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Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Treatment Improvement Protocol (TIP) Series, No. 24.)

Cover of A Guide to Substance Abuse Services for Primary Care Clinicians

A Guide to Substance Abuse Services for Primary Care Clinicians.

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Chapter 6—Implementation and Recommendation Summary

Though the health benefits are great, addressing substance use disorders takes time and requires primary care clinicians to incorporate new behaviors in their practice. While some will act on what they read in this TIP and other resources, studies show that clinicians are more likely to adopt behaviors learned through a combination of didactic and experiential training (Davis et al., 1995).

Achieving Change

Clinician Education

All clinicians and support staff in the practice setting should be trained, and training should be required for all new employees. The straight Continuing Medical Education (CME)-style lecture or conference should be avoided in favor of multifaceted interventions that incorporate handouts, practice-reinforcing strategies, role-playing, videos, outreach visits by peers and other professionals, and lectures by opinion leaders. Throughout the sessions, peer discussion, especially of attitudes toward alcohol and other drugs and personal and family experiences with substance abuse and dependence, should be encouraged. This training should be repeated every 2 to 3 years.

Valuable training curricula include Project ADEPT at Brown University (Dube and Lewis, 1994) and the Substance Abuse Education for Family Physicians project (Project SAEFP) (Fleming et al., 1994). A sample 6-hour training module is described in Figure 6-1.

System Supports and Feedback

The importance of built-in system supports and feedback in efforts to change clinicians' behavior has been strongly affirmed by two recent comprehensive literature reviews. The first review systematically examined effects of a variety of CME strategies to improve physicians' performance and health care outcomes (Davis et al., 1995). A total of 99 controlled CME trials containing 160 separate interventions were reviewed. The least effective change strategy was the formal CME conference or activity that did not include enabling strategies (role play of skills and system supports) and practice-reinforcing strategies (feedback). The most effective change strategies were

  • Clinician reminders
  • Patient-mediated interventions (e.g., patient educational materials and patient reminders)
  • Outreach visits to clinicians by peers and other professionals such as nurse facilitators, including "academic detailing" (i.e., visits by physician educators such as pharmacists)
  • Use of local opinion leaders or influential persons
  • Use of multifaceted interventions combining two or more of the effective strategies

The second literature review examined scientifically rigorous evaluations of 36 programs to improve practice performance in primary care settings (Yano et al., 1995). The reviewers found the following strategies to be the most successful in helping primary care clinicians achieve desired changes in performance:

  • Computer-generated reminders to clinicians to perform an indicated test
  • Audit of administrative and medical record data and personalized feedback to clinicians
  • Social-influence-based methods (e.g., advice, guidance, and feedback from peers)
  • Shifting workload for specific functions (e.g., telephone followup and coordination and assessment) from individual clinicians to multidisciplinary teams

Reminder Systems

Several studies have shown that an effective way to prompt clinician behavior is to incorporate reminders in or on the patient's chart (Davis et al., 1995; Yano et al., 1995). Such reminders alert the clinician that it is time to conduct specific preventive tests, such as mammograms, or to discuss patients' health concerns, such as smoking or drinking. Settings with computerized patient databases will be better able to institute reminder systems of the first type.

Computerized reminder systems are used in some large staff-model health maintenance organizations (HMOs) (Balas et al., 1996). Each time a patient visits his or her physician, the computer generates an individualized, updated health screen report that is placed on the front of the chart before the patient arrives. The report lists several health screen procedures, the frequency with which such tests should be performed based on medical research and decisions by the leadership of the HMO, and the last date on which the patient was screened in these areas. The frequency standard that has been applied to alcohol use history is to review it at every new patient's initial health assessment and during periodic health reviews thereafter. When such a review is due, the computer places an asterisk next to the "Alcohol Use" category on the health screen report.

Summary of Recommendations

The following guidelines are excerpted from the TIP. Supporting citations to the material below can be found in Chapters 2 through 5 and Appendix B.


