The goal of this TIP is to recommend guidelines for primary care clinicians to follow in caring for patients with alcohol and other drug use disorders.

These guidelines were developed by a Consensus Panel of clinicians, researchers, and educators who work on the prevention and treatment of substance use disorders. Protocols are based partly on research evidence, partly on Panel members' clinical experience.

The algorithm follows a patient with substance use problems who presents in a primary care setting. The chart will serve as a guide or road map through screening, brief assessment, brief intervention, assessment, referral, specialized treatment, and followup care as they are detailed in the TIP.

Since substance use disorders are often chronic conditions that progress slowly over time, primary care clinicians, through their regular, long-term contact with patients, are in an ideal position to screen for alcohol and drug problems and monitor each patient's status.

Furthermore, studies have found that primary care clinicians can actually help many patients decrease alcohol consumption and its harmful consequences through office-based interventions that take only 10 or 15 minutes (Kahan et al., 1995;Wallace et al., 1988).

This potential, however, is largely untapped: Saitz and colleagues found that of a sample of patients seeking substance abuse treatment, 45 percent reported that their primary care physician was unaware of their substance abuse *(Saitz et al., in press).

Yet even though screening and limited treatment of substance use disorders do not require a large time investment, the Consensus Panel that developed this TIP recognized that many primary care clinicians are already overwhelmed by the demands imposed by expanded gatekeeper functions.

The Panel realized that a practical approach to addressing patients' substance abuse problems was needed: one that recognized the time and resource limitations inherent in primary care practice and offered a series of graduated approaches that could be incorporated into a normal clinic or office routine.

Biological, medical, and genetic factors as well as psychological, social, familial, cultural, and other environmental features all bear on substance abuse. Addressing the condition effectively requires a team effort, especially when it has progressed beyond the early stage.

For this reason, in addition to screening and intervention treatment options, these guidelines include information about viable referral for assessment and treatment, as well as followup.

Readers will notice that the TIP contains more information on alcohol use and abuse than on use of illicit drugs. This reflects both the scope of the problems and the research literature available about them.

It is estimated that about 18 million people with alcohol use problems and 5 million users of illicit drugs need treatment.

Although the Panel recognizes that tobacco is an addictive substance with a major public health impact, it is not included in this TIP because the topic falls outside CSAT's purview.

Readers are referred to Smoking Cessation: A Guide for Primary Care Clinicians, published by the Agency for Health Care Policy and Research (Agency for Health Care Policy and Research, 1996).

The Consensus Panel's recommendations are based on a combination of clinical experience and research-based evidence.

In the list below, the summary guidelines supported by the research literature are followed by (1); clinically based recommendations are marked (2). Citations supporting the former are referenced in the body of the document. Screening and assessment instruments mentioned below are reproduced and discussed in Chapters 2 and 4 and Appendix C.

The guidelines are presented in more detail in Chapter 6.

General Recommendations

The Consensus Panel that developed this TIP recommends that primary care cliniciansa term that includes physicians, physician assistants, and advanced practice nurses -- follow the guidelines below.

Screening

Periodically and routinely screen all patients for substance use disorders. (2)

Ask questions about substance abuse in the context of other lifestyle questions. (2)

Use the Alcohol Use Disorders Identification Test (AUDIT) to screen for alcohol problems among English-speaking, literate patients, or use the first three quantity/frequency questions from the AUDIT, supplemented by the CAGE questionnaire. (1)

Use the CAGE-AID (Cage Adapted to Include Drugs) to screen for drug use among patients. (1)

Ask "Have you used street drugs more than five times in your life?" A positive answer suggests further screening and possibly assessment. (2)
Ask high-risk patients about alcohol and other drug use in combination. (2)

Use the TWEAK to screen pregnant women for alcohol use. (1)
Ask pregnant women "Do you use street drugs?" If the answer is yes, advise abstinence. (2)

Use the CAGE, the AUDIT, or the Michigan Alcoholism Screening Test -- Geriatric Version (MAST-G) to screen patients over 60. (1)

Screen adolescents for substance abuse every time they seek medical services. (2)

When recording screening results, indicate that a positive screen is not a diagnosis. (2)

Present results of a positive screen (and conduct all discussions about substance use) in a nonjudgmental manner. (1)

Brief Intervention

Perform a brief intervention with patients whose substance abuse problems are less severe. (1)

Include in the brief intervention feedback about screening results and risks of use, information about safe consumption limits and advice about change, assessment of patient's readiness to change, negotiated goals and strategies for change, and arrangements for followup visits. (1)

Assessment and Treatment

Refer high-risk patients to a specialist, if possible, for in-depth assessment. (2)

Ensure that a specialized assessor has familiarity with psychiatric disorders. (2)

Ascertain that assessment is sequential and multidimensional. (1)
Check the gamma-glutamyl transferase (GGT) as part of the assessment process. (2)

Use the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, in combination with the American Society of addiction Medicine's Patient Placement Criteria, Second Edition, to make a diagnosis and devise an assessment-based treatment plan. (1)

Become familiar with available assessment and treatment resources. (2)
Keep encouraging reluctant patients with substance use disorders to accept treatment of some kind. (2)

Confidentiality

Establish recordkeeping systems and reminder programs to provide cues about the need to screen and reassess patients for alcohol and drug abuse. (2)

Do not perform screening or laboratory tests (such as blood or urine tests) without the patient's consent. (2)

Consult the patient before discussing his or her substance use with anyone elsefamily, employers, treatment programs, or the legal system. (2)

The Primary Care Clinician's Opportunity

Visits to primary care clinicians provide unparalleled opportunities to intervene with substance abuse problems at a relatively early stage in disease progression. Office or clinic visits also give clinicians an opening to discuss substance abuse prevention with patients and in many cases, forestall problems from ever developing.

As one primary care physician observed, "With respect to substance abuse, our charge is straightforward: first we must ask something, then we must do something." This TIP is intended to assist primary care clinicians with both tasks.

    [Diagram not included - see source document]

From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians