Embed Size (px)
Citation preview
5/30/2017
1
Adolescent Substance Use: Mastering the CRAFFT
2017 Spring Child Health Provider Meetings
Gerri Mattson, MD, MSPH, FAAP
NC Division of Public Health
Children and Youth Branch
5/30/2017
2
Objectives
• Describe the importance of screening for substance use in adolescents
• Explain how to assess risk and provide screening, brief intervention and/or referral for treatment for concerns for substance use in adolescents
2
5/30/2017
3
Substance Use in Youth: The Bad News
• Significant cause of morbidity and mortality in
adolescents
• Impact on vulnerable and developing adolescent
brain and increased risk for addiction especially
some youth with special health care needs
• Impact on school performance and sexual risk-taking
• Involved as a factor in a significant number of injuries
and deaths
• Increased use among LGBTQ youth as compared to
other youth
3
Source: AAP Clinical Report 2016: Substance Use Screening,
Brief Intervention, and Referral to Treatment
5/30/2017
4
Substance Use: Bad News (cont.)
• Not easily recognized as a problem in youth by parents
or providers
• Decreased perception of harm by some youth
• Experimentation by youth is condoned, facilitated or
trivialized by some adults
• Many adults with substance use disorders started use
before age 18 years
• Almost 2/3 of emergency room visits for adolescents
12-17 years of age involved alcohol, drugs or the
misuse of prescription drugs
4
Sources: AAP Clinical Report 2016: Substance Use Screening, Brief Intervention, and
Referral to Treatment and SAMSHA, Office of Applied Studies, The OAS Report: A Day
in the Life of American Adolescents Substance Use Facts Updates, 2010
5/30/2017
5
5 Slide from Scott Proescheld-Bell from Child Fatality Task Force Presentation 10/2016
5/30/2017
6
Defining Substance Use Disorder
• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer uses the terms substance abuse and substance dependence
• Substance use disorders are defined as mild, moderate, or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual
• Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home
• A diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria
6
Sources: Substance Abuse and Mental Health Services Agency
(SAMSHA) https://www.samhsa.gov/disorders/substance-use and
DSM-5
5/30/2017
7
Substance Use in Youth: Some Good News
• The 2016 national survey, Monitoring the Future, recently published its results:
• The lowest use of alcohol (admitting to being drunk at least once) among 12th graders was 37% which is down from 53% in 2001
• Binge drinking is down to 15.5% among high school seniors from its peak in 1998 of 31.5%
• Other drugs are showing steady declines among adolescents but many youth are using
7
5/30/2017
8
8 8
Release on file for use of photo with Children and Youth Branch
5/30/2017
9
Alcohol Use
• Alcohol is the most commonly used, and misused drug among adolescents in the nation, according to U.S. DHHS
• 2015 NC Youth Risk Behavioral Surveillance Survey (YRBSS) showed that 29.2% of all high school students reported they had one drink in the 30 days before the survey (18.5% of 9th graders vs 40% of 12th graders) which compares to 43.7% in 1993
• A recently released study in the Journal of Studies on Alcohol and Drugs looked at National YRBSS data and showed that those high school girls acting on reported body image misperceptions are more likely to have engaged in heavy drinking than teen girls of the same age without body image issues
9
5/30/2017
10
10 10
Release on file for use of photo with Children and Youth Branch
5/30/2017
11
Cannabis Use
• Marijuana is the most-used drug after alcohol and tobacco in the United States
• According to the 2015 NC YRBSS 22% of high school seniors and almost 17% of 9th graders used marijuana at least once in the last 30 days (overall since 1995 not much change)
• A study by Columbia University published in December 2016 in JAMA Pediatrics showed that marijuana use significantly increased and perceived harm decreased among 8th and 10th graders in Washington state after legalization of recreational marijuana but not in Colorado
