Screening and Brief Intervention - California Society of Addiction

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
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
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
Goals with Each Patient
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
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
Better Definition
Three C’s...
Compulsion to Use
 Loss of Control
 Neg. Consequences
Screening and Assessment
Routine History - Medication Review
Direct Questions
Quantity-frequency, short question(s)
Indirect Screening
CAGE Questions
T-ACE for women
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
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
Developed for use in pregnant
Substitutes Tolerance for Guilt for
> 2 drinks for a high indicates
increasing tolerance
Point on Continuum/Risk Status
Exceed recommended guidelines.
Problem Drinker/User…
Review associated problems.
Compulsion & Loss Control
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
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
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,
Extremities - vascular changes, nicotine stains
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
Readiness for Change
(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!
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
Further assessment, education, motivational
counseling, follow-up
Full Intervention
patient meeting criteria for dependence
“problem-user” patient who fails brief
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
At Risk
“Cut Back”
Problem Use
Brief Intervention
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
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)
Key studies
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
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
What’s next?
Initiation of recovery
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
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
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