1. Substance Use Disorders From Screening to Brief Intervention Maureen Strohm, M.D. Director, USC/California Hospital Family Medicine Residency

2. So what’s the problem? z>1000 tobacco-related deaths/day yabout 100 deaths/d due to 2nd hand smoke z>300 alcohol-related deaths/day zNearly 100 drug-related deaths/day zLIFETIME PREVALENCE AODA 11-16% yfor men, as high as 23% over lifetime z15-20% primary care patients with AODA

3. Substance Use Continuum: All levels carry risk zAbstinence: PH or FH zNon-problem Use: “social use” zProblem Use: public health issue, gray issue zAbuse: 50% may progress to dependence zDependence: abstinence is ONLY option

4. CDC/PHS Guidelines zModerate Drinking yMen <2 drinks/d, < 10 drinks/wk, 4 drink tolerance yWomen/ All over 65 <1 drink/d, < 7/wk, 3 drink tolerance z“At risk” or “Hazardous” Drinking yMen >4 drinks per occasion, >10 drinks/wk yWomen >3 drinks per occasion, >7 drinks/wk y> 2 on CAGE Questions

5. “Problem Drinking/Using” or Abuse is... A Maladaptive pattern of alcohol or substance use leading to xMajor Roles: Problems at work, school or home. xPhysical Hazards: Using while driving car. xLegal Entanglements: Bankruptcy xSocial Difficulties: arguments with spouse, fights x(Health Consequences): Pancreatis, Ulcers, Fractures (DSM-IV, 1994)

6. Spectrum of Substance Use Disorders in Primary Care zAt-Risk ….possible problems in 3-5 years z Problem Use …non-compulsive use associated with negative consequences. z Dependence …compulsive use, loss of control and associated negative consequences.

7. Goals with Each Patient zPrevention zScreening and Assessment zBrief Intervention yheavy use or problem use zFull Intervention yif abuse or dependence identified

8. Goals with Each Patient zASK: Direct and/or indirect screening zASSESS: Point on continuum, Readiness for change zADVISE: Educational feedback, CDC guidelines zASSIST: measures geared for preparation and action steps zARRANGE: follow-up, re-screen, referral

9. BEYOND Brief Intervention: Formal Treatment zDSM IV: Substance Abuse Disorders yuse-related problems at work, home, school yuse when physically hazardous yuse despite problems zDSM IV: Substance Dependence Disorders ytolerance or withdrawal yuse-related focus, unsuccessful at control ycontinued use despite consequences ybetter definition - adds addictive patterns of use

10. Dependence: Better Definition Three C’s... z Compulsion to Use z Loss of Control z Neg. Consequences

11. ASK!! Screening and Assessment zRoutine History - Medication Review zDirect Questions yQuantity-frequency, short question(s) yAUDIT zIndirect Screening yCAGE Questions yT-ACE for women yMAST

12. ASK!! Routine History zUse Medication Review as entry point: zWhat Rx drugs are you taking? zWhat about OTC drugs? zTell me about your own drugs… ycaffeine, tobacco yWhat about alcohol…marijuana...cocaine… IV drugs? zMove on to the direct question(s)

13. ASK!! “ Traditional” questions zSimple quantity/frequency questions are very insensitive (34-47%): yHow much? How often? (think of our games of interpretation!) zMore sensitive (Cyr and Wartman, 1988): yWhen was your last drink? yHave you ever had problems due to alcohol use?

14. Even Better! Single Question zWhen was the last time you had more than “X” drinks in 1 day? (Never, >12 mon, 3-12 mon, <3 mon) zX = 5 drinks for men, X = 4 drinks for women zSensitivity = 88% men, 83% women, overall 86% zSpecificity = 81% men, 91% women, overall 86% zWilliams & Vinson, 2001, ER patients with injuries

15. ASK! Direct Screening zMore specific approach to quantity/frequency yconsumption per week, per occasion yMedication History: Rx -> OTC -> “Personal drugs” (caffeine, tobacco, alcohol, others) zSimple tools/questionnaires yDirect screening: Simple questions, AUDIT yFocus on patterns and amount of use

16. ASK! Indirect Screening zIdentify patient/family risk for problems ydetermine problems related to use zSimple tools/questionnaires yCAGE, T-ACE zGender differences in consequences yMen have more legal consequences xDUI, disorderly conduct, violence yWomen have more relational problems xPH/FH of physical + sexual abuse

17. CAGE Questions: Indirect Screen/Assessment zHave you ever felt the need to CUT DOWN on your drinking (or using)? zHas anyone ANNOYED you by criticizing your drinking (or using)? zHave you ever felt bad or GUILTY about your drinking (or using)? zHave you ever had a drink to settle your nerves or get rid of a hangover? (EYE-OPENER) z91% sensitivity, 77% specificity

18. T-ACE zDeveloped for use in pregnant women zSubstitutes Tolerance for Guilt for women y> 2 drinks for a high indicates increasing tolerance

19. ASSESS! Point on Continuum/Risk Status zAt-Risk yExceed recommended guidelines. zProblem Drinker/User… yReview associated problems. zDependent yCompulsion & Loss Control yCAGE>=2

