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Overview: Screening Brief Intervention and Referral to treatment

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Title: Overview: Screening Brief Intervention and Referral to treatment


1
Overview Screening Brief Intervention and
Referral to treatment
  • Holly Hagle, PhD
  • Director of the Northeast ATTC

2
Objectives for this workshop
  • 1.Compare and contrast alcohol and other drug
    (AOD) use as it relates to the continuum of use,
    abuse, and dependency.
  • 2. Describe the principles of screening, brief
    intervention, and referral to treatment (SBIRT)
    process.
  • 3. Review the stages of change and Motivational
    Interviewing (MI) strategies and their
    implication for the intervention process.
  • 4. Examine the elements of effective brief
    interventions.
  • 5. Examine SBIRT for at risk individuals.

3
SBIRT An Effective Approach
  • Screening
  • Brief Intervention
  • Referral
  • Treatment

4
SBIRT
Intro to SBIRT
Source SBIRT Oregon Residency Program, 2012
5
Alcohol and US
  • Annual cost of alcohol related injuries 130
    billion(1)
  • Substance abuse is strongly associated with
    health problems, disability, death, accident,
    injury, social disruption, crime and violence (1)
  • 30 of trauma center admissions are intoxicated
    (1)
  • 24.255 of high school students have 5 or more
    drinks in a row on at least 1 day during a month
    (2)
  • 49 of men who identified as homosexual ages
    25-29, reported binge drinking (3)

  • Sources
  • H. Gill Cryer, MD, Chief of Trauma, UCLA Medical
    Center
  • CDC study - http//www.cdc.gov/hiv/youth/
  • CDC studyhttp//www.cdc.gov/mmwr/preview/mmwrhtml
    /ss6014a1.htm?s_cidss6014a1_e

6
Alcohol and US
  • National data indicates that the rate of STD
    among female heavy drinkers was 7.3 (highest for
    women 18-25 years old) (1)
  • 79,000 deaths were attributable to excessive
    alcohol use in the US (2)
  • Excessive alcohol use is the third leading
    life-style related cause of death for the US (2)

Sources 1. CDC - http//www.cdc.gov/ncbddd/fasd/
research-preventing.html 2. CDC -
http//www.cdc.gov/alcohol/fact-sheets/alcohol-use
.htm
7
DRUG Use and US
  • Injection drug users (IDUs) account for more than
    60 percent of all new hepatitis C virus (HCV)
    infections in the United States. (1)
  • Fifty to eighty percent of new IDUs are infected
    within 6 to 12 months of initial injection. (1)
  • Of an estimated 15.9 million people who inject
    drugs worldwide, up to 3 million are infected
    with HIV (2)
  • 20.8 of students reported use of marijuana at
    least one time in the last month (3)
  • Ecstasy use in the past year (from 6 percent in
    2008 to 10 percent in 2010).
  • Marijuana use among teens increased by a
    disturbing 22 percent (from 32 percent in 2008 to
    39 percent in 2010).
  • Sources
  • CDC- U.S. Centers for Disease Control and
    Prevention - http//www.thebodypro.com/content/art
    22608.html
  • Mathers, B. et al. (2008) http//www.unodc.org/doc
    uments/frontpage/Facts_about_drug_use_and_the_spre
    ad_of_HIV.pdf
  • CDC - http//www.cdc.gov/hiv/youth/
  • Join together online - http//www.drugfree.org/jo
    in-together/addiction/national-study-confirms-teen
    -drug-use-trending-in-wrong-direction

8
Scope of the Problem
  • Alcohol and/ drugs are a factor in
  • 60-70 of homicides
  • 40 of suicides
  • 40-50 of fatal motor vehicle crashes
  • 60 of fatal burn injuries
  • 60 of drownings
  • 40 of fatal falls

Source Virginia department of Health, Division
of Injury and Violence Prevention, retrieved from
http//www.vahealth.org/Injury/data/reports/docume
nts/2008/pdf/Alcohol20and20Injury20Report.pdf
9
Why SBIRT?
  • SBIRT is a comprehensive, integrated, public
    health approach to the delivery of early
    intervention and treatment services
  • For persons with substance use disorders
  • Those who are at risk of developing these
    disorders
  • Primary care, mental health, AOD and other
    community settings provide opportunities for
    intervention with at-risk substance users
  • Before more severe consequences occur
  • Source The Pacific Southwest Addiction
    Technology Transfer Center - SBIRT webinar
    slides March 2010

