Brief Interventions for Substance Using Adolescents
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The document discusses intervention strategies for substance use among adolescents, highlighting the SBIRT (Screening, Brief Intervention, and Referral to Treatment) approach in school-based health settings. It covers the addiction cycle, neurobiology of substance use, and motivational interviewing techniques to engage and support youth in making healthier choices regarding drugs and alcohol. Key issues surrounding the use of substances like THC, nicotine, alcohol, and various stimulants are addressed along with screening tools and the importance of tailored communication with teens.
![Stimulants
Stimulants increase the amount of dopamine in the reward circuit (causing the
euphoric high) either by directly stimulating the release of dopamine or by
temporarily inhibiting the removal of dopamine from synapses, the gaps between
neurons. These drugs also boost dopamine levels in brain regions responsible for
attention and focus on tasks (which is why stimulants like methylphenidate [Ritalin®]
or dextroamphetamine [Adderall®] are often prescribed for people with attention
deficit hyperactivity disorder). Stimulants also cause the release of norepinephrine,
a neurotransmitter that affects autonomic functions like heart rate, causing a user to
feel energized.](https://image.slidesharecdn.com/sbirtmiintegratedpresentationpdf-190521165826/85/Brief-Interventions-for-Substance-Using-Adolescents-78-320.jpg)
Brief Interventions for Substance Using Adolescents
- 1. Brief Interventions for Substance Using Adolescents Robert Dousa, OUSD TUPE Program Manager & Independent Strengths Building Consultant astrengthsapproach@gmail.com Naomi A. Schapiro, PhD, RN, CPNP, Professor UCSF Family Health Care Nursing & PNP La Clínica de la Raza SBHCs naomi.schapiro@ucsf.edu
- 2. Disclosures The presenters have no financial conflicts of interest to disclose Naomi Schapiro is a member of the national School Based Health Alliance SBIRT steering committee
- 4. Pair and try out active listening Ask each other what is happening at your school site related to drug and alcohol use, and what you want to get out of this training. TRY USING ACTIVE LISTENING & REFLECTIONS INSTEAD OF QUESTIONS, TO ELICIT THE INFORMATION
- 5. California has historically had low teen rates of tobacco use. BUT the significant increase in “vaping” may reverse the previous declines in tobacco use, and increase steady rates of marijuana use
- 7. And yet...
- 8. “Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health” THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION
- 9. The Three Stages of the Addiction Cycle and the Brain Regions Associated with Them
- 10. The Addiction Cycle ● Binge/Intoxication, the stage at which an individual consumes an intoxicating substance and experiences its rewarding or pleasurable effects. ● (Basal Ganglia) ● Withdrawal/Negative Affect, the stage at which an individual experiences a negative emotional state in the absence of the substance. ● (Extended Amygdala) ● Preoccupation/Anticipation, the stage at which one seeks substances again after a period of abstinence. ● (Prefrontal Cortex)
- 11. Addiction Cycle In Summary The power of addictive substances to produce positive feelings and relieve negative feelings fuels the development of compulsive use of substances. The combination of increased incentive salience (binge/intoxication stage), decreased reward sensitivity and increased stress sensitivity (withdrawal/negative affect stage), and compromised executive function (preoccupation/ anticipation stage) provides an often overwhelming drive for substance seeking that can be unrelenting.
- 12. Designer Drugs “Trending Products” THC Vaping, Edible, & Drinkable Products Nicotine Vaping, Alcohol, Ecstasy, Meth Synthetic Opioids & Heroin Mixing Drugs Xanax, Promethazine, etc. How can we approach this?
- 13. Purple, Dro, Grand Daddy (High potency “natural” marijuana)
- 14. WaxShatterOil High Potency THC Products
- 15. All Kinds of Edibles
- 16. The Newest Products of THC
- 18. THC Pods for JUULS
- 19. Cigs, Vapes, Chew, Dip, Blunts Nicotine from Tobacco
- 20. Juice, Hardstuff, Hooch, Suds, Giggle Juice (Alcohol)
- 21. Ex, Skittles, Beans, Hug Drug, Love Pill, Scooby Snacks Ecstasy/Mollys Website to Purchase >
- 22. Stimulants: Meth, Crack, Cocaine, Ritallin, Diet Pills
- 24. Prescription drugs “Pharm Parties” Xanax and Alcohol Mixing in cough syrup Mixing Legal Drugs into Lethal Combinations
- 25. Ice Breaker “Can you believe it?”
