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
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (Institute of Medicine, 1996)
By any measure, effectively treating a primary care patient's substance abuse problem is addressing a significant "personal health care need." Alcohol-related disorders, for example, occur in up to 26 percent of general medical clinic patients, a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes (Fleming and Barry, 1992).
While not specific to the primary care setting, the most recent National Household Survey on Drug Abuse estimates that 12.8 million Americans, or 6.1 percent of the population age 12 and older, currently use illicit drugs, while about 32 million Americans (15.8 percent of the population) had engaged in binge or heavy drinking (five or more drinks on the same occasion at least once in the previous month) (Substance Abuse and Mental Health Services Administration, 1996b).
Using estimates from the Institute of Medicine (Institute of Medicine, 1990), a Robert Wood Johnson Foundation report calculated that about 5 million users of illicit drugs and 18 million people with alcohol use problems need treatment, but only one fourth of them receive it (Institute for Health Policy, 1993).
Accurately gauging the costs of substance use problems, like estimating costs for heart disease or cancer, is difficult. This figure grows or shrinks by billions of dollars depending on the economic assumptions used.
The costs to abusers, their families, and society at large, however, are indisputably enormous and encompass health care costs, premature mortality, workers' compensation claims, reduced productivity, crime, suicide, domestic violence, and child abuse.
Some 100,000 people die each year in the United States as a result of alcohol; illicit drug abuse and related acquired immunodeficiency syndrome (AIDS) deaths account for at least another 12,000 deaths (Rice et al., 1990;Stinson et al., 1993; Rosenberg et al., 1996).
Every man, woman, and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime, and lost productivity due to substance abuse (Institute for Health Policy, 1993).
Furthermore, an "analysis of the epidemiological evidence reveals that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse" (Center on Addiction and Substance Abuse, 1993, p. 21).
Nearly one quarter of Americans say that "drinking has been a cause of trouble in their family" (Institute for Health Policy, 1993, p. 40). A forthcoming study based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a) estimates that 52.9 percent of Americans age 18 and older have a family history of alcoholism among first- or second-degree relatives *(Dawson and Grant, in press).
In short, substance use disorders are simply too pervasive and too costly to be ignored.
Fortunately, not only is effective specialty treatment available for problem drinkers, alcoholics, and illicit drug users, but brief interventions, which can be done in a primary care setting, can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health (Kahan et al., 1995).
In a report on the financially driven changes in health care, the Institute of Medicine highlighted the growing need for primary care clinicians to diagnose and treat a range of problems previously addressed by specialists (Institute of Medicine, 1996).
While not focused specifically on substance abuse, the report credits the "trust and partnership" that exists between primary care clinicians and patients as a key argument for expanding the role of primary care clinicians in screening for early disease detection, managing chronic diseases, and coordinating care among all those involved in providing patient services.
The American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommends patient education, anticipatory guidance, and early intervention strategies to reduce adolescent patients' use of alcohol and other drugs (Elster and Kuznets, 1994). Likewise, the American Academy of Pediatrics advises pediatricians to include anticipatory guidance on substance abuse to all children and adolescents.
In support of these recommendations, universities are implementing medical and nursing school curriculum modules while specialty organizations, including the National Nurses' Society on Addictions, the American Society of Addiction Medicine, the Association for Medical Education and Research on Substance Abuse, the American Association of Obstetricians and Gynecologists, and the Drug and Alcohol Nurses Association, are promoting faculty development and the development of core competencies and practice standards for intervening with and treating substance abuse problems.
In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol- or other drug-related service. Basic skills in identifying and diagnosing patients who are chemically dependent will become essential.
Clinicians in areas with limited substance abuse resources may be responsible for assessments, while those trained in addiction medicine may be providing a range of treatment services.
Regardless of how extensively involved clinicians become, those who are familiar with the medical complications of substance abuse and are able to relate them to other comorbid illnesses will be better equipped to deliver adequate care.
Alcohol Use Among Primary Care Patients
Since more Americans abuse alcohol than illicit drugs, primary care clinicians will encounter substantially more patients with alcohol problems than with drug problems (although many patients who abuse alcohol also abuse illicit drugs or prescription drugs and vice versa).
Though most people who consume alcoholic beverages do not experience problems related to their use, primary care clinicians can expect that 15 to 20 percent of their male patients and 5 to 10 percent of their female patients will be at risk for or already are experiencing related medical, legal, or psychosocial problems.
These problems include unresponsive diabetes, arrests for "driving under the influence," problems with job or school, or family or marital difficulties. Figure 1-1 presents the current prevalence of alcohol use and problems in primary care settings for patients over the age of 18 (Manwell et al., in press).
Levels of Use
The nature and intensity of alcohol-related problems vary according to consumption: Above two to three drinks a day, there is a clear dose-response curve. The higher the levels of consumption, the greater the risk of negative health effects including cirrhosis, cancer, heart disease, stroke, traumatic injury, and depression.
For this reason, the National Institute on Alcohol Abuse and Alcoholism recommends that patients who currently drink adhere to the following:
Men -- No more than two drinks per day
Women -- No more than one drink per day
Men and women over age 65 -- No more than one drink per day (National Institute on Alcohol Abuse and Alcoholism, 1995b)
It is important for primary care clinicians to know patients' drinking levels in order to gauge their potential risk for developing problems. Levels also can be discussed with patients in the context of general health problems where they provide a nonstigmatizing opportunity to share valuable risk reduction information
For example, just as a clinician may point out to patients with blood pressure higher than 140/90 that they are at risk for cardiovascular problems secondary to hypertension, people who consume more than two drinks per day should be told that they are at risk for heart and liver disease.
When presented this way, information about levels may help motivate nonproblem drinkers and abstainers to maintain healthy habits, while offering those at risk for problems an incentive to reduce the amount of alcohol they consume.