10
SBIRT Effectiveness
  • Rates of illicit drug use dropped by 67.7 percent
    six months after patients using illicit drugs had
    received help through a SBIRT program.
  • Heavy alcohol use dropped by 38.6 percent.
  • Illicit drug users receiving brief treatment or
    referral to specialty treatment also reported
    other quality of life improvements
  • 29.3 percent reported feeling generally healthier
  • 31.2 percent reported experiencing fewer
    emotional problems
  • 15.4 percent reported improved employment status
  • 64.3 percent reported fewer arrests
  • 45.8 percent who were homeless reported no longer
    being homeless

Madras, B.K., Compton, W.M., Avula, D.
Stegbauer, T., Stein, J.B., Clark, H.W., Drug
and Alcohol Dependence Volume 99, Issues 13, 1
January 2009, Pages 280295.
11
sbirt effectiveness
Evaluations of SBIRT
  • Meta-analyses reviews
  • More than 34 randomized controlled trials
  • Focused primarily on at-risk and problem drinkers
  • Result 10-30 reduction in alcohol consumption
    at 12 months

Study - Moyer et al, 2002 Whitlock et al, 2004
Bertholet et al, 2005 Ppt. Source SBIRT Oregon
Residency Program, 2012
12
Why SBIRT?
In a nutshell Why SBIRT?
  • Source SBIRT Oregon Residency Program, 2012

13
Lets look at the continuum of use
14
  • Use

15
Screening
Who are we trying to reach?
Advise referral
5
Dependent
8
Harmful
Brief intervention
9
Risky
78
Healthy
No intervention
Source SBIRT Oregon Residency Program, 2012
16
The Drinkers Pyramid
3-7 alcohol dependent or harmful users
10- 15 hazardous, at-risk users
35- 40 low-risk drinkers
40 abstainers
Source World Health Organization (WHO)
17
What is a Low-Risk Limit?
  • No more than two standard drinks a day
  • Do not drink at least two days of the week
  • NIAAA Guidelines

18
What is a Low-Risk Limit?
  • There are times when even one or two drinks can
    be too much
  • When operating machinery
  • When driving
  • When taking certain medicines
  • If you have certain medical conditions
  • If you cannot control your drinking
  • If you are pregnant

19
At Risk Drinking
  • Men more than 14 drinks per week or consuming
    more than 4 drinks per occasion
  • Women (and anyone age 65) more than 7 drinks
    per week or consuming more than 3 drinks per
    occasion
  • Drinking more than 2 standard drinks per day w/o
    abstaining for at least 2 days per week
  • NIAAA
    Guidelines

20
Source NIAAA Guidelines
21
  • Abuse

22
Substance Abuse vs. Substance Dependence
Substance Abuse the misuse of an illicit drug,
prescription drug or over-the-counter
medication. Substance abuse often involves a
pattern of harmful drug use for mood altering
purposes. A person diagnosed with substance abuse
is not considered to be addicted or dependent
(otherwise the diagnosis would be substance
dependence).
23
Definitions Drinking Episodes
  • A drinking binge is a pattern of drinking that
    brings blood alcohol concentrations (BAC) to 0.08
    or above.
  • Typical adult males 5 or more drinks in over a 2
    hour period
  • Typical adult females 3 or more
  • For some individuals, the number of drinks needed
    to reach binge level BAC is lower
  • University of Oklahoma Police Notebook BAC
    Calculator www.ou.edu/oupd/bac.htm

24
  • Addiction

25
Chemical Dependency
  • According to the National Epidemiologic Survey on
    Alcohol and Related Conditions
  • 8.5 percent of adults in the United States meet
    the criteria for an alcohol use disorder
  • 2 percent of adults met the criteria for a drug
    use disorder
  • 1.1 percent of adults met the criteria for both

26
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27
Stereotype
28
Lincoln on Alcoholism
  • In my judgment such of us who have never fallen
    victim (of alcoholism) have been spared more by
    the absence of appetite than from any mental or
    moral superiority over those who have. (remarks
    to the Springfield, Illinois Washingtonian
    Society, February, 1842)

29
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30
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31
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32
Addiction is Manageable Recovery Happens
  • Addiction is Manageable and, with treatment, has
    good outcomes.