20. ASSESS! Level of Risk/Readiness for Change zHistory - MOST important zPhysical Examination yNot good for early assessment! yBlood pressure is one exception y2-3 drinks/day may raise BP to HTN levels zLabs - Most insensitive for screening y“best” = BAC, GGT, MCV zOther “Studies” - Families live with problem drinkers for 7-8 yr before seeking help

21. Raising the Red Flags: Enter the 5As from a different angle zDuring H/P, episodic visits, PE or labs for other reasons yFrequent URIs, bronchitis, pneumonia yChronic pain syndromes: HA, neck pain, LBP yChronic “stress” syndromes: anxiety, depression, insomnia, GI complaints yInjuries and accidents zExplore the use of alcohol/drugs to treat symptoms

22. ASSESS! Physical exam zSkin changes - rosacea, rhinophima, bruises, spider angiomata zHEENT - conjunctival injection zLungs - associated COPD changes zHeart - arrhythmias, tachycardia, cardiomegaly zAbdomen - liver enlargement, tenderness, ascites zExtremities - vascular changes, nicotine stains

23. ASSESS! FAMILY as “Screening Tool” zCo-dependent families: zHigher rate of health care utilization zSimilar cluster on nonspecific problems: yheadaches, back pain, GI complaints yanxiety or depressive disorders zAdolescents as “identified patient” zFamilies live with problem drinkers for 7- 8 years before seeking help

24. ASSESS! Readiness for Change Precontemplation Relapse Contemplation Preparation Maintenance Action (Prochaska, DiClemente, Psychother Theory Res Pract., 1982)

25. Readiness for Change Each stage requires a unique message Precontemplation…Unaware of problem z Contemplation.....Weighs Risks/Benefits z Preparation…....Makes Decision &Plans z Action………...Practices New Behaviors z Maintenance………..Sustaining Change z Relapse………….………………...Oops!

26. ADVISE! zNon-judgemental approach critical zSimple advice about consequences: yCDC guidelines for moderate drinking yHazards of continued use (physical, interpersonal, legal) yPotential for addiction (especially if +PH/FH, current crises)

27. ASSIST! Steps to Intervene zBrief Intervention ypatient at risk due to PH/FH, current use patterns yFurther assessment, education, motivational counseling, follow-up zFull Intervention ypatient meeting criteria for dependence y“problem-user” patient who fails brief intervention

28. ARRANGE! Monitor use and problems zOngoing assessment at follow-up zRepeated screening at regular intervals yat medical, psychosocial, family crises ypreventive health visits zReferral for addiction consultation if questions remain

29. Targeting Substance Use Interventions At Risk“Cut Back” Problem UseBrief Intervention Motivational Interviewing Sub. DependenceFormal CD Tx

30. Moving to Brief Intervention zWhat is it? Time-limited strategy y5 minutes -> 1 hour y1 - 5 sessions xMost studies used 10-15 minute session yBrief advice, self-help booklets, weekly diaries of use yWritten contract with physician

31. BRIEF INTERVENTION zWhat is the aim? yPrevention or elimination of problems yReducing/eliminating use yEliminating/reducing risk of harm

32. BRIEF INTERVENTION: Effectiveness zOver 40 controlled trials zEven control subjects reduced use 10- 30% at 1 year follow-up z66%-74% reduction in quantity/frequency of use (men - women), with 5-15 min physician advice yfewer binge episodes, reduction in total use yimproved liver function (reduced GGT levels)

33. BRIEF INTERVENTION: Key studies zWHO: 10 countries, >1600 nondependent drinkers y3 protocols + 10 item AUDIT questionnaire ysimilar results for simple advice group as for extended counseling + 3 follow-up sessions zBritish Study (1988): 909 heavy drinkers zProject TrEAT (1997): 776 at-risk drinkers yreduced consumption: 39% fewer drinks/wk (18% in controls) y47% fewer binge episodes (21% in controls) yfewer in-hospital days though same # ER visits

34. Summary of Studies zSIMPLY ASKING reduces use and subsequent problems at follow-up (10-30%) zBrief Intervention results in further reduction of use (30-50%), often to “safe” levels zFailure of brief intervention suggests diagnosis of dependence

35. BEYOND BRIEF INTERVENTION What’s next? zInitiation of recovery yDetox = PREPARATION FOR TREATMENT zFormal Intensive CD Treatment Programs yintroduction to concepts and recovery yday treatment, inpatient, medical vs social model zLong Term Remission y12 Step participation shows best chance for remission

36. Remember! zScreening: yimportant throughout the life cycle ySimply asking about use can reduce use ya form of brief intervention by itself ySingle question: When was the last time you had more than X drinks in one day? (men=5, women=4) zSimple tools for brief visit: yAUDIT for detailed direct screening yCAGE, T-ACE for further assessment

37. Remember! zStage-based intervention can speed the process through the cycles of change zMotivational counseling places the patient perspective and needs …and responsibility… at the center zFailure of brief intervention suggests dependence - need for formal treatment zIntervening with the family can enhance the health of family members … z… and may break the cycle of co-dependence and lead to recovery for addicted member

38. JUST ASK!!