Frequency of Problems Related to Use
To determine a patient's risk level, however, the clinician must consider more than consumption levels. Definitions of low-risk and at-risk use are based on the relationship between a given quantity of alcohol used and a number of health effects.
Recognizing at-risk drinkers in particular can be difficult. Researchers have investigated indicators other than consumption levels in an effort to determine other risk factors.
Low-risk drinkers consume less than an average of one to two drinks per day, do not drink more than three to four drinks per occasion, and do not drink in high-risk situations (e.g., while pregnant, driving a car, or taking medication that interacts with alcohol).
At-risk drinkers occasionally exceed recommended guidelines for use. While they are at risk for such alcohol-related problems as burns, motor vehicle crashes, or falls because of their drinking habits, at-risk drinkers may never experience negative consequences as a result of their alcohol use and represent a prime target for preventive, educational efforts by primary care clinicians.
A number of environmental, interpersonal, psychobehavioral, and biogenetic risk factors (e.g., social norms conducive to use, family and marital conflict, early onset of use, and inherited susceptibility) have been identified and are summarized in Figure 1-2(Hawkins et al., 1985;Kandel et al., 1986;Newcomb and Bentler, 1988;Heath et al., 1989; *Brook and Brook, 1990; Landry et al., 1991a;Landry, 1994).
The American Psychiatric Association's DSM-IV classifies mental disorders (including substance-related disorders) to help clinicians make useful diagnoses and to guide scientists' research.
Although this approach works best when there are clear boundaries between types of disorders, categories within disorders cited in the DSM-IV are not necessarily discrete or static.
Moreover, all individuals suffering from the same disorder are not necessarily alike (American Psychiatric Association, 1995). When the DSM-IV refers to such diagnostic levels as substance abuse and dependence, it views them as points on a continuum on which patients' use may vary.
The DSM-IV's dependence is roughly equal to the term alcoholic, and abuse is synonymous with problem drinkers. The latter is seen more than the former in primary care (Kahan et al., 1995).
These nondependent but problematic drinkers account for the "majority of alcohol-related morbidity and mortality in the general population" (U.S. Preventive Services Task Force, 1996, p. 567;Institute of Medicine, 1990).
As a group, problem drinkers experience a range of alcohol-related problems from a "driving under the influence" citation to loss of job or family disruption.
It is important for clinicians to understand, however, that problem drinkers, unlike alcoholics, often respond to clinician counseling and brief intervention efforts (see Chapter 3) and do not always require a referral to specialized treatment.
Alcoholic or dependent drinkers meet at least three of the seven DSM-IV criteria for substance dependence: drinking more than intended; wanting to stop drinking; spending a great deal of time procuring alcohol; giving up social or occupational activities because of alcohol; drinking despite the physical or psychological problems it causes; and, in some cases, experiencing physical dependence as manifested by tolerance to alcohol's effects and withdrawal symptoms.
Figure 1-3 illustrates the relationship between level and frequency of use and the development of alcohol problems (Skinner, 1992).
Continued - see source document:
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
Screening is the application of a simple test to determine if a patient has a certain condition. For screening to be meaningful in the primary care setting, the particular problem
Must be prevalent within the general population
Must diminish the duration or the quality of life
Must have an effective treatment available that reduces morbidity and mortality when given during the asymptomatic stage of the disease
Must be detectable via cost-effective screening earlier than without screening and must avoid large numbers of false positives or false negatives
Must be detectable and treatable early enough to halt or delay disease progression and thereby improve outcome
(U.S. Preventive Services Task Force, 1996;National Institute on Alcohol Abuse and Alcoholism, 1993)
Screening for substance abuse, which meets all the conditions above, need not take long and can be conducted effectively in a variety of settings (National Institute on Alcohol Abuse and Alcoholism, 1993).
The Institute of Medicine has recommended that questions about alcohol use be included among routine behavioral and lifestyle questions asked of all persons who seek care in a medical setting (just like questions about diet, exercise, and smoking) (Institute of Medicine, 1990).
The Goal of Substance Abuse Screening
The goal of substance abuse screening is to identify individuals who have or are at risk for developing alcohol- or drug-related problems, and within that group, identify patients who need further assessment to diagnose their substance use disorders and develop plans to treat them (see Chapter 4).
The Consensus Panel that developed this TIP recommends that primary care clinicians periodically and routinely screen all patients for substance use disorders. Deciding to screen some patients and not others opens the door for cultural, racial, gender, and age biases that result in missed opportunities to intervene with or prevent the development of alcohol- or drug-related problems.
Visual examination alone cannot detect intoxication, much less more subtle signs of alcohol- and drug-affected behavior.
A major advantage of conducting substance abuse screening as part of the ongoing process of primary care is that positive screens can be followed up at subsequent visits.
In many practices, clinicians' long-standing relationships with patients give them the opportunity to conduct preliminary assessments also known as brief assessments.
Depending on the clinician's experience and training and the resources available within a community, he may either develop a treatment plan or refer the patient for assessment by a skilled substance abuse specialist.
In larger practices or clinics where provider-patient relationships are not as close, clear documentation of screening results will help ensure appropriate followup.
Negative screens for substance abuse also warrant discussion. They allow clinicians to play a health promotion and prevention role by reinforcing the wisdom of abstinence from illicit drugs and maintenance of safe levels of alcohol use.
If a clinician does not have the time (or the expertise) for a face-to-face discussion of the problem, she can give the patient lists of resources for additional help and a handout or brochure on the effects of alcohol or the other relevant drug. See Appendix D for selected resources.
Factors To Consider in Selecting a Screening Instrument
In the primary care setting, substance abuse screening is done using brief written, oral, or computerized questionnaires, referred to throughout this TIP as screening instruments.
A number of factors must be considered in determining the suitability of a screening instrument for this setting. These include sensitivity and specificity, cost, ease of administration, and patient acceptance.