.all this bad news! Is there no hope?
Of course there is hope! Recovery is all around
us. No known cure doesnt mean not
untreatable. We dont cure diabetes, we
manage it with proper diet, blood sugar
monitoring and other acts of discipline.
33
Recovery
  • Recovery from alcoholism and drug addiction is a
    process of change through which an individual
    achieves abstinence and improved health,
    wellness, and quality of life. (SAMHSA/CSAT)

34
Why dont we screen and Intervene?
35
Dont Ask-Dont Tell?
  • Alcohol and Drug Abuse problems are often
    unidentified
  • In a study of 241 trauma surgeons, only 29
    reported screening most patients for alcohol
    problems
  • In a study of 7,371 primary care patients, only
    29 of patients reported being asked about their
    use of alcohol or drugs in the past year
  • (Danielson et al., 1999 DAmico
    et al., 2005)

36
Question to the Group
  • What barriers get in the way of screening?

37
Why We Dont Screen Intervene Barriers
  • Lack of awareness and knowledge about tools for
    screening
  • Discomfort with initiating discussion about
    substance- use/misuse
  • Sense of not having enough time for carrying out
    interventions

38
Why We Dont Screen Intervene Barriers
  • Healthcare negative attitudes toward substance
    abusers
  • Pessimism about the efficacy of treatment
  • Fear of losing or alienating patients
  • Lack of simple guidelines/procedures for brief
    intervention

39
Why We Dont Screen Intervene Barriers
  • Uncertainty about referral resources
  • Limited or no insurance company reimbursement for
    the screening for alcohol and other drug use.
  • Lack of education and training about the nature
    of addiction or addiction treatment

40
Why We Dont Screen Intervene Opportunities
  • When AOD screening becomes more routine, you
    typically can expect
  • Greater patient and family satisfaction
  • Better patient management and follow-up

41
Why We Dont Screen Intervene Opportunities
  • The concern shown by healthcare providers, even
    during brief intervention, can provide patients
    with significant motivation for change or
    referral for further assessment and treatment.

42
Why We Dont Screen Intervene Opportunities
  • The costs of AOD counseling for patients in
    relation the costs for AOD related
    hospitalization are small, but the value in terms
    of prevention may be great.

43
Role of Healthcare Profession in Drug and Alcohol
Use What Can We Do To Help?
  • 1. Identify use, misuse, and problematic use
    screen with simple direct methods
  • 2. Connect use/misuse to health related issues
  • 3. Encourage consumption reduction
  • 4. Conduct a Brief Intervention
  • 5. Refer for formal assessment

44
Identification of use, misuse, and problematic
useHow Can We Approach This Process?
  • There are many screening tools that are brief and
    easy to use that can help to determine the
    involvement of a person with AOD.

45
Goals of Screening
  • Identify both hazardous/harmful drinking or drug
    use and those likely to be dependent
  • Use as little patient/staff time as possible
  • Create a professional, helping atmosphere
  • Provide the patient information needed for an
    appropriate intervention
  • Use teachable moments

46
SBIRT An Effective Approach
  • Screening
  • Brief Intervention
  • Referral
  • Treatment

47
SBIRT Effectiveness
  • Alcohol screening and counseling (is) one of
    the highest-ranking preventive services among the
    25 effective services evaluated using
    standardized methods. Since current levels of
    delivery are the lowest of comparably ranked
    services, this service deserves special attention
    by clinicians and care delivery systems.
  • - American Journal of Preventive Medicine

48
SBIRT Effectiveness
  • Rates of illicit drug use dropped by 67.7 percent
    six months after patients using illicit drugs had
    received help through an SBIRT program.
  • Heavy alcohol use dropped by 38.6 percent.
  • Madras, et.al.
    (2009)
  • Harris County (Texas) Hospital District Study
  • Patients reporting any days of heavy drinking
    dropped from 70 at intake to 37 at 6-month
    follow-up
  • Patients reporting any days of drug use dropped
    from 82 at intake to 33 at follow-up
  • Spence, et. al.
    InSight Project Research Group (2009)

49
SBIRT Saves Money
  • Literature reports a 4 to 1 savings with SBIRT
    approach
  • 2002 study published in the journal Alcoholism
    Clinical and Experimental Research (Vol. 26, No.
    1), researchers found that every dollar invested
    in an SBIRT-like approach saved 4.30 in future
    health care costs. These reduced costs are
    associated with changes in
  • Alcohol use
  • ED visits
  • Hospital days
  • Legal events
  • Motor vehicle accidents

50
SBIRT as a Response Option
Brief Intervention
Primary Prevention
AODA Treatment
Abstinence Infrequent use Problematic use
Abuse Dependence
51
Lets look at the screening instruments
52
Screening
  • Involves the use of
  • Alcohol and/or drug abuse screening tools

53
Screening vs. Assessment
  • Screening determining the possibility that a
    condition exists
  • Assessment confirming the existence of a
    condition and its severity.

