Substance Use or Abuse A Guide to Screening, Brief Intervention and Referral for Treatment in Primary Care

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Substance Use or Abuse A Guide to Screening,
Brief Intervention and Referral for Treatment in
Primary Care

• Jamie R. Smolen, MD
• Associate Professor
• University of Florida
• Psychiatry and Addiction Medicine

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S-BI-RT

• Screening to identify patients with high-risk or
  dependent drinking and drug use
• Brief Intervention Conversation to motivate
  patients who screen positive to consider
  healthier decisions (e.g. cutting back, quitting,
  or seeking further assessment)
• Referral to Treatment Actively link patients to
  resources when needed
• With permission from The BNI-ART
  Institute, Boston University School of Public
  Health.

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Impulse ControlRisk Factors - Protective Factors

• Maladaptive risk factors
• high impulsivity, stress reactivity
• novelty seeking, conditioning/habits
• negative emotionality
• poor reality awareness
• Adaptive protective factors
• positive emotionality
• robust inhibitory control and executive function
• strong coping skills and good frustration
  management temper cues for potential reward
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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SAMHSA CSAT Jack B. Stein, MSW, PhD
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Addiction similar to other Chronic Illnesses

• lt30 of patients adhere to prescribed medications
  diet or behavioral changes
• 50 recurrence rate
• Substance abuse should be insured, monitored,
  treated and evaluated like other chronic diseases

Hypertension
Diabetes
Asthma
Addiction
McLellan AT, Lewis DC, et al. JAMA 2000
2841689-1695.
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Treatment Success Depends On

• A comprehensive model that considers
• Interpersonal relationships
• Employment options
• Housing options
• Mental health services
• Safety and support
• Human rights, dignity and more
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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SBIRT Addresses Both

• Continuum of Use
• Low-risk use
• High-risk / unhealthy use
• Abuse and dependence (substance use disorders)
• Continuum of Care
• Brief intervention, action plan
• Wrap-around services
• Detox, treatment types
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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Research Demonstrates Effectiveness

• A growing body of evidence about SBIRTs
  effectiveness, including cost-effectiveness, has
  demonstrated its positive outcomes.
• The research shows that SBIRT is an effective way
  to reduce alcohol and drug related health and
  social/ legal problems.
• With permission from The BNI-ART
  Institute, Boston University School of Public
  Health.

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Making a Measurable Difference

• Since 2003, SAMHSA has supported SBIRT programs
  with over 1.5 million persons screened.
• Outcome data confirm a 40 reduction in harmful
  use of alcohol by those drinking at risky levels
  and a 55 reduction in negative social
  consequences.
• Outcome data also demonstrate positive benefits
  for reduced illicit substance use.
• Based on review of
  SBIRT GPRA data (2003-2011).

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A Ten Minute Brief Negotiated Interview By
Practitioners Reduces Hazardous and Harmful
Drinking Among ED Patients ( Donofrio et al.
Ann of Emerg Med. 2012) N889

• Mean drinks/ past 7 days
• BNI BL 19.8 12 mo 14.3
• SC BL 20.9 12 mo 17.6
• Binge drinking days/past 28
• BNI BL 7.5 12 mo 4.7
• SC BL 7.2 12 mo 5.8
• Driving after gt3 drinks
• BNI BL 38 12 mo 29
• SC BL 43 12 mo 42

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What does SBIRT look like?

• Screening
• Brief Intervention
• Referral to Treatment

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Brief Intervention the BNI

• What
• BNI Brief Negotiated Interview (5-steps)
• When
• Patient screens positive for risky alcohol/drug
  use
• Who
• Health promotion advocate (HPA), health educator,
  nurse, doctor, social worker, medical assistant
• Where
• Bedside, private room/office
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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5 Steps of the BNI

• Build rapport
• Bringing up the topic, being nonjudgmental
• Pros Cons
• Ask what is liked/disliked about the behavior
• Information Feedback
• Give facts and feedback about the behavior, ask
  for thoughts
• Readiness Ruler
• Assess readiness to make any changes (to be
  healthier, safer)
• Prescription for Change
• Ask for action steps, create a plan together
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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Referral to Treatment (or other services)

• What
• Calling service providers, getting medical
  clearance (for detox), calling about insurance,
  arranging transportation, giving information
  handouts, brochures, contact info.
• When
• Patient wants additional services and is a good
  match
• Who
• Health promotion advocate (HPA), health educator,
  social worker, nurse, doctor, medical assistant
• Where
• Bedside, private room/office
• With permission from The BNI-ART Institute,
  Boston University School of Public Health.

