1. Prevention and Early Intervention in
Substance Use
AMFDA Annual Meeting Sheila Specker, MD Associate Professor Department of Psychiatry

2. Funding from NIAAA, NIDA, Conrad Hilton Foundation
Disclosure:
I have no conflict of interest
Funding from NIAAA, NIDA, Conrad Hilton Foundation

3. >90%
BEGAN SMOKING, DRINKING OR USING OTHER DRUGS BEFORE AGE 18
>90%

4. Prevention Primary : Prevent disease or injury before it ever occurs.
preventing, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur.
Secondary:
Reduce the impact
detecting, treating disease ASAP to halt or slow its progress, encouraging personal strategies to prevent recurrence
Tertiary:
Soften the impact of an ongoing illness
Manage chronic diseases, permanent impairments, improve quality of life

5. Addiction Medicine Fellowship PEI Program Requirements
IV.A.2.a).(1) Patient Care
Competence in comprehensive assessment, dx, treatment...along continuum of care including early intervention
Competence providing care….with diversity in age..
Proficiency in screening, brief intervention, and motivational interviewing

6. Addiction Medicine Fellowship PEI Program Requirements
IV.A.2.b).(1) Medical Knowledge
Demonstrate expertise in …..prevention, screening, brief intervention and referral….
medical model of addiction including changes in brain structures
epidemiology...and the genetic and environmental influences…
impact in diverse populations….neonates, children, adolescents, families…
prevention, including identification of risk and protective factors
screening, brief intervention strategies appropriate to risk level
MAT and psychosocial interventions to diverse ... age

7. Addiction Medicine Fellowship PEI Program Requirements
II.C. Other program personnel
Clinicians available such that fellow receive training in SUD’s across the lifespan

8. Conrad Hilton SBIRT Addiction Fellowship “Next Gen” 2015-2016
Project: Prevention, Early Intervention (Brian Grahan, MD, PhD)
Screening of all adolescents presenting to or current patient of fellow child psychiatry clinic, U of MN

9. Conrad Hilton SBIRT Addiction Fellowship Grant 2015-2016
Goal:
Identify youth with risk behaviors for substance use and SUD
Establish systematic method of screening
Educate providers (child fellows, child faculty) on screening, BI

10. Principle #1: Improvement Requires Change
Every system is perfectly designed to achieve exactly the results it gets
Understand the System
Procedures, resources and routines needed to perform a specific activity
You need to:
Know your customers (patients/residents/staff)
Understand system failures and identify what is wrong
Figure out which step needs fixing
Remember that all improvement requires change, but not all change is improvement

11. Principle #2: No One Wants More Work
Sustainability = simplicity
Most people seek the path of least resistance
Anticipate work-arounds
Reliable change requires simpler work flow
Simplification is hard

12. Aim
Screen X% of child/adolescent psychiatry patients for substance use using a standardized tool by [DATE], 2016

13. S2BI In the past year, how many times have you used: Tobacco? Alcohol?
Marijuana?
STOP if all “Never.”
Otherwise, CONTINUE
Prescription drugs that were not prescribed for you?
Illegal Drugs?
Inhalants
Herbs or synthetic drugs (such as salvia, “K2”, or bath salts)?
never
1-2x
monthly
weekly

14. CRAFFT
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 or drugs while you are by yourself, ALONE?
F Do you 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 ever gotten into TROUBLE while you were using alcohol or drugs?
0=no risk 1-2 low risk 3-4 moderate risk 5-6 high risk

15. Adolescent Screening Team: Round 1
Addiction medicine fellow
Chief fellow, child/adolescent psychiatry
Medical director, child/adolescent psychiatry clinic
Child/adolescent psychiatry fellows

16. Initial Status ≥ 9% of patients 12+ yrs old use substances
Chart review of documented substance use status among child/adolescent fellows’ patients in 1 month period (n=115)
No use
Any use
Problem use
No comment
Clinical impression 43 8 2 62
≥ 9% of patients 12+ yrs old use substances
54% of fellows’ patients use status unknown
No standard questions, template

17. Plan
Chief child/adolescent psychiatry fellows willing to try standardized screening tool
No champions: “I already ask about it”
Addiction fellow available for POC consult?
Child fellows prospectively review patient panel for 1 month and estimate substance use
Child fellows use CRAFFT during interview, return results to addiction fellow

18. Results: Feedback “It confirmed what I already knew.”
“It helped because I didn’t have to spend time asking [about use] when I got time alone with the patient. I could get right to the point.”
“The car question was new... I now use that into my practice. The rest... it didn’t help much.”
“If a patient is using, then I usually warn them about my staff’s response. I focus on maintaining rapport, and they tend to come down hard.”