54
We Take a Look at Many Factors
  • pattern(s) of use
  • negative consequences
  • context of use
  • control of use/ motivation
  • previous treatment

55
Screening Tools
  • CAGE
  • 3 question AUDIT
  • 3 question drug screen
  • 1 question binge drinking question
  • BAC

56
C.A.G.E.
  • Please answer yes or no to each item that best
    describes how you
  • have felt and behaved over your whole life.
  • 1. Have you ever felt you should Cut down on your
    drinking?
  • 2. Have people Annoyed you by criticizing your
    drinking?
  • 3. Have you ever felt bad or Guilty about your
    drinking?
  • 4. Have you had an Eye-opener first thing in the
    morning to steady nerves or get rid of a
    hangover?
  • If there is a yes answer to any of these
    questions please complete the
  • full AUDIT.
  • Ewing JA. (1984). Detecting alcoholism, the CAGE
    questionnaire. Journal of the American Medical
    Association, 252(14), 1905-1907.

57
Alcohol Use Disorders Test - AUDIT
  • Full AUDIT 10 question instrument
  • Brief 3 question version
  • Screens for hazardous drinking, harmful use and
    alcohol dependency

58
The AUDIT 3 question version
  • Add the number for each question to get the total
    score for items 1, 2, 3
  • A score of 4 or more for men and 3 or more for
    women is considered positive.
  • (Generally, the higher the score the more likely
    it is that the patients drinking is affecting
    his/her health and safety)
  • 1. How often do you drink anything containing
    alcohol?
  • (0 )Never (1) Less than monthly (2) Monthly
  • (3) Weekly (4 ) 2-3 times a week (5) 4-6 times
    a week (6) Daily
  • 2. How many drinks do you have on a typical day
    when you are drinking?
  • (0) 1 drink (1) 2 drinks (2) 3 drinks
  • (3) 4 drinks (4) 5-6 drinks (5) 7-9 drinks
    (6) 10 or more
  • 3. How often do you have four or more drinks on
    one occasion?
  • (0) Never (1) Less than monthly (2) Monthly
  • (3 ) Weekly (4) 2-3 times a week (5) 4-6
    times a week (6) Daily
  • Babur, T.F., Higgins-Biddle, J.C., Saunders,
    J.B., Maristela G. Monteiro, M.G. (2001). The
    alcohol use disorders identification test
    guidelines for use in primary care.
  • (2nd ed.). World Health Organization,
    Department of Mental Health and Substance
    Dependence.

59
Domains and Item Content of the Full AUDIT
Domains Question Number Item Content
Hazardous Alcohol Use 1 2 3 Frequency of drinking Typical quantity Frequency of heavy drinking
Dependence Symptoms 4 5 6 Impaired control over drinking Increased salience of drinking Morning drinking
Harmful Alcohol Use 7 8 9 10 Guilt after drinking Blackouts Alcohol-related injuries Others concerned about drinking
60
Interpretation of AUDIT-
Score Degree of Problems
0-7 No Problems at this
time 8-15 Hazardous Harmful
Alcohol Use 16-19 High Level of
Alcohol Problems and
Possible Dependence 20-40
Possible Alcohol Dependence

61
Drug Abuse Screening Test (DAST)
  • DAST 10 items used to screen for potential
    involvement in the use of drugs.
  • Three question pre-screen for drug use.

62
Three question pre-screen for drug use
  • If there is a yes response to any item please use
    full DAST.
  • 1. In the last year have you used drugs other
    than those required for medical reasons?
  • Yes No
  • 2. In the last year, have you used prescription
    or other drugs more than you meant to?
  • Yes No
  • 3. Which drug do you use most frequently?
    _________________________________

63
One question screen for binge drinking
  • When was the last time you had more than x (x5
    for men x 4 for women) drinks on 1 occasion?
  • Williams, R.H., Vinson, D.C. (2001). Validation
    of a single question screen for problem drinking.
    Journal of Family Practice 50(4), 307-312.

