Substance Use Disorders From Screening to Brief Intervention Maureen Strohm, M.D. Director, USC/California Hospital Family Medicine Residency So what’s the problem? >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 Substance Use Continuum: 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 CDC/PHS Guidelines 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 “Problem Drinking/Using” or Abuse is... 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) Spectrum of Substance Use Disorders in Primary Care At-Risk….possible problems in 3-5 years Problem Use…non-compulsive use associated with negative consequences. Dependence…compulsive use, loss of control and associated negative consequences. Goals with Each Patient Prevention Screening and Assessment Brief Intervention heavy use or problem use Full Intervention if abuse or dependence identified Goals with Each Patient ASK: Direct and/or indirect screening ASSESS: Point on continuum, Readiness for change ADVISE: Educational feedback, CDC guidelines ASSIST: measures geared for preparation and action steps ARRANGE: follow-up, re-screen, referral BEYOND Brief Intervention: Formal Treatment 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 Dependence: Better Definition Three C’s... Compulsion to Use Loss of Control Neg. Consequences ASK!! Screening and Assessment Routine History - Medication Review Direct Questions Quantity-frequency, short question(s) AUDIT Indirect Screening CAGE Questions T-ACE for women MAST ASK!! Routine History 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) ASK!! “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? Even Better! 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 ASK! Direct Screening 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 ASK! Indirect Screening 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 CAGE Questions: Indirect Screen/Assessment Have you ever felt the need to CUT DOWN on your drinking (or using)? Has anyone ANNOYED you by criticizing your drinking (or using)? Have you ever felt bad or GUILTY about your drinking (or using)? Have you ever had a drink to settle your nerves or get rid of a hangover? (EYE-OPENER) 91% sensitivity, 77% specificity T-ACE Developed for use in pregnant women Substitutes Tolerance for Guilt for women > 2 drinks for a high indicates increasing tolerance ASSESS! Point on Continuum/Risk Status At-Risk Exceed recommended guidelines. Problem Drinker/User… Review associated problems. Dependent Compulsion & Loss Control CAGE>=2 ASSESS! 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 Raising the Red Flags: 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 ASSESS! Physical exam 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 ASSESS! FAMILY as “Screening Tool” 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 ASSESS! Readiness for Change Precontemplation Relapse Contemplation Preparation Maintenance Action (Prochaska, DiClemente, Psychother Theory Res Pract. , 1982) Readiness for Change 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! ADVISE! 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) ASSIST! Steps to Intervene 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 ARRANGE! Monitor use and problems 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 “Cut Back” Problem Use Brief Intervention Motivational Interviewing Sub. Dependence Formal CD Tx Moving to Brief Intervention 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 BRIEF INTERVENTION What is the aim? Prevention or elimination of problems Reducing/eliminating use Eliminating/reducing risk of harm BRIEF INTERVENTION: Effectiveness 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) BRIEF INTERVENTION: Key studies 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 Summary of Studies 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 Remember! 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 Remember! 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 JUST ASK!!