Sensitivity and Specificity
Sensitivity is a screening instrument's capacity to identify true cases of the target condition in a given population. The closer to 100 percent of those with alcohol and other drug problems that a screen identifies as positive for that condition, the more sensitive the test.
Specificity refers to an instrument's ability to identify people who do not have the disorder. False positives (identifying people who do not have the disorder as having it) tend to increase as sensitivity increases, and false negatives (missed cases) tend to increase as specificity increases.
Because screening instruments are imperfect, balancing sensitivity against specificity is a situation-specific issue. Generally, for screening in primary care, sensitivity should be emphasized over specificity -- that is, it is more important not to miss true cases than it is to assess further some patients who ultimately turn out not to have a substance use disorder.
A positive screen can usually be confirmed or refuted with further history taken on the spot or, if necessary, evaluation by a substance abuse specialist. The screening instruments recommended by the Consensus Panel achieve a reasonable balance between sensitivity and specificity (see Appendix C).
Most screening instruments have been designed for substance abuse treatment populations, not primary care populations.
The four-question CAGE questionnaire (Ewing, 1984) and the Alcohol Use Disorders Identification Test (AUDIT)(Babor et al., 1992), however, have been extensively tested in primary care settings, and a number of other studies of outpatient, substance abuse treatment populations support the practice of applying substance abuse screening instruments to primary care populations (Buchsbaum et al., 1991, 1995;Bohn et al., 1995;Barry and Fleming, 1993;Saunders et al., 1993). The CAGE questionnaire is reproduced below, and the AUDIT appears in Appendix C.
Cost
Costs of administering a screen depend on who does the screening (e.g., physician, nurse, nurse practitioner, or physician assistant), how long it takes, and what special training (if any) is required; whether the instrument can be self-administered by the patient via pencil and paper or computer; and how long it takes to score the instrument.
Ease of Administration
The written questionnaire format is self-explanatory; the interview format consists of a clinician's asking the patient a set of predetermined questions. Computerized versions of validated paper questionnaires such as the CAGE are growing in popularity, and preliminary studies on the effectiveness of this approach are promising (Barry and Fleming, 1990).
A study of adolescents found that when 15-year-olds were asked about past-week alcohol use, 10 percent responded positively to a computerized questionnaire, but only 5 percent to a paper questionnaire (Paperny et al., 1990). Across populations, however, studies have shown that similar results were obtained regardless of the form of the test (National Institute on Alcohol Abuse and Alcoholism, 1993).
Computers also can reduce the time needed for manual scoring and keep track of who has been screened and when. In addition, some computerized screens like the Diagnostic Interview Schedule format (Blouin et al., 1988) will automatically ask selected assessment questions if the score on screening is positive.
Patient Acceptance
Simply raising the subject of substance abuse with patients can be useful. Evidence indicates that asking questions about alcohol or other drugs "primes" patients to disclose information and results in a two- to threefold increase in their stated intention to discuss substance abuse problems with their health care provider in the future (Skinner et al., 1985).
While opinions vary about whether to integrate substance abuse screening into a standard history, asking potentially sensitive questions about substance abuse in the context of other behavioral and lifestyle questions appears to be less threatening to patients. Studies have found that screening for alcohol-related disorders is more acceptable to patients if it is part of a comprehensive health-risk evaluation that covers topics like exercise, diet, weight control, and medication use (Allen et al., 1995).
Placing the questions within the larger context of preventive health care can help both patient and clinician feel more comfortable, reduce any perceived stigma or bias about the questions, and decrease anxiety in the patient.
Members of the Consensus Panel have learned that this finding holds true when screening for use of illicit drugs as well (Fleming and Barry, 1991). Primary care clinicians with experience in substance use screening also report that discussing problematic use can help foster the ongoing relationship between patient and clinician.
Screening Instruments
To expedite screening and increase the likelihood of honest answers, clinicians should ask questions sequentially, beginning with the legal drug alcohol (Institute of Medicine, 1990). Typically people with substance use disorders drink, so asking, "Please tell me about your drinking" serves as an effective filter.
If the patient replies that he does not drink, the clinician should ask, "What made you decide not to drink?" If the answer is that the patient is a life-long abstainer or has been in recovery for 5 years or more, the clinician can conclude the screening process (Steinweg and Worth, 1993).
There are a few exceptions. Even if they don't admit to drinking, adolescents should be asked about drug use, particularly marijuana. Pregnant women and women older than 60, as well as women who have experienced a major life transition (e.g., death of a spouse or retirement), should be queried about their psychoactive prescription drug use and use of over-the-counter sleep aids.
See TIPs 3 (Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents) and 4 (Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents) for a full discussion of assessing and treating adolescents (CSAT, 1993b, *1993c) and TIP 2 (Pregnant, Substance-Using Women) for information about that population (CSAT, 1993a).
Substance abuse among people over 60 is covered in a forthcoming TIP, Substance Abuse Among Older Adults (see The National Clearinghouse for Alcohol and Drug Information for TIPs ordering information).
[continued]
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
The type and sequence of activities undertaken in response to screening results will depend on several factors: the severity of any positive findings, the specialized assessment and treatment resources available, and the primary care clinician's expertise in the substance abuse field.
All patients who undergo screening for alcohol and drug use should be told the results. Those who screen negative because they are abstinent should be commended for their health-conscious lifestyle with reinforcing comments about the benefits of drug- and alcohol-free living.
The clinician may wish to ascertain, however, whether current abstinence reflects a lifelong commitment, a recent decision, or recovery from some previous episode of substance abuse or dependence that may indicate a potential for relapse.
This can be resolved by saying, "Not drinking is a healthy decision. What made you decide not to drink?"
Patients with positive findings from the screening will need some type of followup. The next step may not be immediately apparent from the initial screening and depends on how much time and effort the clinician is willing to commit and how much training and experience she has in addiction medicine.