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Approach to Substance Abuse for Primary Care
Clinicians

• Ideal position to screen for substance use
  disorders
• Need to be familiar with basic skills
• Identify
• Diagnose
• Relate to comorbid illnesses
• Evaluative tests
• Placement criteria
• Most effective
• Least restrictive

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Addiction Biopsychosocial Disorder

• Primary care expanded gatekeeper function
• Practical approach to address SUDs
• Team effort

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Evaluate and Treat

• Comprehensive evaluation
• Graduated approach
• Convenient accurate screening tools

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Screening Questionnaires

• AUDIT
• CAGE
• TWEAK
• MAST-G

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Efficacy of Substance Use Treatment in Primary
Care

• Reduction in
• Hospitalization
• Medical costs
• Sick time
• Family problems
• Criminal activity

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Brief Intervention in Primary Care

• Goals
• Moderate alcohol consumption to sensible levels
• Reduce levels of drinking
• Change patterns of drinking
• Eliminate harmful drinking practices
• Binge drinking

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Brief Intervention in Primary Care

• Goals
• Reduce negative outcomes of drinking
• Medical problems
• Injuries
• Domestic violence
• Motor vehicle crashes
• Arrests
• Pregnancy reduce fetal injuries

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Brief Intervention

• Time limited
• Patient centered
• Counseling strategy
• Change patients behavior
• Increase compliance with therapy

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Brief Intervention

• Assessment and direct feedback
• CAGE
• Negotiation and goal setting
• Behavioral modification techniques
• Self-help-directed bibliotherapy
• Follow-up reinforcement

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Brief Intervention Components

• 5-10 minute standard office visit
• 2-3 four visits
• Telephone consultations
• Drinking diary cards
• Clinic health educator

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Role of Brief Intervention

• Reduce alcohol use
• At-risk drinkers
• Problem drinkers
• Minimize risk of alcohol-related social and
  medical problems
• Harm reduction

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Role of Brief Intervention

• Young men death from violent causes
• Increases with alcohol consumption
• Brief intervention
• Reduce use from 5 standard drinks to 2 standard
  drinks per day
• Lowers risk of dying fivefold
• Brief intervention
• Lower the risk of dying from liver cirrhosis

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Facilitate Medical Compliance

• Patients on pharmacotherapy
• Abstinence is preferred
• Co-occurring psychiatric conditions
• Abstinence is preferred
• Medication compliance
• Patients treated with naltrexone
• More likely to remain on medication with brief
  counseling

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Brief Intervention

• Focus of treatment
• Harm reduction
• Not abstinence
• Readiness to change behavior
• Time limited
• Emphasize specific medical problems related to
  alcohol consumption
• Raises patients awareness of serious health
  problems

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Training

• Clinicians do not have adequate skills training
• Clinicians are not compensated for prevention and
  treatment of alcohol problems
• Attend training workshops
• Role-play exercises
• Quality improvement programs
• Monitoring outcomes
• Alcohol use in treatment for hypertension,
  depression and anxiety disorders

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Brief Intervention

• Reasons why Brief Intervention may be sufficient
• Specialized treatment is for severe and chronic
  disorders
• Mild to moderate problems may not require formal
  treatment
• Rapid progression to substance dependence is not
  inevitable
• Spontaneous remission can occur in substance
  disorders as in many medical conditions

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Advantages to Brief Intervention in Primary Care

• Not stigmatizing
• Light to moderate drinkers are unlikely to seek
  help in the specialty treatment system if
  problems are transient or mildly inconvenient
• Health concern results in teachable moment
• Risk factors associated with alcohol and drugs
  are pointed out and behavior potentially changes
• Over 20 million heavy drinker can minimize ER
  visits, domestic violence and road accidents
  major public health burden

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Need Further In-depth Assessment

• Several positive responses to screening
  questionnaires
• Suspiciously heavy drinking
• Drug use history
• Symptoms of substance dependence
• Chronic or escalating use of addictive
  prescriptions
• Current use of illicit drugs
• Complicating medical illnesses
• Psychiatric disorders

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Decisions About Brief Intervention

• CAGE - feeling guilty
• Ask about alcohol related problems e.g. family
  and work
• Drinking or drug using patterns
• Does it suggest tolerance or withdrawal
• Medications
• Affected by alcohol or drug use
• Pregnancy
• Medical conditions - present
• Psychiatric conditions - present

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Less Likely to Respond to Brief Intervention

• Recurrent and significant alcohol or drug related
  problems in the past 12 months
• Role performance
• Legal
• Social
• Pose a danger to the individual
• Pose a danger to others
• Ask specifically about adverse consequences on
  family, work, health etc.

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Who Gets a Referral

• Patient with several diagnostic criteria for
  substance dependence
• Physical tolerance
• Withdrawal symptoms
• Unsuccessful attempts to reduce consumption
• Intensive focus (obsessive) on obtaining the
  alcohol or drug
• Adverse impact on
• Occupational
• Social activities
• Personal life
• Previous substance abuse treatment

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Dont Give Up

• Diagnosable substance use disorder
• Initially resist referral
• Express willingness for Brief Intervention
• Unlikely to cut down
• May become motivated to accept the referral

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Brief Invention Is Best If Its Ongoing

• Not a one time activity
• May successfully reduce consumption
• May abstain
• May relapse
• Time of stress
• Resume heavy use
• Risky use
• Continuity of care
• Ongoing monitoring
• Patient supervision

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Critical Components of Brief Interventions

• Give feedback clarify findings
• Screening results
• Risks
• Impairment
• Inform about safe consumption
• Assess readiness to change
• Negotiate goals and strategies to change
• Arrange for follow-up treatment

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Give Feedback

• Report the questionnaire answers
• Interpret laboratory results
• Physical examination
• Observations
• Be straightforward
• Nonjudgmental
• Understandable medical terms
• Stress the potential or actual health effects

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Sample Scripts of Feedback

• I am concerned about your lab results. These may
  indicate that you may be drinking heavily and
  this could be causing some liver damage. Just how
  much and how often are you drinking?
• I notice from your answers to the CAGE
  questionnaire that your drinking has caused you
  some concern. You also state that you are dinking
  a six-pack every afternoon. Can you tell me more
  specifically what your concerns are?

