Screening for Alcohol and Drug Problems in the Primary Care Setting

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Screening for Alcohol and Drug Problems in the
Primary Care Setting

• Edward Via Virginia College of Osteopathic
  Medicine
• Addiction Medicine
• Block 3 Class of 2008
• Martha J Wunsch MD

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Talking with patients about alcoholism and
addiction

• Our behaviors affect patient responses!

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Three Cs of Addiction for Health Care
Professionals

• We didnt CAUSE the addiction
• We cannot CURE addiction, simply help our
  patients manage the manifestations of this
  disorder
• We cannot CONTROL their use of drugs and alcohol

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Effective Clinician Attributes

• An empathetic, supportive non-confrontative
  counseling style is as important as..
• Variance in patient characteristics (ie severity
  of disease)
• Professional training or experience
• This will improve patient outcomes

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Effective Clinician Strategies

• Establish a helping alliance
• Good interpersonal skills
• Appropriate warmth, friendliness, genuineness,
  respect, affirmation, and empathy
• Patient centered, supportive style
• Using reflective listening and GENTLE persuasion

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Less effective clinical strategies

• Confrontational approach
• Challenging the patient, disputing, refuting,
  using sarcasm
• Arguing with the patient
• Be aware of body language
• Patient outcomes
• More resistance and more consumption of alcohol
  after confrontational sessions
• Miller WR, Benefield RG, Tonigan JS. Journal of
  Consulting and Clinical Psychology 61 (3)
  455-461. 1993.

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Drinkers PyramidWorld Health Organization

• Very High Risk Users (Probable Dependence)
• High Risk Users (Moderate to Severe Risk)
• Low Risk Users (Mild to Moderate
  Risk)
• Abstainers (or Very Low Risk
  Users)

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20
35
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Learning Objectives

• I. Be able to administer and score the Alcohol
  Use Disorders Identification Test (AUDIT).

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Learning Objectives

• II. List the questions that are included in the
  CAGE and CRAFFT and be able to score each test.

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Learning Objectives

• III. Know the National Institute of Alcohol Abuse
  and Alcoholism (NIAAA) defined safe drinking
  levels
• For men and women
• For different ages
• With medical problems

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Learning Objectives

• IV. Know the National Institute of Alcohol Abuse
  and Alcoholism (NIAAA) defined safe drinking
  levels
• For men and women
• For different ages
• With medical problems
•    

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Learning Objective I AUDIT
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Alcohol Use Disorders Interview Test (AUDIT)

• Developed by the World Health Organization
• Validated worldwide
• Relatively free of gender and cultural bias
• Intended for Primary Care Settings
• 10 Questions 2 minutes to complete
• May be self administered or asked by provider
• Babor, T., Higgins-Biddle, J., Saunders, J.,
  Monteiro, M. The Alcohol Use Disorders
  Identification Test Guidelines for Use in
  Primary Care, 2nd Edition, 2001. World Health
  Organization, Dept. of Mental Health and
  Substance Dependence.

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AUDIT

• 10 Questions 3 domains
• Alcohol Use (Questions 1-3)
• Signs of Dependence (Questions 4-6)
• Related Problems (Questions 7-10)
• Questions 1-3 can be used as a prescreening
  tool

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AUDIT

• Alcohol Use (Questions 1-3)
• 1 Frequency of drinking
• 2 Typical quantity consumed
• 3 Frequency of heavy drinking

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AUDIT

• Signs of Dependence (Questions 4-6)
• 4 Impaired control over drinking
• 5 Increased salience of drinking
• 6 Morning drinking

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AUDIT

• Related Problems (7-10)
• 7 Guilt after drinking
• 8 Blackout
• 9 Alcohol-related injuries
• 10 Others concerned about drinking

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Scoring the AUDIT

• Score of 8 gt Indicator of hazardous and harmful
  alcohol use as well as possible dependence.
• Score of 7 gt For all women and men over age 65
  years, using this lower score will increase
  sensitivity of test

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WHO Classification of Alcohol Risk

• Hazardous Drinking
• Harmful Use
• Alcohol Dependence

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Hazardous Drinking

• A pattern of alcohol consumption that increases
  the risk of harmful consequences for the user or
  others. This is of public health significance
  despite the absence of any current disorder in
  the individual user
• Questions 1-3 on AUDIT

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Harmful Use

• Alcohol consumption that results in consequences
  to physical and mental health and in social
  consequences
• Questions 7-10

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Alcohol Dependence

• A cluster of behavioral, cognitive, and
  physiologic phenomena that may develop after
  repeated alcohol use. These include a strong
  desire to consume alcohol, impaired control over
  its use, persistent drinking despite harmful
  consequences, a higher priority given to drinking
  than to other activities and obligations,
  increased alcohol tolerance, and physical
  withdrawal after use is stopped.
• Questions 4-6

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Learning Objectives

• II. List the questions that are included in the
  CAGE and CRAFFT and be able to score each test.

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CAGE

• Tested in Caucasian females (outpatient setting)
  and hospitalized male and female patients.
• Validity in healthcare settinggtgeneral
  population.
• Sensitivity and Specificity vary greatly
• Advantage Easy to remember, lettersquestions
• Problem
• Does not distinguish between current and past
  drinking
• Difficult to use if patient/family denies problem

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CAGE

• Have you ever felt you should Cut down on your
  drinking?
• Have people Annoyed you by criticizing your
  drinking?
• Have you ever felt bad or Guilty about your
  drinking?
• Have you ever had a drink first thing in the
  morning, an Eye-opener, to steady your nerves or
  get rid of a hangover?