- 27. Overview of SBIRT in SBHC Medical Visit Elements • Establish Rapport • Explain confidentiality protections and limits • General psychosocial screen (HEADSS or SSHADESS) Rationale • Basis for client-centered counseling • Establish trust & boundaries • Understand context for substance use • Important to use screen validated for adolescent
- 28. Overview of SBIRT in SBHC Medical/HE Visit Elements • Screen such as CRAFFT for level & impact of substance use • Brief Intervention about results • Referral to treatment Rationale • Important to use screen validated for adolescent • Explore ambivalence, support motivation to change • Behavioral health, dedicated drug treatment counselors, groups, enhanced nursing, health ed, group visits
- 29. Why SBIRT in Medical Visit? •Client centered model incorporating stages of change and motivational interviewing more successful than traditional models • Roots of motivational interviewing in alcohol use counseling • Have been used in a variety of adolescent health counseling/coaching models (drugs/alcohol, sexual health, healthy diet/exercise
- 30. Traditional Approaches to Adolescent Risk Reduction ● Risk Assessment ○ Deficit model ● Anticipatory guidance ● Health Belief Model: ○ Perceived Severity of condition ○ Perceived Susceptibility to Condition ○ Perceived Benefits of Taking Action ● Psychosocial Screen (HEADSSS) – problem oriented ● Home ● Education ● Activities ● Drugs/Diet ● Sexuality & Abuse ● Suicide/Depression ● Safety
- 31. Traditional Approaches to Risk Reduction ● Risk Assessment ● Anticipatory guidance ● Health Belief Model: ○ Perceived Severity of condition ○ Perceived Susceptibility to Condition ○ Perceived Benefits of Taking Action ○ Perceived Costs of Taking Action Outweighed by Benefits
- 32. Sexual Behaviors in US http://www.nationalsexstudy.indiana.edu
- 33. ● California STD Rates Age (2015)
- 34. The intersection of the Health Belief Model with Adolescent Development? ●Teens are ○ present oriented ○ less likely to perceive personal susceptibility to adverse consequences ○ ambivalent about authority/messages about what they should do ○ eager for discussions about risky behaviors and mentoring about making their own healthy choices
- 35. Essential Principles of Motivational Interviewing Express empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy R: Resist the righting reflex U: Understand your patient’s motivations L: Listen to your patient E: Empower your patient O- (ASK PERMISSION!) Open ended questions A-Affirmations R- Reflective/Active Listening S - Summarizing (did I get this right?)
- 36. Start a conversation: •Tailoring what you already do •Starting with youth’s interests SSHADESS Assessment Formal depression screen recommended at least once a year Strengths/Interests School Home Activities Drugs/Substance Use Emotions/Depression Sexuality Safety
- 37. Screening: CRAFFT • Pre-screen: • In the past year have you drunk more than a few sips of alcohol • In the past year, have you used marijuana or any other drugs + Question 1 below? • Ridden in a Car with someone high? - if No, congratulate, if YES ……. • Ridden in a Car with someone high? • Drink/drugs to Relax or fit in? • Drink/drugs while Alone? • Forget things you did on alcohol/drugs? • Family or Friend tell you to cut down? • Trouble from drinking/drugs?