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Sample Scripts of Effective Feedback

• Im concerned that your alcohol use is related
  to many of the health problems weve been talking
  about.
• At this level of consumption, you are at
  increased risk for some health problems as well
  as accidents.
• Our screening questionnaire and your physical
  exam indicates some symptoms of alcohol
  dependence. You have slight tremor in your hand,
  report insomnia and taking an occasional morning
  drink. Does this concern you too?

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Create An Ally

• Avoid being adversarial
• Semantics matter
• Nonpejorative
• Nonstigmatizing
• Neutral language
• The wrong words can trigger resistance
• Provoke guilt, shame or anger
• Avoid alcoholic or addict
• Your substance use is creating problems for you

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How Much is Too Much?

• There are increased risks for alcohol-related
  problems
• Men who drink more than 4 standard drinks in a
  day
• (or more than 14 per week) and
• Women who drink more than 3 standard drinks in a
• day (or more than 7 per week)
• Causes or elevates the risk for alcohol-related
  problems
• Complicates management of other health problems

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Why Screen For Heavy Drinking?

• At-risk drinking and alcohol problems are
  common.
• Heavy drinking often goes undetected.
• Patients are likely to be more receptive, open
  and ready
• to change than you expect.
• You are in a prime position to make a
  difference

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Why Screen For Heavy Drinking?

• Brief interventions can promote significant
  lasting
• reductions in drinking levels in at right
  drinker who are
• not alcohol dependent.
• Some drinkers who are alcohol dependent will
  accept
• referral to addiction treatment programs.
• Even for patients who dont accept referral,
  repeated
• alcohol focused visits with health
  providers lead to
• significant improvement.

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Introduction
Introduction
How Much Is Too Much? Individual responses to
alcohol vary Drinking at lower levels
may be problematic Patients age
Co-existing conditions Use of
medication Note The U.S. Surgeon General urges
abstinence from drinking for women who are or may
become pregnant.
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• Decide on a Screening Method
• The Clinicians Guide provides two methods
• A single question about heavy drinking days
• The AUDIT
• Self-report instrument
• Takes less than five minutes to complete

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Ask About Alcohol Use Prescreen Do you
sometimes drink beer, wine, or other alcoholic
beverages? If NO the screening is
complete. If YES
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• Whats a Standard Drink?
• In the U.S., a standard drink is any drink that
  contains about 14 grams of pure alcohol (about
  0.6 fluid ounces or 1.2 tablespoons).

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Ask the screening question about heavy drinking
days How many times in the past year have you
had...
If YES
5 or more drinks in a day? (for men)
4 or more drinks in a day? (for women)
One standard drink is equivalent to 12 ounces of
beer, 5 ounces of wine, or 1.5 ounces of 80-proof
spirits
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Is the Screening Positive?
Positive Screening 1 or more heavy drinking
days
When using the AUDIT Positive Screening Score
8 for men
Score 4 for women
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• Advise staying within these limits

• Maximum Drinking Limits
• For healthy men up to age 65
• no more than 4 drinks in a day
• no more than 14 drinks in a week
• For healthy women (and healthy men over age 65)
• no more than 3 drinks in a day
• no more than 7 drinks in a week

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If NO then

• In addition
• Recommend lower limits or abstinence
• Medications that interact with alcohol
• Health conditions exacerbated by alcohol
• Pregnant - advise abstinence
• Express openness
• Talking about alcohol use
• Any concerns it may raise
• Rescreen annually

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Screening Positive?

• Your patient is an at-risk drinker.
• For a more complete picture of the drinking
  pattern, determine the weekly average

• On average, how many days a
• week do you have an alcoholic drink? Enter
  amount _______
• On a typical drinking day, how
• many drinks do you have?
  Enter amount _______
• 
  
• 
  Total for one week _______

Keep a baseline record of amounts
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STEP 2 Assess for Alcohol Use
Disorders

• Maladaptive pattern of alcohol use
• Clinically significant impairment or distress

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• In the past 12 months has you patients
  drinking
• repeatedly caused or contributed to
• risk of bodily harm
• relationship trouble
• role failure
• run-ins with the law - DUI
• If YES to one or more your
  patient has Alcohol Abuse
• Next proceed to assess for symptoms of
  Dependence

STEP 2 Assess for Alcohol Use Disorders
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STEP 2 Assess for Alcohol Use
Disorders

• In the past 12 months has your patient.
• not been able to stick to drinking limits
  (repeatedly gone over them)
• not been able to cut down or stop (repeated
  failed attempts)
• shown tolerance (needed to drink a lot more to
  get the same effect)
• shown signs of withdrawal (tremors, sweating,
  nausea, or insomnia when trying to quit or cut
  down)
• kept drinking despite problems (recurrent
  physical or psychological problems)
• spent a lot of time drinking (or anticipating or
  recovering from drinking)
• spent less time on other matters (activities that
  had been important or pleasurable)

