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Children Suffer From Parental Substance Abuse

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Describe the substance use continuum. Cite data on the effectiveness of ... Risky and problematic substance use is common in our settings ... – PowerPoint PPT presentation

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Title: Children Suffer From Parental Substance Abuse


1
(No Transcript)
2
Learning Objectives
  • You will be able to
  • Describe the substance use continuum
  • Cite data on the effectiveness of screening and
    brief intervention
  • Conduct screening, intervention, and referral for
    women of reproductive age

3
NON- PROB USE
AT-RISK USE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


4
Standard Drink
5
At-Risk Drinking
  • Per Week Per Occasion Men gt14 drinks gt4 drinks
  • Women gt7 drinks gt3 drinks
  • Elders gt7 drinks gt1 drink
  • Pregnant Any Any

(NIAAA Physicians Guide, 1995)
6
NON- PROB USE
AT-RISK USE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


7
Rationale for Generalist Care
  • Risky and problematic substance use is common in
    our settings
  • Most affected people receive no intervention or
    treatment
  • Early identification and intervention can prevent
    adverse effects, improve other health outcomes,
    and save money

8
Generalist Care for Substance Use Related
Disorders
Screen if positive, perform brief assessment
Abstinence or low-risk use
At-risk use or abuse
Dependence
Refer to treatment
Prevention message
Brief intervention



Motivational Interviewing
Follow-Up
9
Evidence on Screening
  • Screening instruments are often tested by
    concurrent validity
  • Screen is compared to a gold standard criterion
    measure
  • Gold standard is usually a lengthy diagnostic
    interview

10
Definition of Screening
  • Procedure to recognize individuals with a
    disorder or at-risk for a disorder before obvious
    manifestations of the disorder are apparent.
  • Examples
  • Cancer and depression

11
Choose Screens By ...
  • Number of items
  • Method of administration
  • Substances covered
  • Accuracy by age group, gender, pregnancy status,
    ethnic group

12
AUDIT
  • 10 questions - multiple choice
  • Administered in writing
  • Alcohol only
  • Screens for at-risk drinking, abuse, and
    dependence
  • Accurate across many cultures/nations
  • Sens 51 - 97 Spec 78 - 96

13
CAGE
  • 4 yes/no questions (1 yes positive)
  • Administered by interview
  • Alcohol only
  • Screens for abuse and dependence
  • Add quantity and frequency questions to screen
    for at-risk drinking
  • Sens 43 - 94 Spec 78 - 96

14
CRAFFT
  • 6 yes/no questions (2 yeses positive)
  • Administered by interview
  • Alcohol and drugs
  • Validated for adolescents
  • Sens 92 Spec 82

15
Two-Item Conjoint Screen
  • 2 yes/no questions (1 yes positive)
  • Administered by interview
  • Covers alcohol and drugs
  • Screens for abuse and dependence
  • Add quantity and frequency questions to screen
    for at-risk use
  • Sens 81 Spec 81

16
TWEAK
  • 5 questions
  • Administered by interview
  • Covers alcohol only
  • Screens for abuse and dependence for pregnant
    women
  • Sens 59 - 87 Spec 72 - 94

17
TWEAK
  • Tolerance
  • Worry
  • Eye-Opener
  • Amnesia
  • K (C)ut down

18
Q/F Questions on Alcohol
  • How many days a week do you drink some alcohol?
  • How much do you typically drink when you do
    drink?
  • Whats the most youve had to drink at one time
    in the past 3 months?

19
Other Questions to Consider
  • Have you ever tried or experimented with -
    Marijuana? - Inhalants? - Cocaine? - Pills? -
    Shooting Up? - Any other drugs?
  • Days per week, usual quantity, maximum
  • Have you ever gotten any help for an alcohol or
    drug problem?

20
Transitions to Screening
  • Routine questions
  • Tie into pt's/client's concern.
  • Questions on preventive health
  • Family medical or social history
  • Diet history
  • Leisure activities
  • Stresses and ways of coping

21
Sample Adult Screening Protocol
  • Transition Stresses and ways of coping
  • Do you drink alcohol?
  • Have you ever experimented with any drugs?
  • Ask TWEAK questions
  • Ask Q/F questions on alcohol
  • Usually takes less than one minute

22
Non-Verbal Cues
  • Interpret significant changes in a patient's/
    client's non-verbal cues as a positive screen for
    abuse or dependence
  • Eye contact
  • Fluidity and tone of speech
  • Posture
  • Movements
  • Affect

23
For Especially Sensitive Situations
  • Ask about friends first
  • Ask about prior use first
  • Make normalizing statements before asking
    questions

24
Screen Results and Actions
  • Abstinence (ask why) Prevention message
  • Low-risk drinker Prevention message
  • At-risk drinker or Brief drug user with
    other- intervention wise negative screen
  • Positive screen for abuse Brief or
    dependence assessment