64
Brief Intervention
65
  • Brief interventions are those practices that aim
    to identify a real or potential alcohol or other
    drug (AOD) problem and to motivate an individual
    to do something about it.

66
The Brief Intervention
  • Short dialogues between the medical provider and
    the patient that typically involve
  • Feedback
  • Client engagement
  • Simple advice or brief counseling
  • Goal-setting
  • Follow-up

67
Brief Intervention Models
  • Brief Negotiated Interview
  • FRAMES Approach
  • FLO Feedback, Looking for Change, Options
  • 5As Ask, Advise, Assess, Assist, Arrange

68
World Health Organization(Am J Pub Health 1996)
  • A cross-national trial of brief interventions
    with heavy drinkers
  • Multinational study in 10 countries (n1,260)
  • Interventions included simple advice, brief and
    extended counseling compared to control group
  • Results Consumption decreased
  • 21 with 5 minutes advice, 27 with 15 minutes
  • compared to 7 controls
  • Significant effect for all interventions

69
Assessing Readiness Stages of change
  • Its important to assess for stage of change so
    you can determine the right kind of intervention.
  • Intervention matching individualizes the approach
    to readiness aspects
  • The model describes 5 stages of change
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
  • Prochaska, J.O., DiClemente, C.C. (1982).
    Transtheoretical therapy toward a more
    integrative model of change. Psychotherapy
    Theory, Research and Practice, 19(3), 276-287.

70
3 Tasks of a Brief InterventionFLO
  • Feedback
  • Listen and Understand
  • Options Explored

Source of information for slides 62-80,82,86 The
Pacific Southwest Addiction Technology Transfer
Center - SBIRT PDF 2010
71
Task 1 Feedback
  • Give the Patient Feedback Using
  • Range
  • Accurate Information
  • Normal Ranges
  • Give their score
  • Elicit reaction

72
Example
  • Range BAC can range from 0 (no alcohol
    detected) to .4 (usually lethal)
  • Accurate Information .08 defines drunk driving
    (heavy drinking)
  • Normal Normal drinking range is .03-.05
  • Give their score Your level was
  • Elicit reaction What do you make of that?

73
Feedback
  • Your job is to deliver the feedback
  • Let the patient decide where to go with it

74
Feedback
  • Handling resistance
  • Look, I dont have a drinking problem
  • My dad was an alcoholic Im not like him
  • I can quit anytime I want to
  • I dont know why I had such a high BAC, I hardly
    drank anything
  • As hard as I work, I have a right to drink and
    relax

75
Feedback
  • To avoid this
  • Let Go!!!

76
Feedback
  • Easy Ways to Let Go
  • Id really like to hear your thoughts..
  • Id just like to give you some information..
  • What you do is up to you.

77
Feedback
  • Finding a Hook
  • Ask about their concerns
  • Be non-judgmental
  • Watch for signs of discomfort with the status quo
  • Always ask What role do you think alcohol
    played in your injury?
  • Let the patient decide what they want to do
  • Just bringing up the subject is helpful

78
Task 2 Listen and Understand
  • Listen to what the situation sounds like from
    the patients perspective
  • Show that you understand where they are coming
    from
  • Listen to assess readiness to change

79
Listen and Understand
  • Useful Tools to Promote Change
  • Pros and Cons
  • Importance/Readiness/Confidence Rulers

80
Pros and Cons
  • What do you like about drinking?
  • What do you see as the downside?
  • What else?
  • Summarize both pros and cons
  • On the one hand you said, on the other hand you
    said

81
The Rulers
  • Importance/Readiness/Confidence

82
0 1 2 3 4 5 6 7 8 9 10 Not at all Important Very Important
On a scale from 0 to 10, where 0 is not at all
important and 10 is very important, how important
is it to you to ______ your drinking right now?
83
0 1 2 3 4 5 6 7 8 9 10 Not at all Ready Very Ready
On a scale from 0 to 10, where 0 is not at all
ready and 10 is very ready, how ready are you to
______ your drinking right now?
84
0 1 2 3 4 5 6 7 8 9 10 Not at all Confident Very Confident
On a scale from 0 to 10, where 0 is not at all
confident and 10 is very confident, how confident
are you right now that you can meet your goal of
________ ?
85
The Rulers
  • For each ask
  • Why didnt you give it a lower number?
  • What would it take to

86
Task 3 Options Explored
  • What do you think you will do?
  • What changes are you thinking about making?
  • What do you see as your options?
  • Where do we go from here?
  • What happens next?

