Maureen Strohm, M.D.
Director, USC/California Hospital
Family Medicine Residency

 >1000 tobacco-related deaths/day
 about 100 deaths/d due to 2nd hand smoke
 >300 alcohol-related deaths/day
 Nearly 100 drug-related deaths/day
 LIFETIME PREVALENCE AODA 11-16%
 for men, as high as 23% over lifetime
 15-20% primary care patients with AODA

All levels carry risk
 Abstinence: PH or FH
 Non-problem Use: “social use”
 Problem Use: public health issue, gray issue
 Abuse: 50% may progress to dependence
 Dependence: abstinence is ONLY option

 Moderate Drinking
 Men <2 drinks/d, < 10 drinks/wk, 4 drink tolerance
 Women/ All over 65 <1 drink/d, < 7/wk, 3 drink tolerance
 “At risk” or “Hazardous” Drinking
 Men >4 drinks per occasion, >10 drinks/wk
 Women >3 drinks per occasion, >7 drinks/wk
 > 2 on CAGE Questions

A Maladaptive pattern of alcohol or substance use leading to
 Major Roles: Problems at work, school or home.
 Physical Hazards: Using while driving car.
 Legal Entanglements: Bankruptcy
 Social Difficulties: arguments with spouse, fights
 (Health Consequences): Pancreatis, Ulcers, Fractures
(DSM-IV, 1994)


….possible problems in 3-5 years

…non-compulsive use associated with negative consequences.

…compulsive use, loss of control and associated negative consequences.

 Prevention
 Screening and Assessment
 Brief Intervention
 heavy use or problem use
 Full Intervention
 if abuse or dependence identified

 ASK: Direct and/or indirect screening
 ASSESS: change
Point on continuum, Readiness for
 ADVISE: Educational feedback, CDC guidelines
 ASSIST: measures geared for preparation and action steps
 ARRANGE: follow-up, re-screen, referral

 DSM IV: Substance Abuse Disorders
 use-related problems at work, home, school
 use when physically hazardous
 use despite problems
 DSM IV: Substance Dependence Disorders
 tolerance or withdrawal
 use-related focus, unsuccessful at control
 continued use despite consequences
 better definition - adds addictive patterns of use


Compulsion to Use

Loss of Control

Neg. Consequences

 Routine History - Medication Review
 Direct Questions
 Quantity-frequency, short question(s)
 AUDIT
 Indirect Screening
 CAGE Questions
 T-ACE for women
 MAST

 Use Medication Review as entry point:
 What Rx drugs are you taking?
 What about OTC drugs?
 Tell me about your own drugs…
 caffeine, tobacco
 What about alcohol…marijuana...cocaine… IV drugs?
 Move on to the direct question(s)

Traditional” questions
 Simple quantity/frequency questions are very insensitive (34-47%):
 How much? How often? (think of our games of interpretation!)
 More sensitive (Cyr and Wartman, 1988):
 When was your last drink?
 Have you ever had problems due to alcohol use?

Single Question
 When was the last time you had more than “X” drinks in 1 day?
(Never, >12 mon, 3-12 mon, <3 mon)
 X = 5 drinks for men, X = 4 drinks for women
 Sensitivity = 88% men, 83% women, overall 86%
 Specificity = 81% men, 91% women, overall 86 %
 Williams & Vinson, 2001, ER patients with injuries

 More specific approach to quantity/frequency
 consumption per week, per occasion
 Medication History: Rx -> OTC -> “Personal drugs”
(caffeine, tobacco, alcohol, others)
 Simple tools/questionnaires
 Direct screening: Simple questions, AUDIT
 Focus on patterns and amount of use

 Identify patient/family risk for problems
 determine problems related to use
 Simple tools/questionnaires
 CAGE, T-ACE
 Gender differences in consequences
 Men have more legal consequences
 DUI, disorderly conduct, violence
 Women have more relational problems
 PH/FH of physical + sexual abuse

Indirect Screen/Assessment
 Have you ever felt the need to your drinking (or using)?
CUT DOWN on
 Has anyone ANNOYED drinking (or using)?
you by criticizing your
 Have you ever felt bad or drinking (or using)?
GUILTY about your
 Have you ever had a drink to settle your nerves or get rid of a hangover? (EYE-OPENER)
 91% sensitivity, 77% specificity

 Developed for use in pregnant women
 Substitutes Tolerance for Guilt for women
 > 2 drinks for a high indicates increasing tolerance

Point on Continuum / Risk Status
 At-Risk
 Exceed recommended guidelines.
 Problem Drinker/User …
 Review associated problems.
 Dependent
 Compulsion & Loss Control
 CAGE>=2

