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Resource Guide
This guide is designed to assist clinicians serving adult patients in screening for drug use. This screening tool was adapted from the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Version 3.0, developed and published by WHO (available at http://www.who.int/substance_abuse/ activities/assist_v3_english.pdf).
Screening for Drug Use in General Medical Settings: A Resource Guide for Providers
Table of Contents Introduction BeforeYouBeginScreeningPatients TheNIDAModifiedASSISTScreeningTool Step1:Ask ConductingaBriefIntervention Step2:Advise Step3:Assess Step4:Assist Step5:Arrange Appendices RecommendationsToAddressPatientResistance SampleProgressNotes ChangePlanWorksheet BiologicalSpecimenTesting AdditionalResources
Introduction
ThisResourceGuideisintendedtoprovide cliniciansservingadultpopulations in generalmedicalsettingswiththescreening toolsandproceduresnecessarytoconduct screening,briefintervention,and/or treatmentreferralforpatientswhomay haveorbeatriskofdevelopingasubstance usedisorder.Screeningandbrief interventionprovidesanopportunityfor clinicianstointerveneearlyandpotentially enhancemedicalcarebyincreasing awarenessofthelikelyimpactofsubstance useonapatientsoverallhealth. Why screen for drug use (including tobacco, alcohol, illicit [i.e., illegal], and nonmedical use of prescription drugs)? Druguse(licitorillicit)isharmfuland hasmanyadverseconsequences. Multiplephysicalhealth,emotional,and interpersonalproblemsareassociated withillicitdruguse.Cardiovascular disease,stroke,cancer,HIV/AIDS, anxiety,depression,sleepproblems,as wellasfinancialdifficultiesandlegal, work,andfamilyproblemscanallresult fromorbeexacerbatedbydrugabuse. 1 Theuseofillicitdrugsismorecommon thanyoumightthink.In2007,an estimated19.9millionAmericansaged 12orolder(~8.0percentofthe population)werecurrentillicitdrug users,whichmeanstheyhadusedan illicitdrugduringthemonthpriortothe survey.Nearly1in5Americansaged 1825hadusedillicitdrugsinthepast month. 2 Onlyafractionofindividualswhoneed specialtytreatmentfordrugoralcohol
This resource guide does not specifically address the unique considerations that must be taken into account when screening adolescents or pregnant women.
addictionactuallyreceiveiteachyear. In2007,ofthemorethan23million personsaged12orolderwhoneeded specializedtreatmentforadrugor alcoholproblem,mostalmost21 milliondidnotreceiveit. 3 Routine screeningforsubstanceusedisorders couldalterthisstatisticandgetmore peoplethehelptheyneed. Usingscreeningandbriefintervention proceduresingeneralmedicalsettings canmakeadifferenceindruguse behaviors.Researchhasdemonstrated thatscreeningandbriefinterventioncan promotesignificantreductionsinalcohol andtobaccouse. 