The Consensus Panel that developed this TIP recommends that primary care clinicians—a term that includes all professionals with patient contact in primary care settings -- periodically and routinely screen all patients for substance use disorders. While opinions vary about whether to integrate substance abuse screening into a standard history, asking potentially sensitive questions about substance abuse in the context of other behavioral and lifestyle questions appears to be less threatening to patients. Since problematic use of alcohol, illicit drug use, and the consequences of those behaviors can vary over an individual's lifetime, the Panel recommends periodic rescreening for substance abuse.


Most people with substance abuse disorders drink alcohol. Therefore, to expedite screening and increase the likelihood of honest answers, clinicians should ask questions sequentially, beginning with the legal drug alcohol. If the patient says he or she is a life-long abstainer or has been in recovery for 5 years or more, the clinician can conclude the screening process for alcohol misuse.

To screen for alcohol problems among English-speaking, literate patients, clinicians should use a brief, self-administered, written questionnaire such as the AUDIT, reproduced in Appendix C. If the screen will be administered by a clinician, the CAGE (reproduced in Chapter 2), supplemented by the first three quantity/frequency questions from the AUDIT, is recommended. This combination will increase sensitivity for detection of both problem drinking and alcohol dependence because it includes questions about alcohol consumption and consequences. With the CAGE, two positive answers normally indicate that alcohol may be a problem. However, the Consensus Panel recommends that primary care clinicians lower the threshold to one positive answer to cast a wider net and identify more people who may have a substance use disorder.


Of the drug abuse screening instruments, CAGE-AID (CAGE Adapted to Include Drugs) is the only tool that has been tested with primary care patients. Like the CAGE, CAGE-AID, reproduced in Chapter 2, focuses on lifetime use. While those patients who are drug dependent may screen positive, adolescents and those who have not yet experienced negative consequences as a result of their drug use may not. For this reason, the Consensus Panel recommends asking patients, "Have you used street drugs more than five times in your life?" In Panelists' experience, a positive answer indicates that drugs may be a problem and suggests the need for further in-depth screening and possibly assessment.

The Panel also recommends that clinicians treating patient populations at high risk for drug abuse ask their screening questions regarding alcohol and drug use in combination. (This high-risk group includes those with psychiatric, behavioral, demographic, familial, social, or genetic risk factors that increase the likelihood of drug abuse.)

Special populations

Of the screening instruments that have been modified for pregnant women, the TWEAK has been found to be the most effective for this population for whom any use is relevant. Based on best clinical judgment, the Panel recommends the use of the TWEAK (reproduced in Chapter 2) for pregnant patients in the primary care setting.

The Consensus Panel recommends that all adults age 60 and older be screened for alcohol and prescription drug abuse as part of their regular physical examination by using either the CAGE, the AUDIT, or the MAST-G (reproduced in Appendix C). Because the physical changes that come with age change the effects of alcohol on an individual, it is particularly important with older adults to lower the cutoff score to 1 when using the CAGE. Since the MAST-G was developed specifically for older adults, it provides a sound screening option for clinicians willing to spend the time required to administer this 24-item test. Although the AUDIT has not been evaluated for use with older adults, it has been validated cross-culturally. Since there are few culturally sensitive screening instruments, the AUDIT may prove useful for identifying alcohol problems among older members of ethnic minority groups. If clinicians suspect that older patients are confused about their prescriptions, seeing more than one doctor, using more than one pharmacy, or seem reluctant to discuss their use, further assessment is warranted.

Health care professionals are not exempt from substance abuse problems and should be screened according to the same protocols applied to the larger primary care population.

Since many adolescents do not receive annual physicals or well-care examinations, screening should occur every time they seek medical services, including visits necessitated by acute illness, accidents, or other injuries. Physical or sexual abuse, parental incarceration, and other serious situational or behavioral factors may be red flags for a substance abuse problem.

Who should screen

Physicians, advanced practice nurses, and physician assistants who are familiar with available questionnaires and their interpretation, demonstrate interviewing skills, and are culturally competent can screen patients effectively for substance abuse. To overcome discomfort with screening questions and increase the likelihood of honest answers, clinicians should pose screening questions and accept patient responses matter-of-factly and without judgment.

Documenting screening

When recording screening results, the clinician should specifically indicate that a positive screen is not a diagnosis, which should not be given until and unless the positive screen is confirmed by further assessment and discussed with the patient. An unconfirmed substance use disorder diagnosis entered on a patient's record may cause health insurance problems. Patients should be apprised of their right to deny insurers access to their medical records, but warned that such a refusal also may result in insurance-related problems.