11
5/30/2017
12
12 12
Release on file for use of photo with Children and Youth Branch
5/30/2017
13
Use of Other Drugs in NC Youth
• In 2014, nearly half a million adolescents 12 to 17 years of age in the United States reported using nonmedical opioid pain relievers, and 168,000 adolescents reported having a documented opioid addiction (American Society of Addiction Medicine [ASAM], 2016)
• 17.9 % of high school students in 2015 reported ever having taken prescription drugs without a doctor’s prescription (e.g., opioids or stimulants) which is down from 20.5% in 2009 (NC YRBSS)
• Most adolescents who misuse prescription opioids report receiving these drugs from friends or relatives for free but adolescent prescriptions for opioids are also increasing (ASAM, 2016)
13
5/30/2017
14
14Slide from Scott Proescheld-Bell from Child Fatality Task Force Presentation 10/2016
5/30/2017
15
Drug Testing in Adolescents
• Involuntary drug screening is not recommended by the AAP
• There are emergent situations such as in accidents, suicide attempts, syncope, arrhythmias, or other situations with altered mental status or symptoms but should supplement information on history and physical
• Urine drug screens are most often used to identify substance use or exposure but serum drug screening is available
• Hair, sweat or saliva are much less commonly used
• Need to know which drugs are included in the “panel” used by the laboratory providers use
• Basic urine panels for drugs of abuse typically include amphetamines, cocaine, opioids, marijuana, and phencyclidine
• Several other drugs abused by youth include designer amphetamines such as MDMA (ecstasy), synthetic opioids (such as tramadol), synthetic marijuana, and inhalants and are not picked up by many routine panels (which requires discussion with your lab)
15
Source: 2014, AAP Clinical Report on Testing for
Drugs of Abuse in Children and Adolescents
5/30/2017
16
Drug Screening Results
• Results are reported usually as “positive” or “negative” which can be misleading
• Most routine drug screens are positive if the drug or its metabolite is present at or above an established threshold level when the sample is obtained from a patient (so if low cannot detect)
• It is important not to ignore ongoing symptoms that suggest substance abuse when a drug screen is negative
• False-positive results can occur if there are cross-reacting substances such as dextromethorphan in cough medication can show up as PCP and poppy seeds can show up as opioids
• It is also important not to attribute all signs and symptoms in a patient with a positive drug test and remember to also consider and exclude other diagnoses in the differential
16
Source: 2014, AAP Clinical Report on Testing for
Drugs of Abuse in Children and Adolescents
5/30/2017
17
AAP and Bright Futures Recommend Screening Brief Intervention and Referral for
Treatment (SBIRT)
• Screening brief intervention and referral for treatment (SBIRT) is recommended as part of preventive care during annual well visits for adolescents
• This should be addressed using confidentiality which should be discussed with youth and parents
• The limitations to maintaining confidentiality “relies on the pediatrician’s clinical judgment of the need to prevent imminent harm to the patient or someone else and to protect the patient’s health and safety”
• The most current NC Health Check Program Guide also recommends screening and provides a mechanism for reimbursement using the CRAFFT (acronym for six questions CAR, Relax, Alone, Forget, Friends, and Trouble)
17
Source: 2016 AAP Clinical Report on Substance Use Screening
Brief Intervention and Referral to Treatment by Levy et al.
5/30/2017
18
§ 90-21.5. Minor's consent sufficient for certain medical
health services
(a) Any minor may give effective consent to a physician licensed to
practice medicine in North Carolina for medical health services for the
prevention, diagnosis and treatment of (i) venereal disease and other
diseases reportable under G.S. 130A-135, (ii) pregnancy, (iii) abuse of
controlled substances or alcohol, and (iv) emotional disturbance….