4,5,6 Agrowingbodyof literaturealsosuggestsbenefitsof screeningandbriefinterventionforillicit ornonmedicalprescriptiondruguseas well. 7 How do you screen and provide feedback? Asamedicalprovider,youareanimportant figureinyourpatientslives.Inaveryshort conversation,youhaveawonderful opportunitytoletyourpatientsknowifand howtheirdrugusemaybeputtingtheir healthatrisk. TheFiveAsofIntervention(Ask,Advise, Assess,Assist,Arrange)canbeauseful frameworkforencouragingpatientstoquit smokingandmayalsobeusefulfor screeningandprovidingfeedbackrelatedto otherdruguse. ASKScreeningisthefirstAbecauseitasks oneormorequestionsrelatedtodruguse. ADVISEThesecondAinvolvesstrong directpersonaladvicebytheprovidertothe patienttomakeachange,ifitisclinically indicated. 2
ASSESSThethirdAreferstodetermining ARRANGEThefinalAistoreferthe howwillingapatientistochangehisorher patientforfurtherassessmentand behaviorafterhearingtheprovidersadvice. treatment,ifappropriate,andtosetup followupappointments. ASSISTThefourthAreferstohelpingthe patientmakeachangeifhe/sheappears ready. Ifyouarenotalreadydoingso,weencourageyoutoincorporatedrugusescreeningand briefinterventionintoyourpractice.TheremainderofthisResourceGuideprovidesdetailed informationtobeginscreeningfor:
Tobacco
Alcohol
Illicit Drugs
Beforeyoubegintheinterview,pleasereadthefollowing tothepatient: Hi,Im__________,nicetomeetyou.Ifitsokaywith you,Idliketoaskyouafewquestionsthatwillhelpme giveyoubettermedicalcare.Thequestionsrelateto yourexperiencewithalcohol,cigarettes,andother drugs.Someofthesubstanceswelltalkaboutare prescribedbyadoctor(likepainmedications).ButIaminterestedinthoseonlyifyouhave takenthemforreasonsorindosesotherthanprescribed takenthemforreasonsorindosesotherthanprescribed.Illalsoaskyouaboutillicitor illegaldrugusebutonlytobetterdiagnoseandtreatyou. Ifthepatientdeclinesscreening,advisethepatientthatyourespectthatdecisionbut wouldliketoinformhim/heraboutthepotentialharmsofdruguse. B. Ask patients about lifetime drug use using the Prescreen Question of the NIDA-Modified ASSIST.
Reminder: Patients should be advised of the limits of Withoutbeingjudgmentalorconfrontational,askthe confidentiality and patientifheorshehaseverusedanyofthesubstances insurance coverage for listedseethePrescreenquestionontheNIDAModified conditions occurring ASSIST under the influence of alcohol or illicit drugs ( http://www.drugabuse.gov/nidamed/screening/nmassist.p (these vary by State and df)foralist.Note:Ifthepatientmentionsadrugnoton provider). thelist(e.g.,steroids),pleaseenteritintheother category. Bepreparedtogentlyprobecertainquestions.Forexample,ifthepatientanswers Notoeverysubstance,askaprobingquestionsuchasNotevenwhenyouwere younger,perhapsinhighschoolorcollege? IfthepatientsaysNoforalldrugsinPrescreen,reinforceabstinence.Forexample, youmaysayItisreallygoodtohearyouarentusingdrugs.Thatisaverysmart healthchoice.Screeningiscomplete. IfthepatientsaysYestoanyofthedrugs,gotoC.
Begin the NIDA-Modified ASSIST (Link to PDF of tool). ForpatientswhoanswernevertoQuestion1(Inthepastthreemonths,howoften haveyouusedthesubstancesyoumentioned?):SkiptoQuestions57todetermineif theyhavesymptomsofapriorsubstanceuseproblem.Providefeedback(seeStep2) andreinforceabstinence.
For patients who report use of tobacco: Any tobacco use in the past three months placesapatientatrisk. o Advisealltobaccouserstoquit.Formoreinformationonsmokingcessation, pleaseseeHelpingSmokersQuit:AGuideforCliniciansat http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm. Forpatientswhoreportuseofalcohol:Questionthepatientinmoredetailabout frequencyandquantityofuse: Iftheansweris: None:Advisepatienttostaywithintheselimits. Forhealthymenundertheageof65:Nomorethan4drinksperdayANDno morethan14drinksperweek. Reminder: Forhealthywomenundertheageof65andnot pregnant(andhealthymenovertheageof65): Many people dont know Nomorethan3drinksperdayANDnomorethan what counts as a standard drink (e.g., 12 oz beer, 5 oz 7drinksperweek. wine, 1.5 oz liquor). Recommendlowerlimitsorabstinenceas medicallyindicatedforpatientswho: For information, please see http://pubs.niaaa.nih.gov/publ Takemedicationsthatinteractwith ications/Practitioner/Clinician alcohol sGuide2005/clinicians_guide Haveahealthconditionexacerbatedby 13_p_mats.htm alcohol Arepregnant(adviseabstinence). Encouragepatientstotalkopenlyaboutalcoholandanyconcernsthatmay arise,rescreenannually. Oneormoretimesofheavydrinking(5formen;4forwomen):Patientis anatriskdrinker. 7
PleaseseetheNationalInstituteonAlcoholAbuseandAlcoholism(NIAAA) WebsiteHelpingpatientswhodrinktoomuch:Acliniciansguideat http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clini cians_guide.htmforadditionalinformationtoAsk,Assess,Advise,Assist,and Arrangehelpforatriskdrinkersorpatientswithalcoholusedisorders. For patients who report any illicit or nonmedical prescription drug use, go to Questions2through7.Note:AskQuestion7ifthepatientreportstheuseofanydrug that might be injected, including those that might be listed in the other category (e.g.,steroids).
Forpatientswhoreportalcoholaswellasanyillicitornonmedicalprescriptiondrug use,askalcoholfollowupquestionsandthengotoQuestions27. D. Score the full NIDA-Modified ASSIST for illicit and nonmedical prescription drug use. Foreachsubstance,addupthescoresreceivedforQuestions16.Thisisthe SubstanceInvolvement(SI)score.DonotincludetheresultsfromeitherStep1 (Prescreen)orQuestion7inyourSIscore.ThepatientwillreceiveanSIscoreforeach substanceendorsed,notacumulativescore.Therefore,thepatientsrisklevelmay differfromdrugtodrug. UsetheresultantSIscoretoidentifypatientsrisklevel.Ifmorethanonesubstanceis reported,focusinterventiononthesubstancewiththehighestscore.
Reminder: Use clinical judgment if the patient reports use of multiple drugs but does not score highly on any of them (i.e., consider an intervention).
Whenappropriate,educatepatientsonthefollowing: Reminder: o Useofevensmallamountsofdrugsortobacco maynegativelyimpacthealthandperformance The screen is only one indicator of a patients potential drug use (e.g.,drivingoroperatingmachinery). problem. It is not a substitute o Becausedrugintoxicationcanleadtoimpaired for clinical judgment, which judgmentandriskybehaviors,referallsexually you should use to determine activepatientsforconfidentialtestingforHIVand when an intervention is warranted. othersexuallytransmitteddiseasesorprovidean onsitetestingopportunity,iftheydonotknow theirstatusorhavenotbeentestedrecently.Encourageallpatientstopractice safesex. o Referallpatientswithpastorcurrentinjectiondruguse(Question7)forHIVand HepatitisB/Ctestingiftheyhavenotbeentestedtwiceovera6monthspan followingtheirlastinjection. 10
Moderate risk
Lower risk
* Providers should be aware that many States mandate reporting of drug use during pregnancy and that failure to do so may be a prosecutable offense.
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12
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Risk level High risk Targeted Recommendations Offer Make Obtainrecords additional additional ofassessment brief referralsfor and/or intervention patientswho treatmentfor forpatients missed patientswho whodidnot referral. attended attendthe referraland/or referral. treatment.
Moderate risk Determine whetherthe patient reducedor abstained fromuse. Forpatients whodidnot makeprogress withchange efforts, acknowledge changeishard, repeatbrief intervention, anddiscuss additional waysto supportthe patients efforts. Ifthepatient Encourage indicatedthat abstinence he/shewanted fromtobacco tomakea andillicit change,ask drugsand what,if adviselowrisk anything,the alcoholusers patient toremain decidedtodo within about acceptable substanceuse. drinkinglevels. Forpatients whohave madechanges, reinforce effortsand encourage additional goalsetting.