25
Prevention Messages
  • Brief
  • Relevant information
  • Culturally appropriate
  • Reinforcing

26
NON- PROB USE
AT-RISK USE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence
- - -
- -
-/ -


27
Definition of Assessment
  • A process intended to identify precisely a
    patients category of substance use on the
    continuum

28
Assessment Tools
  • Alcohol levels and drug tests
  • Tests for excessive alcohol use - liver function
    tests, blood counts
  • Physical examination
  • Collateral report
  • Self-report

29
Self-Report
  • Interview is usually the most accurate source of
    information
  • Accurate assessment is usually possible even with
    minimization
  • Appropriate assessment techniques can build
    rapport

30
Brief Assessment Interview
  • Consequences and repetition
  • Physical dependence and loss of control
  • Quantity and frequency

31
Later Consequences
  • Cirrhosis, cardiomyopathy, AIDS, chronic
    pancreatitis, CAD, cancer
  • Severe neuropsychiatric disorders
  • Family dissolution, social isolation
  • Unemployment, homelessness
  • Incarceration
  • Oral cancers and tooth loss

32
Earlier Consequences
Identify problem before irreversible consequences
  • Psychological
  • Family
  • Friends
  • Biomedical
  • Work
  • Legal
  • Financial

33
Early Consequences Psychological
  • Earliest category of consequences
  • Dysphoria, depression, or anxiety
  • Irritability, mood swings, hostility
  • Paranoia, psychosis
  • Any psychiatric symptom can be related to
    intoxication, overdose, or withdrawal

34
Early Consequences Family
  • Marital/family dysfunction
  • Childhood behavior/school problems
  • Mental health problems and somatic symptoms among
    family members

35
Early Consequences Friends
  • Alienation and loss of old friends
  • Gravitation toward others who use substances
    heavily

36
Early Consequences Biomedical
  • Gastritis, peptic ulcer, pancreatitis, vague
    abdominal pain, diarrhea
  • Hypertension
  • Weight gain for alcohol
  • Weight loss for cocaine and amphetamines
  • Sleep and sexual dysfunction
  • Unplanned pregnancies, unwanted sexual advances,
    STD's
  • Periodontal disease

37
Early Consequences Injuries
  • Assaults
  • Domestic violence/family violence
  • Other interpersonal violence
  • Motor vehicle related
  • Motor vehicle crashes
  • Pedestrian motor vehicle crashes
  • Falls
  • Fires
  • Swimming/boating related
  • Suicide attempts
  • Injuries in the home
  • Repeated injury events

38
Early Consequences Work/School
  • Frequent lateness and absences
  • Requests for work excuses
  • Decline in performance
  • Frequent job changes

Preservation of function for highly
motivated individuals, such as many health care
professionals
39
Early Consequences Legal
  • Domestic and other violence
  • Arrests for disturbing the peace
  • DWIs / DUIs
  • Arrests for possession and dealing
  • Burglary, robbery

40
Early Consequences Financial
  • Spending more than one can afford on obtaining
    substances
  • Financial strain
  • Indebtedness
  • Selling possessions

41
Brief Assessment Interview
  • Consequences and repetition
  • Physical dependence and loss of control
  • Quantity and frequency

42
Brief Assessment Interview (continued)
  • Loss of control
  • Setting rules about substance use
  • Having difficulty adhering to rules
  • Physical dependence
  • Withdrawal symptoms
  • Substance use to avoid withdrawal
  • Tolerance

43
Brief Assessment Interview (continued)
  • Consequences and repetition
  • Physical dependence and loss of control
  • Quantity and frequency

44
Brief Assessment Interview (continued)
  • How many days a week do you drink some alcohol?
  • How much do you typically drink at one time when
    you do drink?
  • Whats the most youve had to drink at one time
    in the past 3 months?
  • Take responses at face value

45
Other Important Concerns
  • Cultural Competence
  • Dual Diagnosis

46
Cultural Competence Review
  • Increased concern for cultural competence among
    all health care disciplines.
  • Impetus concern for adequacy of services for
    members of minority groups.
  • Flexible changing process.
  • Each person is unique within their culture.

