Screening

1.

Periodically and routinely screen all patients for substance use disorders

2.

Ask questions about substance abuse in the context of other lifestyle questions

3.

Use the Alcohol Use Disorder Identification Test (AUDIT) to screen for alcohol problems among English-speaking, literate patients, or use the first three quantity/frequency questions from AUDIT, supplemented by the CAGE questionnaire

4.

Use the CAGE-AID (CAGE Adapted to Include Drugs) to screen for drugs use among patients

5.

Ask “Have you used street drugs more than five times in your life?” A positive answer suggests further screening and possibly assessment are needed

6.

Ask high-risk patients about alcohol and drug use in combination

7.

Ask pregnant women “Do you use street drugs?” If the answer is yes, advise abstinence

8.

Use the CAGE, the AUDIT, or the Michigan Alcoholism Screening Test-Geriatric Version (MAST-G) to screen patients over 60

9.

Screen adolescents for substance abuse every time they seek medical services

Brief Intervention

1.

Perform a brief intervention with patients whose substance abuse problems are less severe

2.

Include in the brief intervention feedback about screening results and risk of use, information about safe consumption limits and advice about change, assessment of patient's readiness to change, negotiated goals and strategies for change, and arrangements for followup visits

Assessment and Treatment

1.

Refer high-risk patients to a specialist, if possible, for in-depth assessment

Physical Signs: General

• Dental caries
• Swollen hands or feet
• Swollen parotid glands
• Leukoplakia in mouth
• Gingivitis
• Perforated septum
• Needle track marks
• Skin abscesses, burns on inside of lips
• Disrupted menstrual cycle

Physical Signs: Neurological

• Dilated or constricted pupils
• Slurred, incoherent, or too rapid speech
• Inability to focus (both visually and mentally)
• Unsteady gait
• “Nodding off”
• Blackouts or other periods of memory loss
• Insomnia or other sleep disturbances
• Withdrawal symptoms
• Agitation

Psychiatric

• Depression
• Anxiety
• Low self-esteem
• Low tolerance for stress
• Other mental health disorders
• Feelings of desperation
• Feelings of loss of control over one's life
• Feelings of resentment

Behavioral

• Use of other substances
• Aggressive behavior in childhood
• Conduct disorders; antisocial personality
• Impulsiveness and risk taking
• Alienation and rebelliousness
• School-based academic or behavioral problems
• Involvement with criminal justice system
• Poor interpersonal relationships

Social and Sexual History

• Legal status (minor, in custody)
• Alcohol or drug use by friends
• Level of education
• Occupation/work history
• Sexual preference
• Number of sexual relationships
• Types of sexual activity engaged in
• Whether the patient practices safe sex

Family

• Use of drugs and alcohol by parents, siblings
• Inherited predisposition to alcohol or drug dependence
• Family dysfunction
• Family trauma
• Marital/cohabitation status
• Domestic violence and other abuse history

Demographic

• Male gender
• Inner city or rural residence combined with low-socioeconomic status
• Lack of employment opportunities

Low-Risk and At-Risk

Low-risk drinkers consume less than an average of one to two drinks per day, do not drink more than three or four drinks per occasion, and do not drink in high-risk situations (while pregnant, driving a car, etc.).

At-risk drinkers occasionally exceed recommended guidelines for use. While they are at risk for alcohol-related problems, they may never experience negative consequences as a result of their drinking and represent a prime target for preventive, educational efforts by primary care clinicians.

CAGE-AID

Asking the following questions of every adult routinely and periodically is a cost-effective way of screening for substance abuse and detecting possible problems at an early stage in their development:

• Have you ever felt you ought to cut down on your drinking or drug use?
• Have people annoyed you by criticizing your drinking or drug use?
• Have you felt bad or guilty about your drinking or drug use?
• Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Scoring: Item responses on the CAGE are scored 0 for “no” and 1 for “yes” answers. Consider conducting a brief intervention (see below) with any patient who scores a one or higher.

The AUDIT Questionnaire

The AUDIT is designed to be used as a brief structured interview or self-report survey that can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history. Patients tend to answer it most accurately when:

• The interviewer is friendly and nonthreatening
• The purpose of the questions is clearly related to a diagnosis of their health status
• The patient is alcohol- and drug-free at the time of the screening
• The information is considered confidential
• The questions are easy to understand

Health workers should try to establish these conditions before the AUDIT is given. Answers should be recorded carefully.