(b) Any minor who is emancipated may consent to any medical treatment,
dental and health services for himself or for his child
Reminder: Adolescent Confidentiality in NC
General Statute and Substance Abuse
Source: NC General Statute
5/30/2017
19
HEEADSSS Developmental Surveillance of Adolescents for Health Risks
•Home Environment
•Education/Employment/Eating
•Peer-Related Activities
•Drugs
•Sexuality/Suicide(Depression) and Safety (from injury and violence)
19
5/30/2017
20
Screening for Substance Use
• Research shows that teens are more honest when they fill out a screening tool on their own
• Ideally, the three CRAFFT “screening interview questions” or the S2BI (Screening to Brief Intervention) are recommended for use as part of the HEEADSSS to assess risk of substance use
• However, if you feel an adolescent’s answers are not accurate, you may want to discuss with him/her further
20
Source: SBIRT Training Simulation from AAP
5/30/2017
21
Screening for Substance Use (cont.)
• Tools should be used exactly as written in order to accurately gather information
• Some tools assess level of risk with no risk, low risk, moderate risk or high risk
• Other tools assess frequency of use which can be associated with a level of risk: never (no use and “no risk”), once or twice (low risk), monthly (moderate risk), or weekly or more (high risk)
21
Source: SBIRT Training Simulation from AAP
5/30/2017
22
AAP Free SBIRT Training Simulations
22
Found at: https://aap.kognito.com/
5/30/2017
23
23
CRAFFT Screening Opening Interview Questions: These are not scored!
• Screening should start off with an introduction followed by three opening questions:
23 http://www.ceasar.org/CRAFFT/index.php
5/30/2017
25
CRAFFT Screening Tool
• The CRAFFT is a short, valid, and reliable screening tool that is part of the Bright Futures tools used in local health departments for adolescents under the age of 21 years
• Providers should use the CRAFFT (or make a referral for concerns as per agency policy) if any positive risk factors for alcohol or substance abuse are identified by the HEEADSSS interview or in any other way during the well visit with an adolescent patient
• Three introductory questions followed by up to 6 yes or no questions screen adolescents for high risk alcohol and other drug use disorders simultaneously
25
http://www.ceasar.org/CRAFFT/index.php
5/30/2017
26
CRAFFT Screening Tool
• The tool is meant to “assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted”
• Tool is freely accessible at: http://www.ceasar.org/CRAFFT/index.php
• Available in many languages: English, Spanish, Chinese, Haitian Creole, French, Hebrew, Japanese, Khmer, Laotian, Russian, Portuguese, Turkish and Vietnamese
26
http://www.ceasar.org/CRAFFT/index.php
5/30/2017
27
27
CRAFFT Screening Interview Questions
• Screening should start off with an introduction followed by three opening questions:
27 http://www.ceasar.org/CRAFFT/index.php
5/30/2017
28
The “CAR” Question
• If there is a NO response to all of the questions in Part A, it is important that the youth should still be asked the CAR question
• The CAR question is: Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?
• That car question is concerning if the answer is yes even when it is someone else who was high and requires further discussion
• This may be a reason to break confidentiality and for ERRN’s this may require further discussion with their supervising provider to decide on next actions and plan of care
• The score in this case would be 0 or 1 depending on the answer to the CAR question
• When you do the full 6 questions and the youth is not using alcohol or drugs the score would be expected to be 0 or 1 (depending on the response to the CAR question)
28
http://www.ceasar.org/CRAFFT/index.php
5/30/2017
29
29
CRAFFT Screening Interview Questions
• Screening should start off with an introduction followed by three opening questions:
29 http://www.ceasar.org/CRAFFT/index.php
5/30/2017
30
All 6 Questions for Full CRAFFT Interview
•C= Have you ever ridden in a CAR driven by someone (including
yourself) who was "high" or had been using alcohol or drugs?
•R=Do you ever use alcohol or drugs to RELAX, feel better about
yourself, or fit in?
•A=Do you ever use alcohol/drugs while you are by yourself,
ALONE?
•F= Do you ever FORGET things you did while using alcohol or
drugs?
•F= Do your FAMILY or FRIENDS ever tell you that you should
cut down on your drinking or drug use?
•T= Have you gotten into TROUBLE while you were using alcohol
or drugs?
