substance use disorders from screening to brief intervention maureen strohm, m.d. director,...

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!!