- 38. Prescription Drug Use Ask specifically about use of: Prescription Drugs • Pain pills • Xanax or other benzos • Stimulants (ADHD meds) Ecstasy/Molly Designer drugs (K2, salts)
- 39. Interpreting CRAFFT screen •Full CRAFFT, score each YES as 1 point • •IF 0-1, Brief Advice •CRAFFT ≥ 2, further assessment: •NO signs of acute danger or addiction – –Summary, praise, brief advice harm reduction •≤ 14 yrs, daily or near daily use, CRAFFT ≥ 5, any blackouts – –Refer to treatment –Consider outside confidentiality •Signs of immediate danger (IV, mixing, hospital visits, lethal doses) –Immediate contract for safety –Consider outside confidentiality AAP 2016 SBIRT protocol
- 40. Delivering/discussing results of screen Traditional “You know that this is bad for your health…” “Your MJ use is the reason you are failing math” Shuts down conversation, elicits teen’s defense of risky behavior Fails to elicit context & teen’s point of view Fails to engage teen’s participation
- 41. Delivering/discussing results of screen Brief Intervention/MI “Can we talk about your use of alcohol?” “What do you think are the benefits to you of using marijuana? … Any down sides?” Ending the visit “As you have pointed out, drinking until you forget what you have done is scary. How do you think you can protect yourself in the future?” End with recommendation as HC provider & next steps, based on teen’s readiness to change
- 42. AAP Algorithm for screening & intervention •Discuss possible follow-up with NP/MD/PA •Options for interventions in clinic - BH, HE group w supervision, return to provider •Referrals - school (TUPE)/community
- 43. Motivational Interviewing “Identifying Coaching Points” Develop Motivation/Buy In Listen to Identify Needs Identifying Coaching Points Relevant Informing to Drive Positive Decision-making How can we approach this?
- 44. by Prochaska & Diclemente
- 46. Principles of Motivational Interviewing ● The Client has the answer inside already ● We facilitate them to find it ● Express and Show Empathy Toward Clients. … ● Support and Develop Discrepancy. … ● Deal with Resistance. … ● Support Self-Efficacy. ... ● Develop Autonomy.
- 47. Great Listening = Rapport 1. Initial Rapport 2. Confidentiality & Rapport 3. Listening to the Whys/Needs & Rapport
- 48. Powering Up Motivational Interviewing Listening to the “Likes” to Find the Needs
- 49. Motivational Interviewing Find an Reasons for using - Relevant education Find Most Emotional Reason Summarize Pro & Con
- 50. Let’s Practice Person A 3 likes for using; Person B Reflect Most Emotional Likes Reflect Back
- 51. Continue Let’s Practice Person B Explore the main “like” with A Person A Tell more of main “like” Explore the Main “Like” Find Out What A Knows
- 52. Person B Ask partner A all they know about sober strategies Person A Share as much as you know Explore the Sober Strategies Setting Up Coaching
- 53. Now Summarize & Ask THE Question Based on what we discussed: ● Keep doing things the same ● Make some changes? ● Make a big change?
- 54. If the answer is... “Yes to Change!” Then… Set a strong goal!
- 55. Begin Coaching… SET THE GOAL! ● SMART goal example ● What - How - Measurement? Jon will only smoke weed on Friday and Saturday this week BY ...playing basketball with his brother and will MEASURE his success by putting the money normally spent, in a glass jar.
- 56. Life Skills Coaching… Strengthen Against Relapse Trigger ● Earlier you had mentioned you needed to smoke because…. ● Strengthen Student to Foster Behavior Change Success …. ● COACH THE LIFE SKILL NEEDED
- 57. Setting clear goals ● We have an alignment conversation (co-construct goals) where we agree on the goals and the performance standards for each. ● We write each goal so it is SMART ○ S = Specific ○ M = Motivating ○ A = Attainable ○ R = Relevant ○ T = Trackable Setting Goals
- 58. Coaching Therapy Move them from negative behaviors through deep engagement in building good!
- 59. Coaching Strategies a) Assessment ● What skill does person need? ● Where is person at on skill level? COMPETENCY? COMMITMENT? b) Apply Best Coaching Style
- 60. Self Advocacy Supporting Your Client to Make Their Best Choice
- 61. Kindness, Altruism & Unconditional Love
- 62. Thank You!! Brief Interventions for Substance Using Adolescents Robert Dousa, OUSD TUPE Program Manager & Independent Strengths Building Consultant astrengthsapproach@gmail.com Naomi A. Schapiro, PhD, RN, CPNP, Professor UCSF Family Health Care Nursing & PNP La Clínica de la Raza SBHCs naomi.schapiro@ucsf.edu
- 63. Bonus Slides!!
- 64. Drug Use in Adolescents - Finding Data Youth Risk Behavior Surveillance System (YRBSS) - HS, every 2 years - (only some locations in California) https://www.cdc.gov/healthyyouth/data/yrbs/index.htm California Healthy Kids Survey (CHKS) - at least every 2 years in 5th, 7th, 9th, 11th grades https://www.cde.ca.gov/ls/he/at/chks.asp Monitoring the Future - selected public/private HS in US, HS seniors - with mailed survey f/u for selected sample into adulthood http://www.monitoringthefuture.org
- 66. Your Brain on Edibles
- 67. How does THC Affect Teen Brain Development & Behavior?