The Consensus Panel recommends that clinicians at this point conduct a brief assessment to obtain more information. The questions should cover the severity of the suspected alcohol or drug involvement, the types and frequency of problems connected with the patient's use, and other special medical and psychiatric considerations.
If the patient's responses suggest a diagnosis of a substance abuse or dependence disorder according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a), the clinician should initiate a referral for an in-depth assessment.
However, if only mild to moderate substance abuse problems are apparent, if the patient appears to be at risk for experiencing negative consequences as a result of current consumption patterns, if coexisting illnesses or conditions may be exacerbated by continued drinking or other medications, or if the patient refuses referral for further assessment or treatment, the clinician can initiate a brief, office-based, therapeutic intervention.
Guidelines for Clinician Involvement in the Care Of Substance-Abusing Patients
In 1979, the American Medical Association issued guidelines recommending that all physicians with clinical responsibility become involved in the prevention and treatment of alcohol- and drug-related problems among their patients at one of the following three levels:
Minimally, by learning to recognize dysfunction caused by substance abuse as early as possible by taking a history of alcohol and drug use in any health examination (screening), identifying medical complications or symptoms that suggest alcoholism or drug abuse, attempting to match patient needs for ongoing assessment and treatment with available resources, and making a referral for appropriate medical care
To a limited extent, by assisting patients to become alcohol- or drug-free through management of withdrawal syndromes in preparation for more extensive assessment and/or treatment; teaching selected patients about the disease and formulating a plan for recovery; involving significant others, as appropriate, in the recovery plan; and continuing posttreatment medical management
Comprehensively, after acquiring specialized knowledge, training, and experience, by being available to patients for an indefinite period of recovery; establishing a nonjudgmental and supportive relationship; helping to develop, evaluate, and update an appropriate recovery plan; providing medical care and any necessary pharmacotherapy; involving the patient in appropriate health, social, vocational, and spiritual support systems, including an abstinent peer group; and continually monitoring, treating, or referring any complicating illness or relapse
(American Medical Association, 1979a; Landry et al., 1991b; CSAT, 1995b)
Although these AMA guidelines were promulgated before the development and widespread use of brief interventions in office-based practices, this type of early care seems to fit naturally between the minimal responsibility for early identification of alcohol or drug problems and the more involved, but still limited, responsibilities of primary care clinicians for managing withdrawal and making treatment referrals.
Brief Intervention
Brief intervention is a pretreatment tool or secondary prevention technique that primary care clinicians can easily incorporate into their medical practice settings. Within one or several office visits, a clinician explains screening results, provides information about safe consumption limits and advice about changing, assesses the patient's readiness to change, negotiates goals and strategies for change, and arranges for compliance monitoring.
These five steps are discussed in detail below.
Brief intervention is quite inexpensive for the yield, involving clinician-patient contacts of 10 to 15 minutes -- the typical duration of an office visit -- and a limited number of sessions. At least one followup visit is usually recommended, but the number and frequency of sessions depends on the severity of the problem and the individual patient's response.
The broad goal of brief intervention is to get patients to reduce or eliminate alcohol or other drug consumption and thereby avoid or minimize associated problems, whether through the technique itself or through subsequent referral.
The specific goal varies depending on the patient's current status and previous treatment attempts. For a patient who does not realize there is a problem, the goal may be to get the individual to start thinking about the issue and come back for another visit.
A brief intervention could also be an appropriate primary prevention tool for the alcohol or drug user who is at risk for problem development because of a hazardous consumption pattern but has not yet experienced harmful consequences (e.g., the college student who is drinking heavily in a fraternity setting).
For patients who recognize that some of their health or other problems are alcohol- or drug-related, and who are ready for and capable of change, the goal will be to reduce or eliminate substance use through specified steps.
If the problem is more serious, and if initial attempts to change do not succeed, the goal of brief intervention is to convince a patient to accept a referral for more specialized assessment and treatment services.
Brief intervention is an appropriate response to the types of patients mentioned above for several reasons.
A specialized alcohol and drug treatment network has been developed for persons with relatively severe and chronic substance abuse disorders, but the majority of patients seen in most general practice medical settings are likely to have only mild to moderate substance use problems and may not require treatment in this formal system.
Since rapid progression to a full-scale substance abuse or dependence disorder is not inevitable, specialized treatment is not always advisable. Spontaneous remission occurs in substance disorders as in many other medical conditions, so brief intervention may be all that is needed (Sobell et al., 1993;Vaillant et al., 1983).
Furthermore, brief intervention in a primary care setting does not wield the stigma associated with longer-term specialized treatment. In fact, specialized substance abuse treatment could actually cause harm if, for example, a patient is coerced into participating in a treatment program that is antithetical to her values or if her coexisting psychiatric illness is ignored during formal substance abuse treatment.
Nor are light to moderate consumers of alcohol and other drugs likely to seek help directly from the specialized substance abuse treatment system, particularly if problems related to substance use are transient or only mildly inconvenient. Many persons do not recognize -- or they deny -- that their difficulties are directly caused by or complicated by alcohol or drugs.
The physical condition or health concern that brings the patient to a primary care clinician's office offers a "teachable moment" -- through a traumatic crisis or a welcomed event such as pregnancy -- in which the risk factors associated with alcohol and other drug consumption can be pointed out and behavior potentially changed.
Since all treatment must be considered in the context of risk/benefit analysis, a conservative and palliative approach within a primary care setting may be preferable to specialized treatment absent a well-substantiated diagnosis of a substance use disorder (Institute of Medicine, 1990).
Brief interventions as secondary prevention tools have the potential to help an estimated 15 to 20 million heavy drinkers in the U.S. alone by minimizing serious adverse consequences such as costly emergency room visits, domestic violence, or road accidents (National Institute on Alcohol Abuse and Alcoholism, 1993).