30
http://www.ceasar.org/CRAFFT/index.php
5/30/2017
31
31
CRAFFT Self Administered• Or you can use the self-administered CRAFFT which can be
completed by the adolescent:
31 http://www.ceasar.org/CRAFFT/pdf/CRAFFT_SA_English.pdf
5/30/2017
32
Actions Based on Response to Questions About Use (No, Low, Medium or High Risk)
5/30/2017
33
Positive Reinforcement: No Use
• Teens who report never or no use should still receive genuine, positive reinforcement for their good decisions
• It is important to phrase their abstinence as a decision to acknowledge the challenges involved and empowers teens to continue delaying their use of substances (protect their brain)
Source: SBIRT Training Simulation from AAP
5/30/2017
34
34
Example: Responses to CRAFFT Screening Interview Questions
34 http://www.ceasar.org/CRAFFT/index.phpResponds no to car
5/30/2017
36
Brief Advice: Use Once or Twice in the Past Year (Low Risk)
• Thank the teen for being honest
• Ask permission to share information about how substance use affects the body
• Provide brief advice that it would be best for his/her health if the teen abstains from use and not use at all and the reasons why (i.e., more likely to be hurt or be in an accident even with infrequent use)
• Keep a non-judgmental tone to respect the teen’s autonomy
36
Source: SBIRT Training Simulation from AAP
5/30/2017
37
37
Example: Responses to CRAFFT Screening Interview Questions
37 http://www.ceasar.org/CRAFFT/index.phpResponds no to car
5/30/2017
39
Brief Intervention: Monthly Use (Moderate Risk)
• Most teens who need brief intervention will screen for moderate risk and focus for intervention will be on abstinence or harm reduction (cutting back) to minimize the negative consequences of substance use
• Use motivational interviewing strategies to engage the teen to make a behavior change plan
• With teen’s permission consider a referral for further support by involving parents, guardians or other adults in their lives
• Other options include in person support groups or other professionals such as psychologists, social workers, school or pastoral counselors, or peer specialists
39
Source: SBIRT Training Simulation from AAP
5/30/2017
41
Using the CRAFFT with the S2BI
• The recommendation on the S2BI (Screening to Brief Intervention) is that CRAFFT should be used when youth reports monthly or weekly use of substances
• Each of the six CRAFFT questions should be answered as yes or no
• Yes responses get a score of 1 and no responses get a score of 0
• A score of 0 or 1 is a negative score
• A score of 2 or more is a positive score and requires brief intervention (see later slides)
http://www.ceasar.org/CRAFFT/index.php
5/30/2017
43
Brief Intervention: Weekly or More Use (High Risk)
• These teens should be engaged in a brief intervention
• Those who seem ready to change should also be given a referral for treatment to receive a comprehensive assessment using a warm handoff to facilitate the introduction between the adolescent and specialist
• Pre-existing relationships with medical and behavioral professionals are important to help with the handoff
• Familiarize yourself with outpatient facilities and peer support groups if available in your area
• Identify colleagues who can help assess the level of care needed
43
Source: SBIRT Training Simulation from AAP
5/30/2017
46
Brief Intervention (No Acute Danger)
• A conversation designed to motivate change their behavior by helping them realize their own reasons to make healthy choices
• Goal oriented client-oriented counseling style to elicit behavior change which is motivational interviewing
• Not everyone is ready to make a change during first interaction: ambivalence
46
Source: SBIRT Training Simulation from AAP
5/30/2017
47
Brief Intervention (cont.)
• Goal in brief intervention is to help teen move toward change
• Listen for pro-change or change talk statements when patient in some small way is contemplating change
• “I did not like it when I got really drunk” (thought)
• “I know I should quit” (action)
• Listen for statements also about desires, abilities or beliefs
• Listen for anti-change or sustain talk statements with desire to sustain the current behavior
• “I love how smoking pot makes me feel”
• Avoid spending time on sustain talk and identify and build upon change talk (more talk about changing the more they do change)
47
Source: SBIRT Training Simulation from AAP
5/30/2017
48
Brief Intervention (cont.)
