SBIRT Module 2:
Screening for Substance Use
Problems in Primary Care
UCSF SBIRT Collaborative Education
Project
Janice Tsoh, PhD
Outline
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Basic screening for alcohol and drugs
DSM-IV assessment for substance use
disorders
Relevance to clinical practice at DGIM
SBIRT
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Screening: quickly assess use and severity of
alcohol, illicit drugs, and prescription drug
abuse.
Brief Intervention: a 3-5 minute motivational
and awareness-raising intervention given to
risky or problematic substance users.
Referral to Treatment: referrals to specialty
care for pts with substance use disorders.
Substance Use Continuum

In Module 1, you learned about the continuum of
substance use ranging from:
 abstinence
 moderate
 “at
use
risk” use
 Abuse
 Dependence

“Substance Use Disorders”
(SUD)
Your initial job as a primary care provider is to assess
use, classify appropriately, and screen for possible comorbidities.
Screening Strategy
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Use of most efficient yet
psychometrically sound screening
questions.
 The NIAAA Single Screener
 The Single Question Drug Screener
If you get a positive screen, you’ll have
to ask further assessment questions.
Screening for alcohol use

Start with “Prescreen”
 Do
you sometimes drink beer, wine, or other
alcoholic beverages?
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If no, alcohol screening is complete
If yes, proceed to NIAAA Single Screener
 How
many times in the past year have you had
5 (men) or 4 (women or pts over 65yo) drinks
or more in a day?
What’s 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).
NIAAA Alcohol Screener
“How many times in the past year have you
had X or more drinks in a day?”
X = 5 (for men); 4 (for women or pts >65 y.o.)
“NONE”
Not an “at risk” binge
drinker but may exceed
recommended limits.
Continue to assess

1 or more times
At-risk binge
drinker, inquire
further
Sensitivity/ specificity: 82%/ 79%
Source: Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation
of a single-question alcohol screening test. J Gen Intern Med 2009;24(7):783-8.
Alcohol Screen (cont’d)
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Determine the average drinks per day and
average drinks per week, ask:
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On average, how many days a week do you have an
alcoholic drink?
On a typical drinking day, how many drinks do you
have? (Daily average)
Weekly average = days X drinks
Recommended Limits
Men: 2 per day/ 14 per week
Women / any 65+: 1 per day or 7 drinks per week
> regular limits = At Risk Drinker
A Positive Alcohol Screen
= At Risk Drinker
•Binge drink?
(5 for men or 5 for women /any 65+)
•Exceeds regular limits?
(Men: 2/per or 14/week
Women/any 65+: 1/day or 7/week)
NO
Pt is not at risk.
Move to drug screen
YES
Pt is at risk. Assess for
alcohol use disorders
• maladaptive pattern of use
• clinically significant impairment
SUD: DSM-IV Criteria for
Substance Abuse
Maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by 1 or more
of the following in the past 12 mo

Failure to fulfill obligations at work, school or home
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Recurrent substance use in situations where it would be
hazardous

Recurrent substance related legal problems

Continued use despite persistent or recurrent social or
interpersonal problems caused or exacerbated by effects of
the substance
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),
American Psychiatric Association, 2000.
SUD: DSM-IV Criteria for
Substance Dependence
Maladaptive pattern of substance use leading to clinically significant impairment or
distress, as manifested by 3 or more of the following in the past 12 mo
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Taking the substance often in larger amounts or over a longer period than was
intended.
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A persistent desire or unsuccessful efforts to cut down or control substance use.
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Tolerance, as defined by:
 Need for markedly increased amounts of substance to achieve intoxication or
desired effect
 Markedly diminished effect with continued use of the same amount of
substance
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Withdrawal, as manifested by:
 Characteristic withdrawal syndrome for the substance
 The same substance is taken to relieve/avoid withdrawal symptoms
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Continuing the substance use with the knowledge that it is causing or
exacerbating a persistent or recurrent physical or psychological problem.
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Spending a great deal of time in activities necessary to obtain or use the
substance or to recover from its effects
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Giving up social, occupational, or recreational activities because of substance
abuse.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),
American Psychiatric Association, 2000.
Screening for Drugs
“How many times in the past year have you
used an illegal drug or used a prescription
medication for non-medical reasons?”
(…for instance because of the feeling it caused or
experiences you have…)
“NONE”
Screening is
complete

any number or
suspicious clues
Inquire further
Sensitivity/ specificity: 100%/ 74%
Source: Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question
screening test for drug use in primary care. Arch Intern Med 2010; 170(13):1155-60.
A Positive Drug Screen
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Ask which drugs the patient has been using,
such as:
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Cocaine, meth, heroin, ecstasy, pot, vicodin,
valium, etc.
Determine frequency and quantity.
Ask about negative impacts.
Note: Any positive on the drug screen question
puts the pt in an “at risk” category. The
follow-up questions are to assess impact and
whether or not use is serious enough to
warrant a substance use disorder diagnosis.
Relevance to DGIM
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Every DGIM patient will be screened at once
per year for alcohol, tobacco, illicit drugs and
Rx abuse.
In Fall 2010, you will see screening forms
attached to the front of each patient chart.
Patient fill out screening questions on the top
of the form.
If you see positive answers, you should
continue the assessment – i.e. determine if the
pt is at risk, abusing, or dependent for each
substance.
Take Home Points for
Screening
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Screen every patient
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Screen both alcohol and drug use including Rx
abuse and tobacco
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Explore each substance; many patients use
more than one
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Follow up positives or "red flags" by assessing
details and consequences of use
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Show nonjudgmental, empathic verbal and
non-verbal behaviors during screening