The occasional alcohol- or other drug-related problems of a very substantial number of moderate users account for a large share of the public health burden (Samet et al., 1996).
Effectiveness in General Medical Practice Settings
Clinical trials and research studies in this country and abroad over the past 15 years have demonstrated the feasibility and effectiveness of brief intervention (Kristenson et al., 1983; Persson and Magnusson, 1989; Romelsjo et al., 1989).
The technique is commended as practical and cost-effective by the Institute of Medicine, and several variations have been evaluated as successful on a number of dimensions (Institute of Medicine, 1990). Convincing evidence compiled over the past 20 years demonstrates that this approach, when used with carefully selected patients, can reduce or eliminate alcohol consumption and ameliorate or markedly limit associated problems (Orford et al., 1976;Edwards et al., 1977;Bien et al., 1993).
Though few studies have included illicit drug users, the Panel believes that brief intervention has the potential to stop or curb some patients' drug use also.
[continued]
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
Unlike brief intervention, in-depth substance abuse assessment requires specialized skills and consumes a substantial amount of time -- anywhere from 90 minutes to 2 hours.
As a result, many primary care clinicians will refer patients suspected of having a substance abuse problem to specialists for both assessment and treatment, although clinicians in underserved areas or with expertise in substance abuse may assume partial or total responsibility for this function.
However, even clinicians who will not perform substance abuse assessments should have a basic understanding of their elements and objectives so that they can
Initiate appropriate referrals
Participate effectively as a member of the treatment team, if required
Better fulfill the gatekeepers' monitoring responsibility with respect to patient progress
Carry out needed case management functions as appropriate
Throughout this chapter, assessment will refer to in-depth assessment as distinct from the postscreening brief assessment discussed in Chapter 3.
Assessment Parameters
Substance abuse assessment is the further investigation of patients (1) whose positive screening results indicate that substance abuse is likely and (2) whose responses to the questions in a brief assessment (see Chapter 3) suggest that compulsion to use, impaired control, presence of other psychosocial problems, or absence of social support will render brief intervention ineffective (College of Family Physicians of Canada, 1994).
Information gained through an assessment will clarify the type and extent of the problem and will help determine the appropriate treatment response.
Assessment:
Examines problems related to use (e.g., medical, behavioral, social, and financial)
Provides data for a formal diagnosis of a possible problem
Establishes the severity of an identified problem (i.e., mild, moderate, intermediate, or severe stage)
Helps to determine appropriate level of care
Guides treatment planning (e.g., whether specialized care is needed, components of an appropriate referral, and eligibility for services)
Defines a baseline of the patient's status to which future conditions can be compared (National Institute on Alcohol Abuse and Alcoholism, 1995a)
If one thinks of screening as triage, then assessment is acquiring the information needed to direct a patient to appropriate treatment.
At a minimum, patients must be assessed for:
Acute intoxication and/or withdrawal potential
Biomedical conditions and complications
Emotional/behavioral conditions (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)
Treatment acceptance or resistance
Relapse potential or continued use potential
Recovery/living environment
(American Society of Addiction Medicine, 1996, p. 6)
Assessing along these dimensions helps the assessor confirm that a substance abuse problem exists and recommend an appropriate level of care (see Chapter 5 for a discussion of substance abuse treatment systems and processes).
Through a combination of clinical interview, personal history-taking, and self-reports, supplemented by laboratory testing and collateral reports as appropriate, the assessment process identifies patients' health problems, interest in and readiness for treatment, and feasible treatment options.
It also provides information on a patient's familial, educational, social, and vocational supports and deficits. Like screening, assessment may be a recurring event if clinical evidence indicates the need.
Who Should Assess?
Professional position is less important than specific training for performing accurate assessments. Where possible, the Consensus Panel recommends referring patients to an experienced substance abuse specialist for intensive assessment.
If referral is not possible, the Panel believes that physicians, physician assistants, and advanced practice nurses (nurse practitioners and clinical nurse specialists) with experience in empathic motivational interviewing may perform intensive assessments after receiving training in
The signs and symptoms of substance abuse
The biopsychosocial effects of alcohol and other drugs and likely progression of the disease
Common comorbid conditions and medical consequences of abuse
The terms used in the classification system of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a), their interpretation, and their relationship to the findings that emerged during the assessment history
The appropriate use, scoring, and interpretation of standardized assessment instruments
Understanding the Impact Of Culture and Gender
Clinicians performing in-depth assessments should also understand how patients' gender and cultural background bear on the characteristics and severity of the disease (Spector, 1996).
For example, more males than females abuse alcohol and drugs, and older women are more likely than older men to abuse prescription drugs.
Culture and gender also may influence patients' recognition of their problems (e.g., local cultural norms may condone or accept male drunkenness) and their reaction to the assessment process and recommended treatment interventions (e.g., substantial stigma may be associated with substance abuse treatment, especially for women and older patients of either sex).
Assessors also should be aware of the influence of their own gender and cultural background on their response to patients with suspected substance abuse problems and on their interpretation of the information provided through the assessment process.
While an understanding of "typical" patterns is useful in anticipating problem areas, experienced assessors resist the temptation to stereotype patients and subsume them within broad categories based on language, ethnicity, age, education, and appearance.
An oft-repeated anecdote illustrating the dangers of stereotyping concerns a well-dressed, middle-aged woman and her disheveled teenage son seen in an emergency room following a car accident. The young man was screened for substance abuse; the mother was not. Several hours after admission, the woman went into alcohol withdrawal.
When referring patients for assessment, primary care clinicians should consider whether a particular patient will relate more readily to a male or female assessor of similar cultural background or if a patient who speaks English as a second language will respond more easily to questions posed in his native tongue (Spector, 1996).
