends and doesn’t think it’s a problem. She’s not really interested in quitting. 

So the primary care provider might summarize and identify some of the challenges. You enjoy drinking with your friends and alcohol has also gotten to you– gotten you into some trouble. Where should we go from here? 

Katie doesn’t think that she has an alcohol problem and isn’t interested in quitting, but she does mention that she struggles with anxiety and can contribute– and that can contribute to her alcohol use. So the primary care provider might say something like, I care about you and your health. As your PCP, it’s my recommendation that you don’t drink at all, but I understand that has to be your decision. 

It sounds like anxiety is a struggle for you. I have a team member who works with young people who are struggling with things like anxiety and stress. I think it would be a good idea for you to meet with them and help you learn skills to cope with and hopefully alleviate your anxiety. 

So the important piece about this intervention is Katie’s not ready to talk about her alcohol use. She doesn’t think it’s a problem and she’s not interested in quitting, but she is identifying some other areas that she’s struggling with. For example, her anxiety. So getting– so focusing on what she wants and what she’s identifying as her needs would be a really great way to getting her into at least some initial level of counseling, even if she’s not willing to go and discuss her substance use. 

For people who report weekly use, again, ask those follow up STBI questions and refer to treatment. And the idea is probably providing ongoing treatment. Again, this can range from an outpatient level of care all the way up to residential or inpatient level of care, depending on the patient’s needs. 

Alex is 15 years old, and he presents for a school physical. He reports weekly cannabis use. So just by that report, we know that he meets criteria for severe cannabis use disorder. 

He reports that he started smoking six months ago and is now smoking daily. He uses when he feels stressed. He often smokes by himself. His mother caught him smoking a few times and is now, quote unquote, “constantly on his case.” But he thinks she’s overreacting because “weed is not that bad.” 

He was brought home by the police who caught him smoking in the woods, but no charges were filed. His grades have dropped this year because high school’s a lot harder. He doesn’t believe his cannabis use has anything to do with it. 

Alex doesn’t want to quit, and he can’t imagine how he would manage his stress without using cannabis. His primary care provider acknowledges that stress management is difficult, and he recommends that he talk to a counselor to help him with that and also to talk about his cannabis use. Alex is reluctant, but he agrees. 

So what about the caregivers in these situations? So you’ve had these conversations with the young people, and in this case Alex has agreed to go to talk to a counselor. So you might want to assess, what do the parents or caregivers know about their substance use? 

If they say that their parents do know, you could say something like, I imagine they’ll be happy that you’re ready to talk to someone about it. In my experience, kids do best when their parents and other family members are supporting them. And if you agree, I’d like to tell them that you’re agreeing to see a counselor. 

If the answer is no, you can explore what would happen if they found out. What we know from research is kids do better when parents or caregivers are involved in their care, but you’re going to want to screen for things like active domestic violence or mental health or substance use issues, or anything that could create a situation that might be unsafe for the patient.

If it is safe, you can encourage the teen to involve parents or other family members. Offer support in breaking the news and emphasize that the teen is seeking treatment. You can practice with them beforehand so that they know exactly the words that you’ll use. 

So in Alex’s case, his PCP praises him and asks permission to invite his mother in. The PCP points out that this could be really good for relieving some of that stress at home. Alex agrees, and they talk to Mom together. Mom agrees to help Alex get to his first counseling appointment. And I can tell you, in many situations that is the most important step, because very frequently once they get to that first appointment, they often come back for follow-up visits. 

And finally, one other intervention that primary care providers can offer is caregiver guidance. The primary care provider can provide education and support to parents in most cases. So in situations where parents are concerned but the patient isn’t, or parents are concerned and haven’t explored this with their child, primary care providers can educate parents around the risks of adolescent substance use and the benefits of treatment. They can also help strategize how to increase the likelihood that the patient will accept a referral. And in some situations, some restrictions may apply for patients over 18 in terms of what can be shared with parents in those situations. 

But the most important thing is for primary care providers to screen for adolescent substance use and be prepared to provide brief intervention based on those results. I appreciate you being here today, and I hope you enjoyed this presentation.