87
Offer a Menu of Options
  • Manage your drinking (cut down to low-risk
    limits)
  • Stop drinking
  • Never drink and drive (reduce harm)
  • Nothing (no change)
  • Seek help (refer to treatment)

88
Explore Previous Successes
  • Have you stopped/cut back drinking/drug use
    before?
  • How were you able to do it?
  • Who helped and supported you?
  • Have you made other kinds of changes in your
    life in the past?
  • How did you do that?

89
The Advice Sandwich
  • Ask permission
  • Give Advice/Suggest Options
  • Ask for a response

90
Closing the Conversation- SEW
  • Summarize the patients statements in favor of
    change
  • Emphasize their strength and ability to change
  • What agreement was reached?

91
Spirit of Motivational Interviewing
  • Collaboration (vs. Confrontation)
  • Meeting of aspirations
  • Neither exhortation nor persuasion
  • Evocation (vs. Education)
  • Drawing out
  • Neither instilling nor installing
  • Autonomy (vs. Authority)
  • Personal responsibility
  • Neither imposition nor coercion

92
A Good Outcome from BI
  • Reduction or cessation of use (even temporary)
  • Starting to think about reducing
  • Agreeing to accept referral

93
It matters how you talk to the patient
  • You are singing off key if you find yourself
  • Challenging
  • Warning
  • Finger-wagging
  • Shaming
  • Labeling
  • Confronting
  • Being Sarcastic
  • Moralizing
  • Giving unwanted advice

94
Characteristics ofguiding communication
  • Respect for autonomy of patient and their goals
    and values
  • Readiness to change must be taken into account
  • Ambivalence is common
  • Targets selected by the patient, not the expert
  • Expert is the provider of information (patient)
  • Be empathic, non-judgmental, respectful

Source SBIRT Oregon Residency Program, 2012
95
Referral to treatment
96
Specialty Treatment Near You
  • Do you have a current listing of substance abuse
    treatment centers?
  • Have you developed a referral relationship with
    them?
  • Are you able to do a warm handoff?
  • Do you have information about 12-Step and other
    recovery programs in your area?

97
SBIRT in various settings
  • Universal SBIRT
  • Where can you use SBIRT?

98
Lets use SBIRT
99
Role Plays Relevant to the Sites (large and
small group discussions)
  • Setting Develop scenario relevant to the your
    primary worksite or the target population you
    work with (community health clinic, school,
    hospital, EAP, Jail, ER, Others???)
  • Example scenario
  • Age
  • Gender
  • Other descriptive features (cultural, marital
    status, stressors, etc.)
  • Circumstances leading to the interview
  • AUDIT score 8-15 or DAST 3-5
  • Use BI Observation Sheet as a guide (role play)

100
Thanks for your attention
  • Questions?
  • Holly Hagle, PhD
  • Director, Northeast
  • Addiction Technology Transfer
  • holly_at_ireta.org

101
Selected References
  • Babur, Thomas et al., (2001) AUDIT The Alcohol
    Use Disorders Identification Test Guidelines
    for Use in Primary Care. World Health
    Organization, Department of Mental Health and
    Substance Dependence, Second Edition.
  • Babur, Thomas and Higgins-Biddle, John C. (2001)
    Brief Intervention For Hazardous and Harmful
    Drinking A Manual for Use in Primary Care. World
    Health Organization, Department of Mental Health
    and Substance Dependence.
  • DAmico, E. J., Miles, J. N. V., Stern, S. A.,
    Meredith, L. S. (2008). Brief motivational
    interviewing for teens at risk of substance use
    consequences A randomized pilot study in a
    primary care clinic. Journal of Substance Abuse
    Treatment, 35, 53-61.
  • Dennis, M. ( 2006, April). The current
    renaissance of adolescent treatment. Talk given
    at Project Fresh Light Partnership Meeting,
    Madison, WI. Retrieved from www.chestnut.org/LI/P
    osters/1-The_Current_Renaissance_of_Adolescent_Tre
    atment_4-17-06.pps.

102
Selected References (cont.)
Knight, J. R. (2006, March). Adolescent substance
abuse New strategies for early identification
and intervention in primary medical care.
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