Knowledge of Comorbid Mental Disorders
The relationship between mental disorders and substance use disorders is variable and complicated. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that, in the general population, 4.7 to 13.7 percent of individuals between the ages of 15 and 54 may have both a mental disorder and a substance abuse or dependence problem (Substance Abuse and Mental Health Services Administration, 1995).
Intoxication with a drug can produce psychiatric symptoms that subside with abstinence, but for those with a mental illness, substance use may mask, exacerbate, or be used to ameliorate psychiatric symptoms; precipitate psychological decompensation; or increase the frequency with which individuals require hospitalization.
Because substance abuse disorders often manifest symptoms similar to those of mental health disorders, misdiagnosis may occur.
Inadvertent bias may affect the assessment process when performed by addiction specialists who do not recognize or accept the role of mental disorders in prompting or sustaining substance use or who have no experience with dually diagnosed patients.
Conversely, some mental health practitioners dismiss substance abuse as merely symptomatic of underlying mental health disorders and do not acknowledge it as a problem requiring specific attention.
While screening results, per se, do little to illuminate comorbid mental health disorders, information gleaned through a patient's history or inability to respond to brief intervention may suggest a mental health problem.
If possible, primary care clinicians should refer patients to assessors who understand and are trained in mental health as well as substance abuse assessment and who are willing and able to expand the assessment process as needed to identify the multiple dimensions that may be contributing to a patient's problems (Institute of Medicine, 1990).
Whether referring for or conducting intensive assessments themselves, primary care clinicians also should be alert to the possibility of conflict of interest when assessors are linked to a program or practice providing substance abuse services.
There may be financial incentives (e.g., fee-for-service arrangements) or ideological pressure to interpret assessment results in such a way as to steer patients to a particular program or treatment provider (Institute of Medicine, 1990).
Aside from insisting on an independent assessment source, which may be impractical, clinicians have few options for ensuring objective assessments (Institute of Medicine, 1990).
However, primary care providers who understand the purposes of assessment and are familiar with its components will be in a better position to identify and subsequently avoid biased assessors.
[continued]
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
Primary care clinicians need to be familiar with available treatment resources for their patients who have diagnosed substance abuse or dependence disorders.
The clinician's responsibility to the patient does not end with the patient's entry into formal treatment; rather, the physician may become a collaborative part of the treatment team, or, minimally, continue to treat the patient's medical conditions during the specialized treatment, encourage continuing participation in the program, and schedule followup visits after treatment termination to monitor progress and help prevent relapse.
Understanding the specialized substance abuse treatment system, however, can be a challenging task. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment.
Describing a facility as providing inpatient care or ambulatory services characterizes only one aspect (albeit an important one): the setting.
Moreover, the specialized substance abuse treatment system differs around the country, with each State or city having its own peculiarities and specialties.
Minnesota, for example, is well known for its array of public and private alcoholism facilities, mostly modeled on the fixed-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a strong Alcoholics Anonymous (AA) orientation and have varying intensities of aftercare services.
California also offers a number of community-based social model public sector programs that emphasize a 12-Step, self-help approach as a foundation for life-long recovery.
In this chapter, the term treatment will be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who do not respond to brief interventions or other office-based management strategies.
It is also assumed that an in-depth assessment has been conducted to establish a diagnosis and to determine the most suitable resource for the individual's particular needs (see Chapter 4).
Directories of Local Substance Abuse Treatment Systems
The first step in understanding local resources is to collect information about the specialized drug and alcohol treatment currently available in the community.
In most communities, a public or private agency regularly compiles a directory of substance abuse treatment facilities that provides useful information about program services (e.g., type, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including language proficiency.
This directory may be produced by the local health department, a council on alcoholism and drug abuse, a social services organization, or volunteers in recovery.
Additionally, every State has a single State-level alcohol and other drug authority that usually has the licensing and program review authority for all treatment programs in the State and often publishes a statewide directory of all alcohol and drug treatment programs licensed in the State.
Another resource is the National Council on Alcohol and Drug Dependence, which provides both assessment or referral for a sliding scale fee and distributes free information on treatment facilities nationally. Also, the Substance Abuse and Mental Health Services Administration distributes a National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs (1-800-729-6686).
Knowing the resources and a contact person within each will facilitate access to the system. One useful referral tool is a list of agencies organized across different characteristics, such as services tailored to meet the needs of special populations (e.g., women, adolescents, people who are HIV-positive, and minorities). Resources also should include self-help groups in the area.
Goals and Effectiveness of Treatment
While each individual in treatment will have specific long- and short-term goals, all specialized substance abuse treatment programs have three similar generalized goals (Schuckit, 1994;American Psychiatric Association, 1995):
Reducing substance abuse or achieving a substance-free life
Maximizing multiple aspects of life functioning
Preventing or reducing the frequency and severity of relapse
For most patients, the primary goal of treatment is attainment and maintenance of abstinence (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at "controlled" use before sufficient motivation is mobilized.
Until the patient accepts that abstinence is necessary, the treatment program usually tries to minimize the effects of continuing use and abuse through education, counseling, and self-help groups that stress reducing risky behavior, building new relationships with drug-free friends, changing recreational activities and lifestyle patterns, substituting substances used with less risky ones, and reducing the amount and frequency of consumption, with a goal of convincing the patient of her individual responsibility for becoming abstinent (American Psychiatric Association, 1995).
Total abstinence is strongly associated with a positive long-term prognosis.
Becoming alcohol- or drug-free, however, is only a beginning. Most patients in substance abuse treatment have multiple and complex problems in many aspects of living, including medical and mental illnesses, disrupted relationships, underdeveloped or deteriorated social and vocational skills, impaired performance at work or in school, and legal or financial troubles.
These conditions may have contributed to the initial development of a substance use problem or resulted from the disorder. Substantial efforts must be made by treatment programs to assist patients in ameliorating these problems so that they can assume appropriate and responsible roles in society.
