Why Adopt Brief Interventions for Substance Use?
- Nationwide, approximately 2.4 million youth age 12-17 report having used alcohol in the previous month, and 2.2 million report past month illicit drug use.1
- Opioid poisoning and mortality has significantly increased among both teens and young adults.2
- The vast majority of youth using substances do not have a substance use disorder (SUD) and therefore specialty SUD treatment would be clinically inappropriate.1 However, not addressing substance use increases the risk for serious health, educational, and social problems.3
Brief interventions are structured conversations designed to address alcohol and/or drug use among youth who are using substances, but do not need specialty SUD treatment. They are intended to be used when a young person screens positive for substance use or the need to discuss substance use emerges some other way.
The goal of brief interventions is to have a discussion aimed at reinforcing a youth’s self-determination to reduce their risky behavior. Brief interventions are designed to be delivered in non-SUD treatment settings such as SBHCs.
Motivational interviewing: The best way to conduct brief interventions
Motivational interviewing is a collaborative, client-centered counseling style that guides individuals to elicit and strengthen their motivation for change.4 Rather than advising youth that they “should” or “need to” stop using alcohol or drugs, providers use motivational interviewing to have open conversations, using reflective listening skills and other conversational techniques to mobilize a young person’s own intrinsic values as motivation to change their substance use.
Research shows that motivational interviewing is the most effective tool for achieving meaningful and lasting changes in substance use behavior within a relatively brief time period.5-6 Using motivational interviewing, providers can help youth identify their own reasons to either reduce substance use or stop altogether, and collaboratively develop strategies to achieve behavior change goals.
What are some techniques for brief interventions?
The Brief Negotiated Interview (BNI) is a semi structured interview process based on motivational interviewing and can be completed in 5-15 minutes.
|1. Engagement||“Before we get started, I’d like to know a little more about you. Would you mind telling me a little bit about yourself?”
“What’s a typical day like for you? What do you like to do? How does Vicodin fit in?”
|2. Pros & Cons
||“I’d like to understand more about your use of Vicodin. What do you like about it?”
“What do you like less about Vicodin? Do you ever regret using Vicodin?”
If they can’t think of any cons, explore problems mentioned on the CRAFFT, i.e.:
“You said that you have gotten into trouble while using Vicodin. Tell me more about that.”
“So on one hand you enjoy Vicodin because….and on the other hand it has caused these problems…”
||“I have some information about the use of opioids by young people that I’d like to share with you. Would that be ok?”
“We know that use of opioids by young people has some negative consequences. They can lead to short-term problems like impaired ability to learn, family relationship issues, and overdose & death, along with long-term consequences like collapsed veins, respiratory problems, and liver disease.”
“Young people who use prescription opioids in their early teens are more likely to be using heroin when they graduate from high school. Because your brain is still developing, opioids can cause permanent changes in your brain and make you more vulnerable to addiction as an adult.”
“What do you think about this information?”
|4. Readiness Ruler
Use to determine how ready the young person is to make a change, how important making a change is to them, or how confident they are that they will be able to make the change
|“On a scale of 1 to 10, how ready would you say you are to change any aspect of your use of Vicodin?”
“Why did you choose that number and not a lower number, like a 1 or a 2?”
“That’s great, it means you’re ___% ready to make a change.”
Reflect their response and say:
“So it sounds like you have some reasons to make a change.”
|5. Negotiate Action Plan
||“So what are you willing to do right now to be healthy and safe?” (Ask youth to write down action plan)
“What do you want your life to look like down the road?”
“How does this change fit in with those goals?”
“What might be some challenges in accomplishing your goal with regard to Vicodin?”
“What’s something you have accomplished in the past that you felt proud of? Who or what helped you succeed in that How can you use that (person or method) to help you with the challenges of making this change now?”
“If you make this change, how would things be better for you?”
|6. Summarize and Thank
||“So let me summarize what we’ve discussed, and you let me know if there’s anything you’d like to add or change.” (Review action plan)
(If available, present list of local resources)
“OK, here’s the action plan we’ve discussed. This is really an agreement between you and yourself.”