J. A. Ewing. Detecting alcoholism The CAGE
questionnaire JAMA, Vol. 252 No. 14, October 12,
1984
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CAGE

• C Lack of control and chronicity
• AConsequences in relationships, difficulties at
  work and home
• GGuilt or shame about drinking
• EDependence with onset of withdrawal when
  alcohol stopped
• SCORE gt 2 positive

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CRAFFT

• Formulated at Boston Childrens Hospital in
  Adolescent Clinic
• An amalgam of several other screening tools
• Sensitivity, Specificity still under evaluation
• Problem Tested in Urban area, unsure if
  applicable to rural teens

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CRAFFT

• Have you ridden in a Car driven by someone
  (including yourself) who was high or had been
  using alcohol or drugs?
• Do you ever use alcohol or drugs to Relax, feel
  better about yourself, or fit in?
• Do you use alcohol or drugs while you are by
  yourself, Alone?
• Do you ever Forgot things you did while using
  alcohol or drugs?

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CRAFFT

• Do your family or Friends ever tell you that you
  should cut down on your alcohol or other drug
  use?
• Have you gotten in Trouble while you were using
  alcohol or drugs?
• Score Answering yes to 2 or more of these
  questions indicates a problem which needs
  follow-up
• Knight JR, Sherritt L, Shrier LA, Harris SK,
  Chang G. Validity of the CRAFFT substance abuse
  screening test among general adolescent clinic
  patients. Archive of Pediatrics and Adolescent
  Medicine 2002156607-614

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Learning Objectives

• IV. Know the National Institute of Alcohol Abuse
  and Alcoholism (NIAAA) defined safe drinking
  levels
• For men and women
• For different ages
• Contraindications for drinking

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Safe Drinking Guidelines USDA/NIAAA

• Drinking more than these limits is RISKY
• Men lt 65 yrs 2 drinks/day or 14 drinks/week
• Men gt65 yrs 1 drink/day or 7 drinks/week
• Women 1 drink/day or 7 drinks/week
• Standard Drink
• 12 oz. Beer
• 5 oz. Wine
• 1.5 oz. Spirits

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Contraindications to Drinking

• Age under 21 years
• Medical Conditions Chronic Medical Conditions
  (Diabetes) Mental Illnesses (Depression,
  Schizophrenia)
• Medications which may interact with alcohol (
  Acetaminophen)
• A previous diagnosis of Alcoholism or Drug Abuse

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Contraindications to Drinking

• Supervising young children
• Operating heavy machinery/automobile
• Attempting Conception
• Sexually active without contraception
• Pregnant or Nursing

Center for Substance Abuse Treatment, TIP 24
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Talking with patients FRAMES

• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Self-Efficacy

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FRAMES

• FEEDBACK about personal risk or impairment
• According to individual status
• Not drinking while driving
• Avoiding alcohol during pregnancy
• Not lecturing
• Not generalities

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FRAMES

• Emphasis on personal RESPONSIBILITY for change
  and freedom of choice
• Its up to you, youre free to decide to change
• No one else can decide for you or force you to
  change
• Youre the one who has to do it if its going to
  happen

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FRAMES

• Clear ADVICE to change and the need to change and
  decrease consumption
• Supportive and concerned manner
• Not authoritarian
• Avoidance of arguments

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FRAMES

• Offer a MENU of alternative change options
• Encourage patient to develop these options
• Three choices maximum
• Abstain for 30 dayssee how it goes
• Attempt to consume at a safe level
• Make no change in drinking behavior
• Patient chooses more appealing or suitable option
  and is more willing to follow through on change

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FRAMES

• Clinician EMPATHY is effective
• Acceptance
• Careful listening and reflection
• Empathetic, warm, reflective, supportive style is
  linked to better outcomes
• Remember that the patients time frame for change
  may not fit yours!

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FRAMES

• Facilitate patient SELF-EFFICACY or optimism
• Help patient recognize barriers to change
• Establish a sense of discrepancy, or cognitive
  dissonance, between the persons current
  situation or goals
• Reinforce the patients expectation that they
  will be able to change

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Learning Objectives

• III. For the three screening instruments
  discussed in class (CAGE, CRAFFT, AUDIT)
• a.    Practice using an instrument
• b.    List the population most appropriate for
  each screening instrument.   

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Practice Screening a Patient

• Patient and Student Doctor practice using a
  screening instrument
• Educate your patient about safe drinking levels
• Discuss, using the FRAMES approach, the results
  of your screening
• Switch roles

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References

• Babor, T.F. de la Fuente, J.R. Saunders, J.
  and Grant, M. AUDIT. The Alcohol Use Disorders
  Identification Test. Guidelines for use in
  primary health care. Geneva, Switzerland World
  Health Organization, 1992.
• Saunders, J.B. Aasland, O.G. Babor, T.F. de la
  Puente, J.R. and Grant, M. Development of the
  Alcohol Use Disorders Screening Test (AUDIT). WHO
  collaborative project on early detection of
  persons with harmful alcohol consumption. II.
  Addiction 88791-804, 1993.
• Ewing, JA. Detecting alcoholism The CAGE
  questionnaire, JAMA, Vol. 252 No. 14, October 12,
  1984
• Knight JR, Sherritt L, Shrier LA, Harris SK,
  Chang G. Validity of the CRAFFT substance abuse
  screening test among general adolescent clinic
  patients. Archive of Pediatrics and Adolescent
  Medicine 2002156607-614.