This entails maximizing physical health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship issues, resolving financial and legal problems, and improving or developing necessary educational and vocational skills.
Many programs also help participants explore spiritual issues and find appropriate recreational activities.
Increasingly, treatment programs are also preparing patients for the possibility of relapse and helping them understand and avoid dangerous "triggers" of resumed drinking or drug use. Patients are taught how to recognize cues, how to handle craving, how to develop contingency plans for handling stressful situations, and what to do if there is a "slip."
Relapse prevention is particularly important as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.
While the effectiveness of treatment for specific individuals is not always predictable, and different programs and approaches have variable rates of success, evaluations of substance abuse treatment efforts are encouraging.
All the long-term studies find that "treatment works" -- the majority of substance-dependent patients eventually stop compulsive use and have less frequent and severe relapse episodes (American Psychiatric Association, 1995;Landry, 1996).
The most positive effects generally happen while the patient is actively participating in treatment, but prolonged abstinence following treatment is a good predictor of continuing success. Almost 90 percent of those who remain abstinent for 2 years are also drug- and alcohol-free at 10 years (American Psychiatric Association, 1995).
Patients who remain in treatment for longer periods of time are also likely to achieve maximum benefits -- duration of the treatment episode for 3 months or longer is often a predictor of a successful outcome (Gerstein and Harwood, 1990).
Furthermore, individuals who have lower levels of premorbid psychopathology and other serious social, vocational, and legal problems are most likely to benefit from treatment.
Continuing participation in aftercare or self-help groups following treatment also appears to be associated with success (American Psychiatric Association, 1995).
An increasing number of randomized clinical trials and other outcome studies have been undertaken in recent years to examine the effectiveness of alcohol and various forms of drug abuse treatment. It is beyond the scope of this chapter to report the conclusions in any depth. However, a few summary statements from an Institute of Medicine report on alcohol studies are relevant:
No single treatment approach is effective for all persons with alcohol problems, and there is no overall advantage for residential or inpatient treatment over outpatient care.
Treatment of other life problems associated with drinking improves outcomes.
Therapist and patient (and problem) characteristics, treatment process, posttreatment adjustment factors, and the interactions among these variables also determine outcomes.
Patients who significantly reduce alcohol consumption or become totally abstinent usually improve their functioning in other areas (Institute of Medicine, 1990).
A recent comparison of treatment compliance and relapse rates for patients in treatment for opiate, cocaine, and nicotine dependence with outcomes for three common and chronic medical conditions (i.e., hypertension, asthma, and diabetes) found similar response rates across the addictive and chronic medical disorders (National Institute on Drug Abuse, 1996).
All of these conditions require behavioral change and medication compliance for successful treatment. The conclusion is that treatment of drug addiction has a similar success rate as treatment of other chronic medical conditions (National Institute on Drug Abuse, 1996).
Treatment Dimensions
The terminology describing the different elements of treatment care for people with substance use disorders has evolved as specialized systems have developed and as treatment has adapted to changes in the health care system and financing arrangements.
Important differences in language persist between public and private sector programs and, to a lesser extent, in treatment efforts originally developed and targeted to persons with alcohol- as opposed to illicit drug-related problems.
Programs are increasingly trying to meet individual needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.
A recent publication of the Substance Abuse and Mental Health Services Administration, Overview of Addiction Treatment Effectiveness(Landry, 1996), divides substance abuse treatment along three dimensions: (1) treatment approach -- the underlying philosophical principles that guide the type of care offered and that influence admission and discharge policies as well as expected outcomes, attitudes toward patient behavior, and the types of personnel who deliver services; (2) treatment setting -- the physical environment in which care is delivered; and (3) treatment components -- the specific clinical interventions and services offered to meet individual needs.
These services can be offered for varying lengths of time and delivered at differing intensities. Another important dimension is treatment stage, because different resources may be targeted at different phases along a continuum of recovery. Programs also have been developed to serve special populations -- by age, gender, racial and ethnic orientation, drug of choice, and functional level or medical condition. Some of these offer the most appropriate environment and services for special populations.
[continued]
From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians
Though the health benefits are great, addressing substance use disorders takes time and requires primary care clinicians to incorporate new behaviors in their practice.
While some will act on what they read in this TIP and other resources, studies show that clinicians are more likely to adopt behaviors learned through a combination of didactic and experiential training (Davis et al., 1995).
Achieving Change
Clinician Education
All clinicians and support staff in the practice setting should be trained, and training should be required for all new employees. The straight Continuing Medical Education (CME)-style lecture or conference should be avoided in favor of multifaceted interventions that incorporate handouts, practice-reinforcing strategies, role-playing, videos, outreach visits by peers and other professionals, and lectures by opinion leaders.
Throughout the sessions, peer discussion, especially of attitudes toward alcohol and other drugs and personal and family experiences with substance abuse and dependence, should be encouraged. This training should be repeated every 2 to 3 years.
Valuable training curricula include Project ADEPT at Brown University (Dube and Lewis, 1994) and the Substance Abuse Education for Family Physicians project (Project SAEFP) (Fleming et al., 1994). A sample 6-hour training module is described in Figure 6-1.
System Supports and Feedback
The importance of built-in system supports and feedback in efforts to change clinicians' behavior has been strongly affirmed by two recent comprehensive literature reviews.
The first review systematically examined effects of a variety of CME strategies to improve physicians' performance and health care outcomes (Davis et al., 1995). A total of 99 controlled CME trials containing 160 separate interventions were reviewed.
The least effective change strategy was the formal CME conference or activity that did not include enabling strategies (role play of skills and system supports) and practice-reinforcing strategies (feedback).
