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