• If Yes to three or more your patient has
• Alcohol Dependence

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HOW TO HELP PATIENTS A CLINICAL APPROACH
STEP 2 Assess for AUDs
Does the patient meet the criteria for alcohol
abuse or dependence?
If NO patient is still at risk for developing
alcohol-related problems. Go to Steps 34 for
At-Risk Drinking page 6
If YES Your patient has an alcohol use disorder.
Go to Steps 34 for Alcohol Use Disorders page 7
Page 6
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STEP 2 Assess for Alcohol Use
Disorders
Does the patient meet the criteria for alcohol
abuse or dependence?
If NO The patient is still at risk to develop
alcohol-related problems Advise and Assist with
Brief Intervention for at risk drinking.
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AT-RISK DRINKING no abuse or dependence

• Advise and Assist
• State your conclusion and recommendation clearly

You are drinking more than is medically safe.
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AT-RISK DRINKING no abuse or dependence

• Advise and Assist
• State your conclusion and recommendation clearly

I strongly recommend that you cut down (or
quit), and Im willing to help.
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AT-RISK DRINKING no abuse or dependence

• Advise and Assist
• State your conclusion and recommendation clearly

• Gauge readiness to change drinking habits

Are you willing to consider making changes in
your drinking?
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Readiness To Change

• Behavioral change is difficult
• Realistic change is incremental
• Stages of change
• Precontemplation
• Contemplation
• Preparation/Determination
• Action
• Maintenance
• Relapse

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Precontemplation - Denial

• I dont have a problem
• And if I did, I dont see any reason to do
  anything about it right now.

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Use Empathy - Not Confrontation

• Resistance is not a challenge to the clinicians
  authority
• Confrontation increases patient resistance
• Empathy and support
• Creates a safe environment for establishing
  alliance
• Cooperation
• Compliance
• Success

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Be Reassuring and Keep Your Cool

• Avoid arguments
• I know people who drink a lot more than me
• Be the medical expert
• Important knowledge
• Potential negative health effects
• Be reassuring
• Alcohol and drugs problems are not anyones
  fault.
• The problems can be addressed.
• Be prepared and tolerant
• Patients will over react embarrassed, hostile,
  astonished, denial

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
NO
Do not be discouraged Ambivalence is common.
Your advice has likely prompted a change in your
patients thinking With continued reinforcement,
your patient may decide to take action.
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Precontemplation - Interview Guidelines

• Express concern about the patient and substance
  use
• Unfortunately, substance use is causing you some
  problems.
• Be nonjudgmental
• Agree to disagree about the severity of the
  problem
• Our opinions differ on how bad things have
  gotten for you, and thats okay for now.
• Suggest abstinence to clarify the issue
• If you quit drinking for while, maybe youll be
  able to see how much of a problem it really was.

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Patients Reaction

• Most patients in primary are in the first three
  stages
• Ambivalence and resistance are expected
• Severity of substance use and readiness dont
  always correlate
• Stressful life events divorce, death in the
  family, financial problems, work problems can
  slow down or even speed up the readiness process
• Be prepared for resistance and setbacks

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Precontemplation Interview Guidelines

• Suggest bringing a family member to an
  appointment
• Id really like to meet your wife so we can all
  talk about your medical conditions and how
  drinking has affected them.
• Patients perception of a substance use problem
• How would your drinking have to change for you
  to consider it a problem?
• Emphasize the importance of seeing the patient
  again
• Its really important that we see each other
  again. I understand it may be uncomfortable
  talking about your drinking but your health is at
  stake and its my job to help you take better
  care of it.

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
NO

• For now
• Restate your concern about his or her health.

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Contemplation

• You mean my drinking is causing all this
  trouble.

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
NO

• Encourage reflection
• Ask patients to weigh what they like about
  drinking versus their reasons for cutting down.
  What are the major barriers to change?

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Contemplation

• Now you give me something to think
  about.

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
NO

• Reaffirm your willingness to help when he or she
  is ready.

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Contemplation

• But Im just not ready to give it up yet.

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Persuasive Comments

• Your blood pressure is high and your abdominal
  pain may be caused by gastritis or an ulcer.
  Until we can investigate further, Id like you to
  stop drinking for at least 6 weeks to let your
  stomach heal. You do think you can do this?

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Contemplation Interview Guidelines

• Elicit positive and negative aspects of substance
  use
• Ask about positive and negative aspects of past
  periods of abstinence
• Summarize the patients comments on substance use
  and abstinence
• Make explicit discrepancies between values and
  actions
• Consider a trial of abstinence

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Persuasive Comments

• In reviewing your responses to our screening
  questionnaire, I notice that you are drinking a
  lot of beer of weekends. You dont seem to be
  having any direct problems as a result, but Im
  concerned that your judgment may be off when you
  drink and you could end up driving when youre
  not completely safe behind the wheel. Youve got
  your family to consider. Id like you to read
  this pamphlet and I hope you will think seriously
  about cutting back before you have some problems.

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Persuasive Comments

• Thank you for being honest with me about your
  marijuana use. One concern of mine is your
  asthma, because marijuana smoke does affect your
  lungs. No matter how much it may help you to
  relax, Id rather work on some safer ways to
  accomplish that. Continuing to smoke can only
  makes matters worse at some point down the road.
  Lets work on a plan to help you quit.

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
YES
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Preparation/Determination

• Ok doc, you got my attention.
• I dont feel good and Im stressed out.
• I dont want to stay like this.
• Im ready to listen.
• What if I wanted to do something about it.

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
YES
Im willing to give it a try.
Okay Mr. Smith, youve made a wise decision.
I have some very helpful suggestions
for you to consider.
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Action Taking Steps

• Okay Mr. Smith, lets review your pattern of
  drinking and see what changes make sense to you
  now that you know how much it makes your blood
  pressure go up and how it breaks up your sleep.
• How would like to approach cutting back? Give me
  your best idea on how to go about it.
• I think that sounds reasonable and I am really
  proud of you for choosing to do something now.
  How motivated are you to get started?

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
YES
Help set a goal to cut down within
maximum limits Help set
a goal to abstain
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Inform The Patient About Unsafe Consumption

• Substance abuse or dependence no safe levels
• Specified medical conditions
• Pregnancy
• Breast cancer
• Peptic ulcer
• Adolescence no alcohol and no drugs
• Abstinence from illegal drugs is always the
  ultimate goal
• Reduce consumption as an intermediate step

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Low-Risk Amounts Can Be Conditional

• Low-risk considerations
• Reactions to alcohol
• Body weight
• Age
• Gender influences
• Two drinks can be dangerous
• Consumed rapidly
• On an empty stomach
• Especially to infrequent drinkers
• Blood alcohol and driving
• The legal limit can be higher than the level that
  slows reaction time

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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
YES

• Agree on a plan, including
• specific steps the patient will take
• not go to a bar after work,
• measure all drinks at home,
• alternate alcoholic and non-alcoholic beverages

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Persuasive Advice Works Best

• Clearly state the consumption goals
• Keep within the context of lifestyle and living
  habits
• Integrate the consumption goal with health
• Emphasize the health concerns
• Emphasize the consequences of continued use
• Utilize clinician authority
• Be strongly motivating
• Encourage responsibility
• Encourage compliance

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Low Risk Drinking Limits
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AT-RISK DRINKING no abuse or dependence
Advise and Assist
Is the patient ready to commit to change at this
time?
YES

• Agree on a plan
• how drinking will be tracked - diary
• how to manage high-risk situations
• who might be willing to help
• such as a spouse or non-drinking friends

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Negotiate Goals Strategies For Change

• Develop a realistic plan
• Goals that the patient considers achievable
• Reduce consumption below what is unsafe or
  potentially hazardous
• Based on what weve been discussing, would be
  willing to change your drinking habits (or drug
  use)?
• What do you think you can do to cut back?
• Can we set a specific date to reduce your
  alcohol use? Could you cut back beginning this
  week?
• Would you be willing to see a counselor to
  discuss your drug use further? Think of this as
  comparable to a sending you to a cardiologist for
  a heart problem.

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When Patient Sets The Goals Motivation Increases

• Ask and expect the patient to help set the goals
• Self- help manuals assist with planning
  strategies
• Women prefer self-instruction manuals
• Fear of social stigma
• Suggest readings
• What to do instead of drinking
• What to do when temptation occurs
• Consumption diary for accuracy

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Goals of Intervention

• Goals are based upon the patients current
  situation and responsibilities in life
• Pregnancy
• Abstinence
• Airline pilots, physicians and nurses
• On the job abstinence
• Interactive medications
• Sedatives, antianxiety, antidepressant, opioids
  analgesics
• Abstinence
• Mental disorders
• Bipolar and schizophrenia
• Abstinence

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Compliance And Trust

• Monitoring compliance is a trust issue
• Clinician should express trust in the patient
• Dishonesty about reporting substance use
• Renegotiate the parameters of the relationship
• Honesty must be a ground rule
• Patients who are motivated to preserve trust are
  more likely to return for monitoring follow-up
• Dealing with deception
• Your continued use of alcohol (drug) is a
  problem. What do you think will help you stop
  using?

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Monitoring Compliance

• Collateral informant
• Significant other
• Supportive
• Make sure there is sufficient martial harmony

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HOW TO HELP PATIENTS A CLINICAL APPROACH
AT-RISK DRINKING no abuse or dependence
STEP 4 At Followup Continue Support

• REMINDER At each visit
• document alcohol use, and
• review goals

• Obtain the drinking quantity and frequency at
  followup visits

Tip Download Progress Notes from
www.niaaa.nih.gov/guide
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AT-RISK DRINKING no abuse or dependence
At Follow-up
Was the patient able to meet and sustain the
drinking goal?
NO

• Acknowledge change is difficult.
• Support any positive change and address barriers
  to reaching the goal.
• Renegotiate the goal and plan consider a trial
  of abstinence.
• Consider engaging significant others.
• Reassess the diagnosis if the patient is unable
  to either cut down or abstain.