The most effective change strategies were
Clinician reminders
Patient-mediated interventions (e.g., patient educational materials and patient reminders)
Outreach visits to clinicians by peers and other professionals such as nurse facilitators, including "academic detailing" (i.e., visits by physician educators such as pharmacists)
Use of local opinion leaders or influential persons
Use of multifaceted interventions combining two or more of the effective strategies
The second literature review examined scientifically rigorous evaluations of 36 programs to improve practice performance in primary care settings (Yano et al., 1995).
The reviewers found the following strategies to be the most successful in helping primary care clinicians achieve desired changes in performance:
Computer-generated reminders to clinicians to perform an indicated test
Audit of administrative and medical record data and personalized feedback to clinicians
Social-influence-based methods (e.g., advice, guidance, and feedback from peers)
Shifting workload for specific functions (e.g., telephone followup and coordination and assessment) from individual clinicians to multidisciplinary teams
Reminder Systems
Several studies have shown that an effective way to prompt clinician behavior is to incorporate reminders in or on the patient's chart (Davis et al., 1995; Yano et al., 1995).
Such reminders alert the clinician that it is time to conduct specific preventive tests, such as mammograms, or to discuss patients' health concerns, such as smoking or drinking. Settings with computerized patient databases will be better able to institute reminder systems of the first type.
Computerized reminder systems are used in some large staff-model health maintenance organizations (HMOs) (Balas et al., 1996). Each time a patient visits his or her physician, the computer generates an individualized, updated health screen report that is placed on the front of the chart before the patient arrives.
The report lists several health screen procedures, the frequency with which such tests should be performed based on medical research and decisions by the leadership of the HMO, and the last date on which the patient was screened in these areas.
The frequency standard that has been applied to alcohol use history is to review it at every new patient's initial health assessment and during periodic health reviews thereafter.
When such a review is due, the computer places an asterisk next to the "Alcohol Use" category on the health screen report.
Summary of Recommendations
The following guidelines are excerpted from the TIP. Supporting citations to the material below can be found in Chapters 2 through 5 and Appendix B.
Screening
The Consensus Panel that developed this TIP recommends that primary care cliniciansa term that includes all professionals with patient contact in primary care settings -- periodically and routinely screen all patients for substance use disorders.
While opinions vary about whether to integrate substance abuse screening into a standard history, asking potentially sensitive questions about substance abuse in the context of other behavioral and lifestyle questions appears to be less threatening to patients.
Since problematic use of alcohol, illicit drug use, and the consequences of those behaviors can vary over an individual's lifetime, the Panel recommends periodic rescreening for substance abuse.
Alcohol
Most people with substance abuse disorders drink alcohol. Therefore, to expedite screening and increase the likelihood of honest answers, clinicians should ask questions sequentially, beginning with the legal drug alcohol.
If the patient says he or she is a life-long abstainer or has been in recovery for 5 years or more, the clinician can conclude the screening process for alcohol misuse.
To screen for alcohol problems among English-speaking, literate patients, clinicians should use a brief, self-administered, written questionnaire such as the AUDIT, reproduced in Appendix C.
If the screen will be administered by a clinician, the CAGE (reproduced in Chapter 2), supplemented by the first three quantity/frequency questions from the AUDIT, is recommended.
This combination will increase sensitivity for detection of both problem drinking and alcohol dependence because it includes questions about alcohol consumption and consequences.
With the CAGE, two positive answers normally indicate that alcohol may be a problem. However, the Consensus Panel recommends that primary care clinicians lower the threshold to one positive answer to cast a wider net and identify more people who may have a substance use disorder.
Drugs
Of the drug abuse screening instruments, CAGE-AID (CAGE Adapted to Include Drugs) is the only tool that has been tested with primary care patients. Like the CAGE, CAGE-AID, reproduced in Chapter 2, focuses on lifetime use.
While those patients who are drug dependent may screen positive, adolescents and those who have not yet experienced negative consequences as a result of their drug use may not.
For this reason, the Consensus Panel recommends asking patients, "Have you used street drugs more than five times in your life?" In Panelists' experience, a positive answer indicates that drugs may be a problem and suggests the need for further in-depth screening and possibly assessment.
The Panel also recommends that clinicians treating patient populations at high risk for drug abuse ask their screening questions regarding alcohol and drug use in combination. (This high-risk group includes those with psychiatric, behavioral, demographic, familial, social, or genetic risk factors that increase the likelihood of drug abuse.)
Special populations
Of the screening instruments that have been modified for pregnant women, the TWEAK has been found to be the most effective for this population for whom any use is relevant. Based on best clinical judgment, the Panel recommends the use of the TWEAK (reproduced in Chapter 2) for pregnant patients in the primary care setting.
The Consensus Panel recommends that all adults age 60 and older be screened for alcohol and prescription drug abuse as part of their regular physical examination by using either the CAGE, the AUDIT, or the MAST-G (reproduced in Appendix C).
Because the physical changes that come with age change the effects of alcohol on an individual, it is particularly important with older adults to lower the cutoff score to 1 when using the CAGE. Since the MAST-G was developed specifically for older adults, it provides a sound screening option for clinicians willing to spend the time required to administer this 24-item test.
Although the AUDIT has not been evaluated for use with older adults, it has been validated cross-culturally. Since there are few culturally sensitive screening instruments, the AUDIT may prove useful for identifying alcohol problems among older members of ethnic minority groups.
If clinicians suspect that older patients are confused about their prescriptions, seeing more than one doctor, using more than one pharmacy, or seem reluctant to discuss their use, further assessment is warranted.
Health care professionals are not exempt from substance abuse problems and should be screened according to the same protocols applied to the larger primary care population.
Since many adolescents do not receive annual physicals or well-care examinations, screening should occur every time they seek medical services, including visits necessitated by acute illness, accidents, or other injuries.
Physical or sexual abuse, parental incarceration, and other serious situational or behavioral factors may be red flags for a substance abuse problem.
[Continued]
Also see source document for appendices:
SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians