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.

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