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AT-RISK DRINKING no abuse or dependence
At Follow-up
Was the patient able to meet and sustain the
drinking goal?
YES

• Reinforce and support continued adherence to
  recommendations.
• Renegotiate drinking goals as indicated.
• Encourage patient to return if unable to
  maintain adherence.
• Rescreen at least annually.

103
Maintenance Avoiding Relapse

• Your commitment to keep your drinking at a safe
  limit seems really strong. Whats the primary
  reason why you are able to accomplish that?
• What changes have you made in your life style so
  that you can drink less and still enjoy
  yourself.
• I am really proud of you for drinking less. Why
  has that become so important to you?

104
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105
Assess For Alcohol Abuse

• Determine whether there is
• Maladaptive pattern of alcohol use
• Clinically significant impairment
• Clinically significant distress
• In the past 12 months drinking as repeatedly
  caused
• Risk of bodily harm drinking and driving,
  machinery
• Relationship trouble family or friends
• Role failure home, work, school obligations
• Run-ins with the law arrests or other legal
  problems
• One or more alcohol abuse

106
Assess For Alcohol Dependence

• Has your patient, in the past 12 months
• Unable to stick to drinking limits (repeatedly
  gone over them)
• Unable to cut down or stop (repeated failed
  attempts)
• Shown tolerance (needed to drink more for the
  same effect)
• Shown signs of withdrawal (tremors, sweating,
  nausea, insomnia)
• Kept drinking despite problems (physical or
  psychological)
• Spent a lot of time drinking (or anticipating or
  recovering from it)
• Spent less time on other matters (important or
  pleasurable activities)
• Three or more Alcohol Dependence

107
If the patient assessment indicates
Alcohol Use Disorder
Next Step Advise and Assist Brief
Intervention For Alcohol Use Disorder
108
HOW TO HELP PATIENTS A CLINICAL APPROACH
109
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• State your conclusion and recommendation clearly.

• Relate to the patients concerns and medical
  findings if present.

I believe that you have an alcohol use disorder.
I strongly recommend that you quit drinking and
Im willing to help.
110
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• Negotiate a drinking goal
• Abstaining is the safest course for most patients
  with alcohol use disorders.
• Patients who have milder forms of alcohol abuse
  or dependence and are unwilling to abstain may be
  successful at cutting down.

111
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• Consider referring for additional evaluation by
  an addiction specialist, especially for
  dependence.
• Consider recommending a mutual help group.

112
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• For patients who have alcohol dependence,
  consider
• medically managed detoxification

113
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• For patients who have alcohol dependence consider

• prescribing a medication for patients who endorse
  abstinence as a goal

114
ALCOHOL USE DISORDERS abuse or dependence

• Advise and Assist
• Arrange follow-up appointments
• including medication management support if
  needed.

115
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116
HOW TO HELP PATIENTS A CLINICAL APPROACH
117
ALCOHOL USE DISORDERS
At Follow-up Continue Support

• REMINDER At each visit
• document alcohol use
• review goals

• Obtain the drinking quantity and frequency at
  follow-up visits

118
Action Interview Guidelines

• Be a source of encouragement and support
• Acknowledge the uncomfortable aspects of
  withdrawal
• Reinforce the importance of remaining in recovery

119
Maintenance Interview Guidelines

• Anticipate difficulties as a means of relapse
  prevention
• Recognize the patients struggle
• Support the patients resolve
• Reiterate that relapse should not disrupt the
  medical care relationship

120
Relapse Interview Guidelines

• Explore what can be learned from the relapse
• Express concern and even disappointment about the
  relapse
• Emphasize positive aspects of the effort to seek
  care
• Support the patients self-efficacy so that
  recovery seems achievable

121
Determination Interview Guidelines

• Acknowledge the significance of the decision to
  seek treatment
• Support self-efficacy
• Affirm patients ability to successfully seek
  treatment
• Help the patient decided on appropriate,
  achievable action
• Caution that the road ahead is tough but very
  important
• Explain that relapse should not disrupt the
  patient-clinician relationship

122
Referring For Further Assessment or Treatment

• One treatment failure is no reason to give up
• Reduction of use or stopping make take several
  tries
• Be willing to accept limited or incremental goals
• Attitude and readiness to change may improve
  slowly
• You werent able to cut down your alcohol use as
  you contracted to do so. Does this make you think
  this a bigger problem for you than you thought?
• Relative recovery
• Improved health but not perfect health
• Chronicity of substance use disorders
• May require repeated interventions or treatments

123
Referral For Treatment

• Clinician cannot force a patient to undergo
  further assessment or accept a referral for
  specialized treatment.
• Even if the substance use disorder is severe
• Work within the limitation of brief intervention
  if this is the best you can do
• Always make the patient aware of the symptoms or
  the possibility of withdrawal and its clinical
  significance.
• Morbidity and mortality of withdrawal
• Make follow-up more frequent and intensive if
  necessary

124
When to Refer For Assessment

• Positive screening indicates the likelihood of
  abuse or dependence
• Compulsion to use
• Impaired control
• Psychosocial problems
• Absence of support will render Brief Intervention
  ineffective
• Assessment is necessary
• To clarify the type of problem
• To clarify the extent of the problem
• Determine what treatment is appropriate to
  recommend