47
Dual Diagnosis
  • Co-existing substance use disorder and another
    psychiatric disorder
  • Identify primary and secondary disorder, if
    possible
  • If SUD may be primary, and if psychiatric
    symptoms are not pressing, try abstinence without
    medications

48
Conventional Explanatory Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
49
Another Possible Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
50
Another Possible Model (continued)
Psychological Disorder
Stressful Circumstances
Substance Use Disorder
Cycle can start anywhere
51
Evidence on Brief Interventions
  • Intervention - up to 15 minutes of dialogue with
    up to 3 follow-up sessions
  • Feedback
  • Responsibility
  • Advice
  • Menu
  • Empathy
  • Self-efficacy

52
Evidence on Brief Interventions (continued)
  • Several randomized controlled trials
  • Subjects at-risk and problem drinkers
  • Control subjects improved - screening and
    assessment can elicit behavior change
  • Experimental subjects improved more
  • Statistically significant differences in
  • Self-reported Q/F
  • Liver inflammation
  • Attendance at work
  • Days in hospitals
  • Costs of health care, car crashes and criminal
    justice

53
Evidence on Brief Interventions (continued)
  • Per subject
  • Costs savings in health care, car crashes,
    criminal justice 1146
  • Cost of screening/intervention 250
  • Net cost savings 946

Fleming et al, Medical Care, 2000.
54
Evidence on Treatment
  • Consider SUDs as chronic relapsing and remitting
    conditions
  • Abstinence is not the sole criterion for
    evaluating effectiveness of treatment
  • Other criteria for effectiveness are less
    substance use, better function, improved quality
    and duration of life

55
Evidence on Treatment (continued)
  • Effective for those who commonly receive them
  • Inpatient outpatient alcohol treatment
  • Naltrexone for alcohol dependence (short-term)
  • Opioid maintenance treatment
  • Long-term residential drug treatment

56
BI/Referral - Principles
  • Feedback
  • Responsibility
  • Advice
  • Menu of options
  • Empathy
  • Self-efficacy

57
BI/Referral - Steps
  • Feedback
  • Education
  • Recommendation
  • Negotiation
  • Secure agreement
  • Set follow-up

58
Feedback
  • Summarize negative consequences
  • Describe relevant risks
  • Raise concern about substance use
  • Seek reaction
  • Listen and acknowledge
  • Explain how their use compares to norms

59
Education
  • Educate about how substance use is linked to
    consequence or risk
  • Assess prior knowledge and
  • culturally linked perceptions
  • Assess interest in information
  • Convey information
  • Assess understanding

60
Initial Recommendations
  • For at-risk use or abuse
  • For family history abstinence
  • For family history low-risk use
  • For pregnancy abstinence
  • For dependence
  • Abstinence
  • Referral to specialist/treatment

61
Negotiation
  • Listen and acknowledge response
  • If recommendation is resisted
  • Ask about interest in change
  • Suggest further change if risks or consequences
    will continue
  • Identify and help remove barriers to change
  • Accept decision support any change

62
Secure Agreement
  • Ensure specificity and concreteness
  • Record agreement for client/pt and practitioner
  • Express optimism and support
  • Suggest use of drinking or substance using diary
  • Give warning about withdrawal symptoms

63
Set Follow-Up
  • Suggest follow-up at one month
  • Offer follow-up sooner
  • Emphasize desire for follow-up regardless of
    progress
  • Reassure about lack of anger and judgment if
    pt/client has difficulty
  • Make statement of partnership

64
Follow-Up
  • Assess progress after intervention
  • Reassess if necessary consequences, dependence,
    Q/F
  • Make recommendation
  • Negotiate
  • Secure agreement set follow-up

65
At Follow-Up, If No Better
  • Use motivational interviewing, OR
  • for dependence
  • Recommend referral, continue discussing over time
  • For abuse or at-risk use
  • Continue discussing over time
  • Consider specialized assessment or consultation

66
Watch for Dual Diagnosis
  • Continuation of symptoms despite decreased use
  • Unmasking of new psychiatric symptoms

67
Documentation
  • Advantages
  • Reminder to attend to issue in future
  • Useful information for colleagues
  • Documents quality of care
  • May facilitate reimbursement
  • Disadvantages
  • Colleagues/staff may be judgmental
  • Breaches of confidentiality
  • Legal, economic, and social ramifications
  • Insurance issues

68
Documentation (continued)
  • Possible Ramifications
  • Subpoena
  • Insurance applications
  • Child custody decisions
  • Mandatory or optional reporting of pregnant
    substance users may lead to imprisonment and/or
    forced treatment in some states

69
Principles of Documentation
  • Practitioner owns record patient/client owns
    information
  • Written permission required to release records
    (except when life is at risk)
  • Federal confidentiality law
  • Must have specific permission to release
    information on substance abuse, mental health,
    HIV/AIDS, and STDs
  • Must include effective and expiration dates and
    purpose of information release

70
Implementation
  • Training alone is minimally effective in changing
    practitioner behavior
  • Bolster training with
  • Directives
  • Peer consensus
  • Incentives
  • Reminders
  • Team approaches
  • Systemization
  • CQI

71
Summary
  • All generalist health professionals should
    screen, intervene, and refer
  • Intervene and refer using FRAMES FERNSS
  • Follow-up
  • Document with care
  • Consider implementation issues
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