Responding to a positive screen

Clinicians should present results of positive screens in a nonjudgmental manner. In areas where specialized substance abuse resources are available, the Consensus Panel recommends that high-risk patients be referred to a substance abuse expert for assessment.

Brief Intervention

When screening or brief assessment indicates a problem with substance use, especially if such use is not life-threatening, a brief intervention is recommended. Brief intervention is a pretreatment tool or secondary prevention technique that involves office-based, clinician-patient contacts of 10 to 15 minutes for a limited number of sessions. The Consensus Panel recommends at least one followup visit to the initial brief intervention, but the number and frequency of sessions depend on the severity of the problems and the individual patient's response. Brief intervention is not a one-time event but rather a step that can be useful before or after an in-depth assessment and after specialized treatment as part of followup and relapse prevention.


The Consensus Panel recommends that primary care clinicians do the following as part of a brief intervention.

  1. Give feedback about screening results, impairment, and risks while clarifying the findings.
  2. Inform the patient about safe consumption limits and offer advice about change.
  3. Assess the patient's readiness to change.
  4. Negotiate goals and strategies for change.
  5. Arrange for followup treatment.

The sequence and specific emphasis placed on these five elements will vary for individual patients.

Appropriate candidates

The Consensus Panel recommends that the following types of patients receive brief intervention: patients with positive but low scores on any screening tests (e.g., one positive response to the CAGE or CAGE-AID or a score of less than 8 on the AUDIT, see Chapter 2) and patients with at-risk drinking (e.g., above established cutoff limits), occasional use of marijuana (e.g., five or more episodes in a lifetime), or questionable use of mood-altering prescription medications.

The Consensus Panel believes that patients with these less severe problems are the most likely candidates for a successful brief intervention. The technique, however, can serve a different purpose for another set of patients: those with several positive responses to screening questionnaires and suspiciously heavy drinking or problematic drug use histories, symptoms of substance dependence, chronic or escalating use of addictive prescription medications, current use of illicit drugs, or complicating medical illnesses and psychiatric disorders. These patients need further in-depth assessment to confirm a substance use disorder, but they may initially resist a referral. They may, however, be willing to participate in a brief intervention. Even though they are unlikely to be successful in cutting down their use or maintaining recovery for any length of time through informal self-help mechanisms, a brief intervention may help motivate them to accept the needed referral or come to terms with the diagnosis.

Moving from the brief intervention

One of the most important concepts of substance use treatment is that one treatment failure is no reason to give up. Clinicians should be prepared for the brief intervention to fail: The patient may not be able to achieve or maintain the mutually established goal of reducing or stopping use.

Lack of success in following the advice given and the strategies undertaken in a brief intervention can be a learning and motivating experience, evidence to a patient that substance use may be more of a problem than previously thought. The clinician can steer a patient toward such a revelation by saying something like, "You weren't able to cut down your alcohol use as you contracted to do. Does this make you think this is a bigger problem for you than you thought?" Failure to achieve the goals of an initial brief intervention may move the patient along the continuum of change.

It is important to remain flexible vis-_-vis goals when performing brief interventions. If problem use persists, those discussions between clinician and patient should serve as a springboard to a more in-depth assessment or referral to specialized treatment.


Many primary care clinicians will refer patients suspected of having a substance abuse problem to specialists for both in-depth assessment and treatment, although clinicians in underserved areas or with expertise in substance abuse may assume partial or total responsibility for this function. However, even clinicians who will not perform substance abuse assessments should have a basic understanding of their elements and objectives so that they can

  • Initiate appropriate referrals
  • Participate effectively as a member of the treatment team, if required
  • Better fulfill the gatekeepers' monitoring responsibility with respect to patient progress
  • Carry out needed case management functions as appropriate

Information gained through an in-depth assessment will clarify the type and extent of the problem and will help determine the appropriate treatment response. At a minimum, patients must be assessed for

  1. Acute intoxication and/or withdrawal potential
  2. Biomedical conditions and complications
  3. Emotional/behavioral conditions (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications)
  4. Treatment acceptance or resistance
  5. Relapse potential or continued use potential
  6. Recovery/living environment

