Saturday, September 28, 2013

Youth Pill and Pot Abuse and SBIRT

SBIRT for youth - pills and pot
Primary care approaches to Screening, Brief Intervention and Referral to Treatment

Dr. Sharon Cirone MD CCFP(EM) ASAM (Cert)

Presentation given at Canadian Society of Addiction Medicine 2013 - Vancouver

This was a superb presentation that was very useful from a clinical perspective.  It was challenging and encouraged more active consideration of use of tools and organized thinking in the office.  Well researched, extremely well presented, and very informative and obviously coming from a lot of thought and experience. These are my rough notes which I hope will give some idea of the depth and breadth of material.

Youth Alcohol and Substance Abuse
greater than 50% past year
greater 30 % use illicit drugs
-22% marijuana

Harms of Youth Alcohol and Substance Abuse
-Impact on
-academic achievement
Sexuality, family, mental health

Alot of Concurrent Mental Health Disorder

Teen Age Brain Development and Vulnerability to Drug Use
-the later the youth puts off substance abuse the less likely the child will go onto to develop addiction in adult hood
-teen age brain more developped in ‘risk taking’ than ‘consequence consideration’ given the evolutionary development - to move out of home and into wild

The Harm of Youth Cannabis Use
-increasing presentations of cannabis induced psychosis
-exploring the link
-increased access with new legislation

“I’m a consultant to a hospital youth unit and at least once a month see cannabis induced psychosis”

Access to Prescription Opioids
-nomedical use of opiods by youth
  • youth start by accessing opioids in home cabinets

SBIRT -Calling All Youth - Raise the Subject!  Develop a specific approach! Support a youth friendly environment!

Primary Care
-while you are here, can I ask you few questions?
-how is school/work going
-how are things at home
-have you ever had alcohol to drink
-have you ever smoked marijuana or hash
-have you ever used pills or other drugs to get high
-have you ever driven in the car of a driver who had used alcohol or drugs?
What next?  SBIRT

Universal Screening
Brief Intervention
Referral to Treatment

This is for all 12 and up youth - ask all , no matter what they present with

Primary care offers a “teachable moment in a confidential setting”

Collaborative interventions are congruent with adolescent development 
-motivational interviewing is - collaborative - youth have skills to build on 

Brief Interventions with Youth Work

Decrease alcohol and substance us - Breslin research SBIRT in Pediatrics

Screening CRAFFT

Have you ever ridden in a CAR drivine by someone ‘high’ or 
Do you ever use alcohol to RELAX

Making Screening Easier
-Pre printed questioniones in the waiting room or handed out
-put CRAFT on your desktop to ask

-if adolescent says they’ve not used - praise and say how good they’re doing - hope you keep it up!
-if low risk -ask more questions -advise of brain development effects -  some praise with ‘lets talk about low risk drinking guidelines 
CASE PRESENTATION of low risk 15 year old brought in by mother for stealing money from her wallet for once a week marijuana use ‘he’s on drugs’ 
“if you tell me you’re dealing drugs I’m not going to report this however is you are using your seven year old sister with you to deal crack I’m going to have to disclose - set limits of confidentiality”

Affirm - I appreciate you have really considered this and are making some smart decisions regarding marijuana (eg not carrying it to school, not driving with it, etc, whatever positive you’ve heard)
Advice “As a physician, for your health sake, I strongly advise you against use of marijuana”
Open Ended Questions - we both know that only you can decide about how often and how much you smoke marijuana - what do you thihnk is best. 

What if things are more complicated? Moderate or High Risk Use

Moderate Risk - brief Motivational Intervention -and/or referral
High risk - Refer

Use with Risk - Assess
-can you tell me more  about your use
how often
has it caused any problems
have you ever tried to cut down or quit
Do you think you wnat to change anything

Affirm - give positive feedback on healthy decisions

Risk/Confidence assessment
On scale of 1 to 10 how interested are you in changing
On scale of 1 to 10 how confident are you in your ability to risk

Advice - abstience challenge, discuss harm reduction, provide psychoeducation

Assist - Motivational Interviewing, Weigh Pros and Cons, Discuss and write down action plan
Arrange - provide hand out , web based resources, discuss/make referrals

Video used to show brief interventions for a primary care clinician to use with a high risk youth who has reported high risk in context of presenting premenstrual pain and admitting using percocets for the pain
-primary care physician and actor

Decisional Balance Tool
  1. Things I like about....
  2. Things I don’t like about

Send patient home with homework

Referral to Treatment
-further assessment - youth community alcohol and substance use counselling services
-addiction medicine specialists
-mental health providers

Outpatient counselling
Day Treatment
Residential Treatment
Inpatient medical treatment

Take home message

Physicians need to ask
Future direction - we need alot more research and implementation of more SBIRT models
Physicians need to especially ask adolescents about marijuana

I care about you
I am concerned about you
I will be here for you
-Dr. Knight

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