- 68. Marijuana (Cannabis) Leads to increased dopamine in the basal ganglia, producing the pleasurable high. It also interacts with a wide variety of other systems and circuits in the brain that contain receptors for the body’s natural cannabinoid neurotransmitters. Effects can be different from user to user, but often include distortions in motor coordination and time perception. Cannabis addiction follows a pattern similar to opioids. This pattern involves a significant binge/intoxication stage characterized by episodes of using the substance to the point of intoxication. Over time, individuals begin to use the substance throughout the day and show chronic intoxication during waking hours. Withdrawal is characterized by negative emotions, irritability, and sleep disturbances.
- 69. Basic Vaping THC Key Points for Concerns ● Breathing Issues: Vaping marijuana can aggravate asthma conditions. bronchial tubes spasms ● Cancer Risk: Cancer-causing substances like tars & tumor inducing chemicals may be released ● Intoxication: The marijuana oils that are sometimes used for vaping can be highly concentrated with up to 90% of the drug’s active ingredient, THC
- 70. Basic Vaping THC Key Points for Concerns ● Pre-existing Conditions: If you suffer from heart or circulatory disorders, low blood pressure, diabetes or schizophrenia, marijuana ingested in any form can pose a health risk to you. Double heart rates. ● Dependence: Although marijuana isn’t as addictive as tobacco, its use is known to cause a dependency upon the substance. ● Brain Issues: The THC in marijuana is absorbed into your bloodstream and carried to your brain where it interacts with cell receptors that control neurological development and other brain functions.
- 71. Who Owns 70% of the Tobacco Vaping Market? JUULS!
- 72. Nicotine on the Brain
- 73. Basic Vaping Nicotine Key Points for Concerns ● Heart disease due to stimulant ● Aerosol irritates eyes and respiratory tract ● High potency THC/nicotine leading to addiction ● Accidental poison you (or a child) if liquid swallowed ● Harm dopamine receptors altering brain development ● Nitrosamines in E-Cigs can cause cancer ● E-cig batteries can explode in use (hand or face)
- 74. Alcohol and Your Brain
- 75. Alcohol When alcohol is consumed it interacts with several neurotransmitter systems in the brain, including the inhibitory neurotransmitter GABA, glutamate, and others that produce euphoria as well as the sedating, motor impairing, and anxiety reducing effects of alcohol intoxication. Alcohol addiction often involves a similar pattern as opioid addiction, often characterized by periods of binge or heavy drinking followed by withdrawal. As with opioids, addiction to alcohol is characterized by intense craving that is often driven by negative emotional states, positive emotional states, and stimuli that have been associated with drinking, as well as a severe emotional and physical withdrawal syndrome.
- 76. Ecstasy Effects
- 77. Meth on the Brain
- 78. Stimulants Stimulants increase the amount of dopamine in the reward circuit (causing the euphoric high) either by directly stimulating the release of dopamine or by temporarily inhibiting the removal of dopamine from synapses, the gaps between neurons. These drugs also boost dopamine levels in brain regions responsible for attention and focus on tasks (which is why stimulants like methylphenidate [Ritalin®] or dextroamphetamine [Adderall®] are often prescribed for people with attention deficit hyperactivity disorder). Stimulants also cause the release of norepinephrine, a neurotransmitter that affects autonomic functions like heart rate, causing a user to feel energized.
- 79. What Happens When DRUNK & HIGH
- 80. Xanax Impacts on Brain
- 81. Fentanyl & Carfentinil Opioids Video
- 82. Opioids Opioids attach to opioid receptors in the brain, which leads to a release of dopamine in the nucleus accumbens, causing euphoria (the high), drowsiness, and slowed breathing, as well as reduced pain signaling (which is why they are frequently prescribed as pain relievers). Opioid addiction typically involves a pattern of: (1) intense intoxication, (2) the development of tolerance, (3) escalation in use, and (4) withdrawal signs that include profound negative emotions and physical symptoms, such as bodily discomfort, pain, sweating, and intestinal distress and, in the most severe cases, seizures. As use progresses, the opioid must be taken to avoid the severe negative effects that occur during withdrawal.