• Use motivational interviewing (MI) strategies to invite collaboration (OARS)
• Open ended questions• How often do you use alcohol?
• How do you spend your free time?
• Affirmations• School is important to you, so you do not want alcohol to get in the
way of good grades.
• You have really been working hard on this!
48
Source: SBIRT Training Simulation from AAP
5/30/2017
49
Brief Interventions (cont.)
• Reflections• Paraphrase to draw out the feelings behind the words
• Double side reflections start with statement that supports sustaining the behavior and ends with previous consequence expressed by the youth and should end with change talk (not sustain talk)
• Amplified reflections use change talk to exaggerate what the youth says to the point that youth might disagree with it; however, you must be careful not to go too far and upset the youth
49
Source: SBIRT Training Simulation from AAP
5/30/2017
50
Brief Intervention (cont.)
• Summaries
• Combine different points made by the patient and check your understanding about what patient has said
• Can serve as a useful transition between various points of the conversation
“Let me see if I have this right. Marijuana helps you relieve stress. And at the same time you are worried about all of
the money you are spending and that your father may find out and ground you.”
50
Source: SBIRT Training Simulation from AAP
5/30/2017
51
Brief Negotiation Intervention Model
• Build rapport
• Elicit pros and cons
• Provide feedback
• Assess readiness
• Negotiate action plan
• Summarize and thank
51
Source: SBIRT Training Simulation from AAP
5/30/2017
53
More Details and Practice With Free SBIRT Training Simulations
53
Found at: https://aap.kognito.com/
5/30/2017
55
SBIRT Billing and Coding
• The most current Health Check Program Guide has information about coding and billing:
• CPT code 96127
• Screening with CRAFFT with less than five minutes or no counseling and negative score: CPT code 96127
• CPT code 99408
• Alcohol and/or substance (other than tobacco) abuse structured screening and brief intervention services; 15 to 30 minutes
• CPT code 99409
• Alcohol and/or substance (other than tobacco) abuse structured screening and brief intervention services; greater than 30 minutes
Use the both the 25 modifier and EP modifier with these codes
for well visits
55
Source: https://ncdma.s3.amazonaws.com/s3fs-public/Health_Check_Program_Guide_2016_10.pdf
5/30/2017
56
CRAFFT Brief Screen
• NEW CPT code for use with CRAFFT brief screen
• A brief screen alone (using the questions in Parts A and B of the CRAFFT) with no counseling (or less than 5 minutes as per the CRAFFT instructions for a negative score) is to be billed using CPT code 96127 with EP modifier (or TJ with Health Choice)
• This would occur with a negative score of 0 or 1 on the CRAFFT
• If youth answers no to the questions on Part A and the provider just does the CAR question, this can be considered using the CRAFFT brief screen and billed using the 96127 EP (or TJ with Health Choice)
• Recommend still provide anticipatory counseling related to abstinence
56
Source: https://ncdma.s3.amazonaws.com/s3fs-public/Health_Check_Program_Guide_2016_10.pdf
5/30/2017
57
Documentation
• As with any screen, the provider must document the screening tool used, the results of the screening tool, the discussion with parents, and any referrals made
• Please refer to the most current Health Check Program Guide for the most up to date guidance on documentation
• Your agency policy should support documentation
• Your regional child health nurse consultants are a resource to help with guidance about documentation and can help review your policy
57
Source: https://ncdma.s3.amazonaws.com/s3fs-public/Health_Check_Program_Guide_2016_10.pdf
5/30/2017
58
Summary
• Screening for substance use in adolescent is important using validated questions at annual well visits during the HEEADSSS interview (i.e., CRAFFT Screening Interview or S2BI questions)
• Ask additional questions for a brief assessment based on the initial response if use is monthly or more
• Always provide brief advice or brief intervention using motivational interviewing strategies
• Bill and document following the Health Check Program Guide and your agency policy
• Practice using the SBIRT simulations from the American Academy of Pediatrics at: https://aap.kognito.com/
58