19. Results/Conclusions Only 1 of 7 fellows reported any quantitative data
Need frequent in-person contact with addiction provider
Medical assistants reliably screen using standardized tools
Parental presence skews adolescents responses
Computerized screening ?

20. Adolescent Screening Team: Round 2
Addiction medicine fellow
Program director, child/adolescent psychiatry fellowship
Medical director, child/adolescent psychiatry clinic
Clinic manager, outpatient psychiatry clinics
Consulting physician, pediatric addiction medicine
Child/adolescent psychiatry fellows
Front desk & intake staff representative
Medical assistant

21. Barriers No quality improvement culture/expertise on staff
Minimal informatics support
High staff turnover
Substance use low priority in child/adolescent fellowship

22. Obstacle to Prevention Efforts: Understanding the System
Procedures, resources and routines needed to perform a specific activity
You need to:
Know your customers (patients/residents/staff)
Understand system failures and identify what is wrong
Figure out which step needs fixing

23. Conrad N. Hilton Foundation’s Youth Substance Use Prevention and Early Intervention Strategic Initiative: Impacting Youth Substance Use, Health, and Wellbeing
Setting by Number of Grantees and Organizations (as of June 30, 2015)
Number of Grantees Number of Sites
Community
School/SBHC
Health care
Community behavioral health 2 29
Criminal Justice 2 9

24. Conrad N. Hilton MPower Project University of Minnesota
Enroll youth with mild-mod SU and parents in SBIRT study in pediatric health clinics and high schools
Kaiser: health clinics
UMN : high schools
Same intervention

25. Conrad N. Hilton MPower Project University of Minnesota
Goals:
Develop and use new screening tool for SU and MH
Develop manual
Comparison of 2 brief interventions:
Single session psychoeducation with teen alone
4 sessions: teen alone, parent alone, teen alone, teen + parent
Follow up intervals to 6 months

26. Conrad N. Hilton MPower Project University of Minnesota
Single session:
CORE: Personal strengths, life stressors, social support
FLEX:
If teen requests alternate topic to discuss
If high stress/cognitive emotional regulation needs
If need for increased decision making skills
If alcohol/other drug use

27. Conrad N. Hilton MPower Project University of Minnesota
4 sessions:
Session 1 (teen alone): coping with life stressors
Session 2 (parent alone): parenting teens
Session 3 (teen alone): addresses risk factors, including SU and decision making skills
Session 4 (parent + teen): family communication, drug education: “getting on the same page”

28. Conrad N. Hilton Project University of Minnesota
Enroll 150 parent- teen dyads
Identified through school system
Teen with “mild-mod” substance use
Used a substance once/last 6 months
and/or
Sxs of depression, anxiety, PTSD, ADHD, ED

29. Conrad N. Hilton Project University of Minnesota
Exclusion:
Received SU treatment
Mental health interfering
Non-English speaking
Must have both parent/teen involvement

30. Conrad N. Hilton Project University of Minnesota
Hypothesis: either program helps the teen to:
Make healthier choices
Improve family relationships
Reduce alcohol/other drug use

31. Addiction Fellow Prevention/Early Intervention Learning
Didactics, webinars, seminars (knowledge)
Many excellent resources on line:

32. Addiction Fellow Prevention/ Early Intervention Learning
Team: “buy in”
Can’t do it alone!
Faculty, fellow, case manager, SW, nurse
“Hands on”
Know your system
Guidance

33. Addiction Fellowship Challenges to Training in Prevention
Identifying a specific need area
Faculty with expertise
Most of trainees days busy
Unfamiliarity – where to start?

34. Summary Start small and think ahead a few steps Test changes
Continuous improvement often requires a few cycles

35. Thank you! Sheila Specker, MD speck001@umn.edu