Who should assess

Where possible, the Consensus Panel recommends referring patients to an experienced substance abuse specialist for in-depth assessment. If referral is not possible, the Panel believes that empathic primary care clinicians including physicians, physician assistants, and advanced practice nurses (nurse practitioners and clinical nurse specialists) with proven interviewing skills may perform intensive assessments after receiving training in

  • The signs and symptoms of substance abuse
  • The biopsychosocial effects of drugs and alcohol and likely progression of the disease
  • Common comorbid conditions and medical consequences of abuse
  • The terms used in the American Psychiatric Association's Diagnostics and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification system, their interpretation, and relationship to the findings that emerged during the assessment history
  • The appropriate use, scoring, and interpretation of standardized assessment instruments

Primary care clinicians should refer patients to assessors who understand and are trained in mental health as well as substance abuse assessment and who are willing and able to expand the assessment process as needed to identify any coexisting psychiatric disorders that may be contributing to a patient's problems

Setting and components

Like screening, assessments must be conducted in private, and patients must be assured that the information they provide is confidential. Patients often will not reveal information about drug or alcohol use because they fear that information will be shared with their family members or employers or be used against them by health insurance organizations or law enforcement agencies. Prior to conducting an assessment, assessors should review current legal protections with the patient and discuss the limitations that apply to sharing information.

The Consensus Panel recommends sequential and multidimensional assessments for alcohol- and other drug-related problems. Sequential assessment entails separating assessment into stages ordered to naturally lead to the next. In this model, a broad-based assessment is conducted first. If the information compiled suggests that other problems may be present, such as a psychiatric disorder, then a series of progressively more intense procedures would be initiated to confirm and characterize that finding. A multidimensional approach to assessment includes consideration of all the factors that impinge on an individual's substance abuse (level, pattern, and history of use; signs and symptoms of use; and consequences of use) when evaluating individual patient problems and recommending treatment.

Based on their clinical experience, the Consensus Panel recommends that an in-depth assessment include a medical and psychological history along with family, social, and sexual histories, a mental status examination, and a physical examination. Specific elements and suggested wording for sensitive questions appear in Chapter 4.

Supplementing assessment results

Collateral reporting (information supplied by family and friends) can help a clinician or assessor validate substance use because patients do not always reply honestly to assessment questions, especially questions concerning illicit drug use. Before contacting family members and significant others, however, the assessor must obtain the patient's consent.

In emergency situations or hospital-based settings, especially when responding to trauma victims, blood alcohol concentrations (BACs) contribute information important to clinicians in devising effective treatment plans. However, the Consensus Panel does not recommend their routine use in the office-based primary care setting. Based on their clinical experience, members of the Consensus Panel do recommend checking the enzyme gamma-glutamyl transferase (GGT) results as part of the assessment process. If it is elevated, lowering it can serve as a measurable goal of treatment. Much like supplemental laboratory tests for alcohol, urine drug tests may be used during assessment to encourage honest responses to questions, to confirm suspicions about use when it is denied, and to verify use of heroin prior to referral or admission to a methadone program. During treatment, urine tests help to monitor progress and, in methadone programs, help ensure that patients are taking their methadone. Although not required, a positive urine screen—together with findings from a patient's history, mental assessment, and physical examination -- provides strong support for a diagnosis of substance use disorder.

Making the diagnosis

Drug-specific diagnosis (including alcohol) are made using the criteria in the American Psychiatric Association's DSM-IV. However, assessment results also guide both the choice and content of needed treatment. For this reason, the Panel recommends that clinicians follow the guidelines presented in the second edition of the American Society of Addiction Medicine's Patient Placement Criteria when devising assessment-based treatment plans (see Chapter 4).


To refer patients for appropriate care, primary care clinicians need information about available substance abuse treatment resources, including the type of services offered and the treatment philosophy espoused. The clinician's responsibility to the patient does not end with the patient's entry into formal treatment. The clinician frequently continues to treat the patient's medical conditions, encourages the patient's continuing participation in the program, and schedules followup visits after treatment termination to monitor progress and help prevent relapse.