125
Specialty Assessment

• Examine the problems
• Medical
• Behavioral
• Social
• Financial
• Formal diagnosis
• Establish severity mild, moderate, severe
• Guides treatment
• Appropriate level of care
• Defines baseline status for comparison to future
  conditions

126
Components of Multidimensional Assessment

• Acute intoxication and/or withdrawal potential
• Biomedical conditions and complications
• Emotional/behavioral conditions
• Psychiatric
• Transient neuropsychiatric complications
• Co-occurring diagnoses dual diagnosis
• Psychological
• Changes in mental status
• Poor impulse control
• Treatment acceptance or resistance
• Relapse potential or continued use
• Recovery/living environment

127
Levels of Care For Substance Use Disorders

• I Outpatient treatment
• II Intensive outpatient (IOP)
• Partial hospital program (PHP)
• III Residential/Inpatient
• IV Medically managed intensive inpatient

128
ASAM Levels of Care For Detoxification

• ID Detoxification without extended
  on-site monitoring
• II D Detoxification with extended on-site
  monitoring
• III 2D Clinically-managed residential detox
• III 7 D Medically-monitored inpatient detox
• IV D Medically-managed inpatient detox

129
Resources of Information

• Substance Abuse Mental Health Services
  Administration
• www.findtreatment.samhsa.gov (treatment locator)
• 800-662-Help (4357)
• National Institute on Alcohol Abuse and
  Alcoholism
• www.niaa.nih.gov
• A Guide to Substance Abuse Services for Primacy
  Care Clinicians www.samhsa.gov TIP series 24
• American Academy of Addiction Psychiatry
  www.aaap.org
• 401-524-3076
• NAADAC Substance Abuse Professionals
  www.naadac.org
• 800-548-0497

130
Mutualhelp Groups

• Alcoholics Anonymous www.AA.org
• Online meetings and chat
• Narcotics Anonymous www.NA.org
• Online meetings and chat
• www.Intherooms.com online video AA/NA meetings
• SMART Recovery www.smartrecovery.org 215-536-8026
• Moderation Management www.moderation.org
  212-871-0974
• Women For Sobriety www.womenforsobriety.org
  214-536-8026

131
Resources of Information

• Helping Patients Who Drink Too Much at
  www.niaaa.nih.gov
• Clinicians Guide to Online Training
  www.niaaa.nih.gov which includes video cases with
  Mark Willenburg, MD
• National Clearinghouse for Alcohol and Drug
  Information
• www.ncadi.samsha.gov 800-729-6686

132
Who Should Assess?

• Experienced Substance Abuse Specialist
• Addiction Medicine trained
• Addiction Psychiatrist
• If a specialist is unavailable
• Physician
• Addiction Medicine
• Addiction Psychiatrist
• Physicians assistant
• Advanced practice nurse
• Nurse practitioner
• Clinical nurse specialist

133
Difficulties Diagnosing The Problems

• Denial
• Avoidance of detection because of knowledge
• Plausible rationalizations
• Myth of invulnerability

134
What Predisposes A Professional To Problems?

• Stress
• Training
• Access to drugs
• Professional stature
• Lack of substance abuse and mental health
  education
• Axis II personality issues

135
Possible Warning Signs Of Impairment

• Multiple medical problems
• Self-medication
• DWI charges
• Family conflict
• Inappropriate behavior or dress
• Changes in ordering, prescribing, or taking mood
  altering drugs

136
Possible Warning Signs Of Impairment

• Changes in attitude, behavior, or demeanor
• Long absences from the office with disruption of
  appointments
• Complaints by office staff, coworkers, patients,
  or customers
• Making rounds or at work at unusual times

137
Consequences of Impairment/Distress

• Not all health professionals with addiction
  display impairment in their work, especially at
  first
• However, eventually addiction will inevitably
  lead to distress and lower quality of life
• Mood disturbance/suicidality
• Finances
• Relationships
• Spiritual fitness
• Physical health

138
Background

• Substance use disorders occupational hazard
  among physicians, and other healthcare providers
• Baldisseri, Crit Care Med, 2007 35(2), S106-116
• Research showed physicians at greater risk of
  becoming addicted than general public
• Hughes et al., JAMA, 199226723339.
• The prevalence of psychiatric comorbidity appears
  to be increasing among physicians
• Angres et al. J Addict Dis, 2003 22(3)79-87
• Addiction can cause significant distress and
  impairment in the lives of health professionals,
  their patients, and their loved ones

139
Order of Substance Use Initiation
140
Doctors Reasons for Misusing Rx Drugs

• MANAGING PHYSICAL PAIN I was under pain
  management and I had an endless supply of
  drugsI was on a Fentanyl patch and a Fentanyl
  lollipop ... And the minute you started taking
  that, within three of four days, you crave it. I
  mean youre addicted to it.
• MANAGING EMOTIONAL/PSYCHIATRIC SYMPTOMS Drugs
  treated a rather overwhelming anxiety and not
  being comfortable in my own skin, being shy,
  being uncomfortable around other people, being
  worried all the time about things, just an angst
  and malaise that, fortunately, I no longer have.