In addition to these general considerations, the following interviewing techniques should be used:

• Try to interview patients under the best possible circumstances
• Look for signs of alcohol or drug intoxication—patients who have alcohol on their breath or appear intoxicated may be unreliable respondents
• It is important to read the questions as written and in the order indicated

Circle the number that comes closest to the patient's answer.

1.

How often do you have a drink containing alcohol?

(0) Never

(1) Monthly or less

(2) Two to four times a month

(3) Two to three times a week

(4) Four or more times a week

2.

How many drinks containing alcohol do you have on a typical day when you are drinking?

[Code number of standard drinks. In determining the response categories it has been assumed that one drink contains 10 g of alcohol. In countries where the alcohol content of a standard drink differs by more than 25 percent from 10 g, the response category should be modified accordingly.]

(0) 1 or 2

(1) 3 or 4

(2) 5 or 6

(3) 7 to 9

(4) 10 or more

3.

How often do you have six or more drinks on one occasion?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

4.

How often during the last year have you found that you were not able to stop drinking once you had started?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

5.

How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

6.

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

7.

How often during the last year have you had a feeling of guilt or remorse after drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

8.

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

9.

Have you or has someone else been injured as a result of your drinking?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

10.

Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?

(0) No

(2) Yes, but not in the last year

(4) Yes, during the last year

Procedures for scoring AUDIT

Question 1: Never = 0

Monthly or less = 1

Two to four times per month = 2

Two to three times per week = 3

Four or more times per week = 4

Question 2: 1 or 2 = 0

3 or 4 = 1

5 or 6 = 2

7 to 9 = 3

10 or more = 4

Questions 3–8: Never = 0

Less than monthly = 1

Monthly = 2

Weekly = 3

Daily or almost daily = 4

Questions 9–10: No = 0

Yes, but not in the last year = 2

Yes, during the last year = 4

The minimum score (for non-drinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.

TWEAK Test

Use the TWEAK test to screen pregnant women.

T Tolerance: How many drinks can you hold?

W Have close friends or relatives worried or complained about your drinking in the past year?

E Eye-opener: Do you sometimes take a drink in the morning when you first get up?

A Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

K Do you sometimes feel the need to cut down on your drinking?

Scoring: A 7-point scale is used to score the test. The “tolerance” question scores 2 points if a woman reports she can hold more than five drinks without falling asleep or passing out. A positive response to the “worry” question scores 2 points, and a positive response to the last three questions scores 1 point each. A total score of 2 or more indicates a woman is likely to be a risky drinker.

Screen all adults age 60 or older for alcohol and prescription drug abuse as part of their regular physical.

Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)

The following are yes or no questions:

1.

After drinking have you ever noticed an increase in your heart rate or beating in your chest?

2.

When talking with others, do you ever underestimate how much you actually drink?

3.

Does alcohol make you so sleepy that you often fall asleep in your chair?

4.

After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn't feel hungry?

5.

Does having a few drinks help decrease your shakiness or tremors?

6.

Does alcohol sometimes make it hard for you to remember parts of the day or night?

7.

Do you have rules for yourself that you won't drink before a certain time of the day?

8.

Have you lost interest in hobbies or activities you used to enjoy?

9.

When you wake up in the morning, do you ever have trouble remembering part of the night before?

10.

Does having a drink help you sleep?

11.

Do you hide your alcohol bottles from family members?

12.

After a social gathering, have you ever felt embarrassed because you drank too much?

13.

Have you ever been concerned that drinking might be harmful to your health?

14.

Do you like to end an evening with a nightcap?

15.

Did you find your drinking increased after someone close to you died?

16.

In general, would you prefer to have a few drinks at home rather than go out to a social event?

17.

Are you drinking more now than in the past?

18.

Do you usually take a drink to relax or calm your nerves?

19.

Do you drink to take your mind off your problems?

20.

Have you ever increased your drinking after experiencing a loss in your life?

21.

Do you sometimes drive when you have had too much to drink?

22.

Has a doctor or nurse ever said they were worried or concerned about your drinking?

23.

Have you ever made rules to manage your drinking?

24.

When you feel lonely does having a drink help?

Scoring: 5 or more “yes” responses are indicative of an alcohol problem.

Suggestions for Screening

Selecting Appropriate Patients for Brief Intervention

In response to screening questionnaires patients can be categorized into one of three groups:

1.