Goals of treatment

While each individual in treatment will have specific long- and short-term goals, all specialized substance abuse treatment programs have three similar generalized goals:

  • Reducing substance abuse or achieving a substance-free life
  • Maximizing multiple aspects of life functioning
  • Preventing or reducing the frequency and severity of relapse

Other goals of treatment include maximizing physical health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship issues, resolving financial and legal problems, and improving or developing necessary educational and vocational skills. Programs also prepare patients to understand and guard against relapse by teaching about "triggers" for use, how to recognize cues, how to handle craving, alternative responses to stressful situations, and what to do if there is a "slip."

The continuum of care

The four treatment settings, ranging from most intensive to least, are inpatient hospitalization, residential treatment, intensive outpatient treatment, and outpatient treatment. Although patients should be placed initially in the least restrictive environment that is still safe and effective, relapse or failure to progress in one setting may require transfer to a more restrictive environment or a different mix of services.

Good treatment management requires continuity of care and the flexibility to adjust components, approaches, techniques, and settings. Important aspects of appropriate care include

  • Repeating assessments to evaluate a patient's changing medical, psychological, social, vocational, educational, and recreational needs, especially as more basic and acute deficits or crises are resolved and new problems emerge or become amenable to treatment.
  • Developing a comprehensive treatment plan that clearly reflects all identified problems, has explicit goals and strategies for their attainment, and specifies techniques and services to be provided by designated specialists at particular frequencies or intensities.
  • Monitoring progress and clinical status through written notes or reports that describe responses to treatment approaches and outcomes of services provided. Records should include counseling sessions, group meetings, urine or other biological testing, physical examinations, administered medications, and referrals for other care. Each patient should have an individual treatment record that includes all appropriate materials.
  • Establishing a therapeutic alliance with an empathic primary therapist or counselor who can gain the confidence and trust of the patient, significant others, and family members and take responsibility for continuity of care. This is particularly important in the early stages of treatment to prevent dropout and encourage participation.
  • Providing education to help the patient and designated others understand the diagnosis, the etiology and prognosis for the disorder, and the benefits and risks of anticipated treatment(s). Patients with special problems will need more extensive information. As with other medical treatments, informed consent to potentially risky procedures should always be obtained.


The Consensus Panel recommends that primary care clinicians receive training in substance abuse screening and assessment during medical and nursing school. This will require increased attention to content and to skill acquisition included in medical and nursing programs.

In addition, the Panel recommends that clinicians and clinic staff

  • Master screening, assessment, brief intervention, and referral techniques
  • Develop an understanding of the pharmacotherapies used in treating substance use disorders
  • Become familiar with and sensitive to standards of care for persons with substance use disorders
  • Establish recordkeeping systems and reminder programs to cue clinicians about the need to screen and rescreen patients for alcohol and drug abuse


Screening, assessing, and treating substance use disorders present primary care clinicians with legal and ethical questions about privacy and confidentiality. No screening or laboratory tests (such as blood or urine tests) should be performed without the patient's consent.

Most primary care clinicians are not subject to 42 C.F.R. Part 2, the Federal rules covering patient confidentiality. Practitioners should be aware, however, that if a health care practice includes someone whose primary function is to provide substance abuse assessment or treatment and if the practice benefits from "Federal assistance," that practice must comply with the Federal law and regulations and implement special rules for handling information about patients who may have substance abuse problems.

Depending on their professional training (and licensing), primary care physicians, physician assistants, advanced practice nurses, nurses, and others may be covered by State prohibitions on divulging information about patients. Note that even within a single State, the kind of protection afforded medical information may vary from profession to profession. Clinicians should learn whether any confidentiality law in the State in which they practice applies to their profession.

The clinician should consult the patient before discussing his or her substance use with anyone else—family, employers, treatment programs, or the legal system.

Prevention and Gatekeeping

The changes in the health care system brought about by managed care reaffirm the critical importance of the primary care prevention mission. Substance use disorders, as preventable as they are ruinous to patients' health, must be acknowledged as part of that mission. The information in this TIP can help clinicians forestall incipient problems from progressing to full-blown disorders and help them intervene in later stages of the disease. While following these guidelines will not "cure" substance abuse, it will improve the nation's health.


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