“Thanks so much for coming in and talking with me today! I’d love to see you come back in X weeks.”
FLO stands for Feedback, Listen & Understand, and Options Explored. It takes 15 minutes and condenses the main elements of brief interventions into three steps.
|Feedback||Discuss the screening results and what they say about the youth’s risk level.|
|Example||“Your score was [between 0-6] on the CRAFFT. A higher score is usually associated with substance use/dependence. As your medical provider, I recommend you not use alcohol or drugs at all. Alcohol and drug use can harm brain development as well as increase the risk of car accidents, injuries, failing in school, and other problems.”|
|Listen & Understand||Use a warm reflective listening approach and ask for the youth’s personal understanding of their substance use. During “Listen & Understand” the provider is also listening for change talk: anything the provider hears from the youth that indicates they have the desire, ability, or reason to make a change.
The provider is listening for their reasons for using substances (trying to understand them), and their reasons for reducing or stopping. “What would be some of the good things about cutting down or stopping your use of Vicodin?” is a question that directly “pulls” for change talk.
|Options Explored||Ask the youth what alternatives they might pursue or provide youth with a range of alternative strategies to reduce or stop use. The goal is for the youth to generate acceptable options toward change and then to select at least one that they are willing to try.
The provider can offer options if the youth has difficulty coming up with their own ideas. Try to provide concrete examples of things they can do to reduce their risk of harm, e.g., not drinking or cutting back on the number of drinks per day. Remember that youth have a choice. Doing nothing is also an option. The provider can also offer to check in frequently. Very often, attention paid to one’s behavior can be an intervention.
What are best practices when implementing brief interventions?
Brief interventions, in conjunction with screening, should begin at age 12. Youth should receive brief interventions whenever they screen positive for a substance use screening.
The provider (medical, behavioral health, or health education) should conduct the brief intervention with the young person while they are in a private room. The provider should also summarize the brief intervention in their chart notes.
The next step depends on the level of intervention that the young person needs:
- For mild/moderate substance use, the brief intervention should be sufficient.
- For severe substance use, the provider should move to the third part of SBIRT: referral to treatment. Providers should be trained to recognize any needs or goals that are beyond the scope of brief interventions. If the youth has multiple or complicated issues it may be necessary to refer them to a provider who specializes in SUD treatment.
In either case, a follow-up appointment should be scheduled so the SBHC provider can check in with the young person and ensure they are receiving the care they need.
What should I do now?
- Share this quick guide with SBHC colleagues. Help raise awareness about SBIRT and reduce stigma about SUDs in the adolescent primary care community.
- Train providers on motivational interviewing.
- Develop “cheat sheets” with motivational interviewing techniques for providers.
- Create opportunities for providers to practice motivational interviewing with each other.
Facilitating Change for Excellence in SBIRT – Guidance on using SBIRT from the National Council for Behavioral Health, Improving Adolescent Health
Adolescent Substance Use Screening Overview – Resources on screening for adolescent substance use from the Conrad N. Hilton Foundation and UCLA’s Integrated Substance Abuse Program
Interactive Behavioral Health Role-Play Simulation – Kognito (paid resource)
Adolescent Substance Use Implementation Guidance – Conrad N. Hilton Foundation and UCLA’s Integrated Substance Abuse Program
1.Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/
2.McCabe SE, West BT, Teter CJ, Cranford JA, Ross-Durow PL, Boyd CJ. (2012). Adolescent nonmedical users of prescription opioids: brief screening and substance use disorders. Addictive Behaviors, 37(5):651–656. doi:10.1016/j.addbeh.2012.01.021
3.Mitchell, S. G., Gryczynski, J., O’Grady, K. E., & Schwartz, R. P. (2013). SBIRT for adolescent drug and alcohol use: Current status and future directions. Journal of Substance Abuse Treatment, 44(5), 463-472.
4.Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford press.
5.Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88(3), 315-336.
6.Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, Brief Intervention, and Referral to Treatment (SBIRT) toward a public health approach to the management of substance abuse. Substance Abuse, 28(3), 7-30.