Patients who do not appear to have any alcohol- or drug-related problems. These patients require no further intervention.

2.

Patients with positive but low scores on any screening tests or who occasionally use marijuana. These patients may be appropriate candidates for brief intervention.

3.

Patients with several positive responses to screening questionnaires and suspicious drinking or drug use histories, symptoms of substance dependence, or current use of illicit drugs. These patients need further assessment.

Conducting Brief Interventions

1.

Give feedback about screening results, impairment, and risks while clarifying the findings

• Give prompt feedback to the screening.
• Present results in a straightforward, nonjudgmental manner and in terms a patient can readily understand.
• Concerns about potential or actual health effects should be stressed. For example, “At this level of consumption, you are at increased risk for some health problems as well as accidents.”
• Avoid being adversarial and pay attention to semantics. For example, the phrase “people for whom substance abuse is creating a problem” is less off-putting than the labels “alcoholic” or “addict.”
• Remain tolerant of the range of patient reactions, including astonishment, embarrassment, hostility, and denial.
• Try to avoid arguments or discussions about how much others can drink without adverse consequences.
• Be reassuring that alcohol and drug problems are not anyone's “fault” and can certainly be addressed during visits.

2.

Inform the patient about safe consumption limits and offer advice about change

• Explain what acceptable and safe use levels are for the relevant substance. Low-risk drinking is no more than two drinks per day for men and one drink per day for women.
• Patients should understand concepts of tolerance and metabolism.
• Clearly state recommendations about consumption goals, keeping these in the context of lifestyle issues and living habits. For example, “In reviewing your response to our screening questionnaire, I notice that you are drinking a lot of beer on weekends. You don't seem to have any direct problems as a result, but I'm concerned that driving while intoxicated is not safe and you have a young family to consider.”
• Clinician authority in offering advice can be strongly motivating.

3.

Assess the patient's readiness to change

• A patient's reaction to initial feedback about screening results offers strong clues about readiness to change.
• People with substance abuse disorders generally fall into one of five stages along a continuum that provides a useful framework for monitoring progress:

  • - Precontemplation: Not seeing the behavior as a problem or not wanting to change the behavior.
  • - Contemplation: Beginning to understand that the behavior is causing difficulties in living or taking a toll on their health and happiness.
  • - Preparation/Determination: Considering various options for change.
  • - Action: Taking concrete steps to change the behavior in a specific way.
  • - Maintenance: Avoiding relapse into problem behavior.
• Be prepared for resistance and setbacks.
• Avoid the temptation to regard resistance as a challenge to authority or to react in an authoritarian way.
• Have an emphatic and supportive attitude and create an atmosphere that the patient will be comfortable returning to even if goals are not successfully achieved.

4.

Negotiate goals and strategies for change

• With alcohol, suggest that the client reduce consumption to below unsafe or potentially hazardous levels. For example, “Can we set a specific date to reduce your alcohol use? Could you cut back, beginning this week?”
• If a patient who is using illegal drugs does not feel ready to discontinued use, suggest a tapering schedule.
• The clinician can only remind the patient that reducing or stopping alcohol use or abstaining from other drug use will eliminate the health or social problems substance use is causing: Ultimately the patient must choose the goal.
• Suggest that patients keep track of consumption in a daily diary to make them more aware of how much they consume. Even patients who are not ready to change their behavior may be willing to keep a diary.
• Patients will be more motivated to change if they are helping to set goals and develop strategies for change. Some studies have found that self-help manuals can be a helpful adjunct for planning change.
• A written contract is a good idea since sometimes patients forget what they agreed to do.

5.

Arrange for followup treatment

• Monitor any health problems or abnormal physical markers.
• Express trust in the patient.
• Confront the patient if he or she is not honest about reporting substance use.
• The use of any form of objective monitoring beyond self-reports of substance abuse must be negotiated between the clinician and the patient.
• Tell patients exactly who will see their medical charts and what information about screening and intervention will be recorded.
• One researcher found that reduction of alcohol consumption correlated with the number of practitioner intervention sessions that were delivered.

Deciding To Refer for Further Assessment or Treatment

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 after one try, or even several tries. Clinicians cannot force a patient to undergo further assessment. However, if problem use persists after a brief intervention, those discussions should serve as a springboard for a more in-depth assessment or specialized treatment.