Post on 16-Dec-2015
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/dayNearly 100 drug-related deaths/dayLIFETIME PREVALENCE AODA 11-16%
for men, as high as 23% over lifetime15-20% primary care patients with
AODA
Substance Use Continuum:All levels carry risk
Substance Use Continuum:All levels carry risk
Abstinence: PH or FHNon-problem Use: “social use”Problem Use: public health issue, gray
issue Abuse: 50% may progress to dependenceDependence: 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
PreventionScreening and AssessmentBrief Intervention
heavy use or problem useFull Intervention
if abuse or dependence identified
Goals with Each PatientGoals with Each Patient
ASK: Direct and/or indirect screeningASSESS: Point on continuum, Readiness
for changeADVISE: Educational feedback, CDC
guidelinesASSIST: measures geared for preparation
and action stepsARRANGE: follow-up, re-screen, referral
BEYOND Brief Intervention:Formal TreatmentBEYOND 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 AssessmentASK!!Screening and Assessment
Routine History - Medication ReviewDirect 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 ScreeningASK! 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 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 importantPhysical 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 injectionLungs - associated COPD changesHeart - arrhythmias, tachycardia,
cardiomegalyAbdomen - liver enlargement, tenderness,
ascitesExtremities - vascular changes, nicotine stains
ASSESS! FAMILY as “Screening Tool”
Co-dependent families:Higher rate of health care utilizationSimilar 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!ADVISE!
Non-judgemental approach criticalSimple 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 problemsARRANGE! Monitor use and problems
Ongoing assessment at follow-upRepeated 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 InterventionMoving 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 trialsEven control subjects reduced use 10-30%
at 1 year follow-up66%-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 INTERVENTIONWhat’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!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!!