Level of Risk/Readiness for Change
 History MOST important
 Physical Examination
 Not good for early assessment!
 Blood pressure is one exception
 2-3 drinks/day may raise BP to HTN levels
 Labs - Most insensitive for screening
 “best” = BAC, GGT, MCV
 Other “Studies” Families live with problem drinkers for 7-8 yr before seeking help

Enter the 5As from a different angle
 During H/P, episodic visits, PE or labs for other reasons
 Frequent URIs, bronchitis, pneumonia
 Chronic pain syndromes: HA, neck pain, LBP
 Chronic “stress” syndromes: anxiety, depression, insomnia, GI complaints
 Injuries and accidents
 Explore the use of alcohol/drugs to treat symptoms

 Skin changes rosacea, rhinophima, bruises, spider angiomata
 HEENT conjunctival injection
 Lungs associated COPD changes
 Heart arrhythmias, tachycardia, cardiomegaly
 Abdomen liver enlargement, tenderness, ascites
 Extremities - vascular changes, nicotine stains

 Co-dependent families:
 Higher rate of health care utilization
 Similar cluster on nonspecific problems:
 headaches, back pain, GI complaints
 anxiety or depressive disorders
 Adolescents as “identified patient”
 Families live with problem drinkers for 7-8 years before seeking help

Readiness for Change
Precontemplation
Relapse Contemplation
Preparation
Maintenance
Action
(Prochaska, DiClemente, Psychother Theory Res Pract. , 1982)

Each stage requires a unique message

Precontemplation …Unaware of problem
Contemplation.
....Weighs Risks/Benefits

Preparation …....Makes Decision &Plans

Action ………...Practices New Behaviors

Maintenance ………..Sustaining Change

Relapse ………….………………...Oops!

 Non-judgemental approach critical
 Simple advice about consequences:
 CDC guidelines for moderate drinking
 Hazards of continued use (physical, interpersonal, legal)
 Potential for addiction (especially if +PH/FH, current crises)

 Brief Intervention
 patient at risk due to PH/FH, current use patterns
 Further assessment, education, motivational counseling, follow-up
 Full Intervention
 patient meeting criteria for dependence
 “problem-user” patient who fails brief intervention

 Ongoing assessment at follow-up
 Repeated screening at regular intervals
 at medical, psychosocial, family crises
 preventive health visits
 Referral for addiction consultation if questions remain

Targeting Substance Use
Interventions
At Risk
Problem Use
Sub. Dependence
“Cut Back”
Brief Intervention
Motivational
Interviewing
Formal CD Tx

 What is it? Time-limited strategy
 5 minutes -> 1 hour
 1 - 5 sessions
 Most studies used 10-15 minute session
 Brief advice, self-help booklets, weekly diaries of use
 Written contract with physician

 What is the aim?
 Prevention or elimination of problems
 Reducing/eliminating use
 Eliminating/reducing risk of harm

 Over 40 controlled trials
 Even control subjects reduced use 10-
30% at 1 year follow-up
 66%-74% reduction in quantity/frequency of use (men - women), with 5-15 min physician advice
 fewer binge episodes, reduction in total use
 improved liver function (reduced GGT levels)

 WHO:
10 countries, >1600 nondependent drinkers
 3 protocols + 10 item AUDIT questionnaire
 similar results for simple advice group as for extended counseling + 3 follow-up sessions
 British Study (1988): 909 heavy drinkers
 Project TrEAT (1997): 776 at-risk drinkers
 reduced consumption: 39% fewer drinks/wk (18% in controls)
 47% fewer binge episodes (21% in controls)
 fewer in-hospital days though same # ER visits

 SIMPLY ASKING reduces use and subsequent problems at follow-up (10-30%)
 Brief Intervention results in further reduction of use (30-50%), often to “safe” levels
 Failure of brief intervention suggests diagnosis of dependence

BEYOND BRIEF INTERVENTION
What’s next?
 Initiation of recovery
 Detox = PREPARATION FOR TREATMENT
 Formal Intensive CD Treatment Programs
 introduction to concepts and recovery
 day treatment, inpatient, medical vs social model
 Long Term Remission
 12 Step participation shows best chance for remission

 Screening:
 important throughout the life cycle
 Simply asking about use can reduce use
 a form of brief intervention by itself
 Single question: When was the last time you had more than X drinks in one day? (men=5, women=4)
 Simple tools for brief visit:
 AUDIT for detailed direct screening
 CAGE, T-ACE for further assessment

 Stage-based intervention can speed the process through the cycles of change
 Motivational counseling places the patient perspective and needs …and responsibility… at the center
 Failure of brief intervention suggests dependence - need for formal treatment
 Intervening with the family can enhance the health of family members …
 … and may break the cycle of co-dependence and lead to recovery for addicted member