Singhakant, Merlo, Cummings, Cottler. (under
review).
141
Doctors Reasons for Misusing Rx Drugs

• MANAGING STRESS As I got into motherhood and
  trying to work part-time at the same time, and
  also got sick with sinusitis and got started
  being prescribed narcotics the switchover from
  using it just for pain to pain and stress relief
  was subtle but really entrapping. I thought it
  was helping me.
• RECREATIONAL USE Id mix cocaine with alcohol
  and benzodiazepines Once I start drinking it
  sets up the craving for the coke. And, bang!
  Youre off to the races and then I took the
  benzos to come down.
• PREVENT/ALLEVIATE WITHDRAWAL I would find that
  if I didnt take it, I would have symptoms of
  withdrawal, so I would need to take the
  medication on a regular basis just to feel
  normal. Just to maintain.

142
Psychological Disorders for PRN Physicians and
Other Health Professionals
Physician (n101) Non-Physician (n156) p-value
Anorexia 1 (1.0) 4 (2.5) 0.65
Antisocial Personality Disorder 7 (7.1) 35 (22.6) lt0.01
ADHD 1 (1.0) 5 (3.2) 0.41
Conduct Disorder 3 (3.0) 3 (1.9) 0.68
Major Depressive Episode 30 (29.7) 53 (34.0) 0.47
Dysthymic Disorder 0 (0.0) 2 (1.3) 0.52
Generalized Anxiety Disorder 7 (6.9) 14 (9.0) 0.56
Hypomanic Episode 5 (5.1) 3 (1.9) 0.27
Manic Episode 6 (6.1) 9 (5.8) 0.92
Obsessive-Compulsive Disorder 1 (1.0) 2 (1.3) 1.00
Oppositional Defiant Disorder 4 (4.0) 9 (5.8) 0.77
Panic Attack/Agoraphobia/Phobias- 12 (12.0 ) 28 (18.0) 0.19
Pathological Gambling Disorder 1 (1.0) 2 (1.3) 1.00
Pain Disorder 13 (12.9) 24 (15.4) 0.57
Posttraumatic Stress Disorder 8 (7.9) 18 (11.5) 0.35
Separation Anxiety Disorder 0 (0.0) 6 (3.8) 0.08
Somatization Disorder 0 (0.0) 0 (0.0) 1.00
Schizophrenia 0 (0.0) 0 (0.0) 1.00

143
Barriers To Intervening

• Inability to recognize symptoms
• Reluctance to harm careers
• Lack of knowledge or belief in the disease model
• Presence of other psychiatric problems
• Fear of being sued, especially if the
  professional has made threats in the past or is
  perceived as powerful

144
Barriers To Intervening

• Lack of policies or resources
• Denial of problems by the impaired professional
• Denial of problems and enabling behaviors by
  other professionals and staff (particularly when
  alcohol is concerned) as in I only had 1 drink

145
When To Intervene

• Need to use common sense
• Do not wait until the situation is completely out
  of hand as early intervention is important
• Dont jump to conclusions about what is going on
  with a professional because you may be very wrong

146
When To Intervene

• Look at your motivations and dont diagnose
• Look at the policies and procedures that govern
  you
• Call your state program for information
• Remember ignoring potential signs of a problem
  could result in the death of your colleague

147
When To Intervene

• Talk to the colleague if you can, although
  sometimes it is not wise
• Talk to your supervisor or EAP
• Talk to your State Professional Program
• Call your Board only as a last resort
• Confidentiality is of utmost importance!

148
Formal Interventions

• Are never fun
• Best left to the professional who does them for a
  living
• Ultimately interventions help protect the
  professional and their license
• Professional programs are about advocacy, not
  about getting the professional

149
Referring For Assessment

• Report to the state professional health program
• Document, document, document
• Dont wait thinking things will get better
• Understand what your resources and policies are
• Understand the limitations of your resources
• Sometimes an outpatient evaluation results in an
  inpatient evaluation

150
Concerns About Reporting

• Health professionals have an ethical
  responsibility to report colleagues suspected of
  incompetence/impairment
• Less than 70 of physicians polled felt prepared
  to deal with impaired colleague
• Over 1/3 of physicians who knew of an impaired or
  incompetent colleague failed to report them

DesRoches, Rao, Fromson, Birnbaum, Iezzoni,
Vogeli, Campbell (2010). JAMA.
151
Views Regarding Helpfulness of Treatment
152
What I Wish Id Known Before Treatment

• That I wasnt so bad that I was beyond help /
  Recovery is possible
• I had a problem / Its okay to be honest
• Addiction is a disease I cant outsmart or
  control it
• How much better life is in recovery
• That the PHP existed
• How expensive / time-consuming it is

153
What I Wish Id Known Before Treatment

• I dont have to fix everything / How to ask for
  help / I cant do it alone
• To trust God / God loves me
• That recovery is a process and it takes time / It
  works if you work it
• Not to use alcohol or drugs in the first place /
  That self-medicating was dangerous
• 12-step philosophy
• That I wasnt alone / Im not unique / There are
  other professionals like me
• Everything I learned DURING treatment

154
Simplified View
155

• Thank you