Lower risk
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Appendix 1Recommendations to Address Patient Resistance (may not be applicable in every case)
PatientResistanceScenario Patientanswersno,seeminglywithout consideringitthoughtfullyorisreluctant togivedetails. Patientisuncomfortabledisclosing personalsubstanceuseonaform. Patientappearsashamedorembarrassed aboutrecommendationstochange substanceusebehaviors. Atriskpatientappearsambivalenttothe ideaofchanginghis/hersubstanceuse behavior. Patientbecomesupset,argumentative. PhysicianResponse Gentlyprobewithaquestionlike:Notevenwhenyouwere inschool? Encouragediscussionbysayinggoonortellmemore. Letthepatientknowyouwillfollowupinpersonaboutthe screening. Reinforcethatallinformationprovidedwillbekept confidentialwhenpossible. Ifpatientisstilluncomfortable,skipscreeningbutprovide informationaboutharmsassociatedwithdruguse. Statethatthisisahealthrelatedmedicalrecommendation andisnotmeanttojudgeorstigmatizethem. Remindthepatientofyourrolethatphysicianshaveaduty tosharetestresultswiththeirpatients. Acknowledgethepatientsambivalenceandthefactthat ambivalenceiscommon. Stateyourconcernaboutspecificwaysthatdrugsmay negativelyaffectyourpatientshealthorpersonallife. Donotarguewiththepatient.Givethepatienttimetomake adecision(unlesstheconditionislifethreatening). Discusshis/herconcernsandreflectthemback(e.g.,convey thatyouunderstandthepatientsclaimthatdrugsmake themfeelbetterorthattheirpeersusethem). Exploreconcernsabouttheassessment. Emphasizethatreferralforanassessmentmaynotmean enteringsubstanceabusetreatmentandthattreatment,if recommended,likelywillincludedifferentoptions. Problemsolveaboutbarriersandoffersupport,suchas remindercalls,assistancearrangingtransportation,andchild care. Clearlystatethatyouarenotinsistingonformaltreatment. Explainthattreatmentisofteneasierthanquittingcold turkeyandthatstoppingtheuseofcertaindrugs(e.g., alcohol,benzodiazepines)withoutmedicalsupervisioncan bedangerous. Acknowledgethatchangeisdifficult. Repeatthebriefinterventionanddiscussotherwaysto supportthepatientsefforts. Makeadditionalreferralsforpatientswhodidnotattendthe referral.
Patientresistsreferralforadditional assessment
Infollowupvisits,patientshowsno progresswithchangeefforts.
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Past3months(list substances):_______________
BiologicalTestResults:_______________
PLAN: Discussedscreeningresultswithpatient (checkifcompleted)______ ProvidedaBriefIntervention(checkifcompleted)______ Howreadyispatienttochangebehavior?Unwilling_____Tentative______Ready_______ ChangePlancompleted?Yes____(attach)No____N/A____ ChangePlanappointment?Yes____No___N/A____ REFERRALSTATUS: Referforfurtherassessment?__________Refused?____________N/A_______ Refertodetox?_________Refused?___________N/A_______ FOLLOWUPPLANS: Dateofnextappointmenttocheckprogress______ Orforlowriskpatients,rescreenonnextRTC________,oroneyear(ifnegative). ProviderSignature:________________________PatientSignature:_____________________
Level of risk associated with different Substance Involvement Score ranges for illicit or nonmedical prescription drug use 03 Low Risk 426 Moderate Risk 27+ High Risk
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National Institute on Alcohol Abuse and Alcoholisms Helping Patients Who Drink Too Much: A Clinicians Guide:
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm.
NIDAs National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs: http://www.drugabuse.gov/CTN/ctps.html. Resources on Certification in Office-Based Buprenorphine: http://buprenorphine.samhsa.gov/howto.html.
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Devlin, R.J,, and Henry, J.A. Clinical review: Major consequences of illicit drug consumption. Crit Care. 12(1):202, 2008. Available at http://www.ncbi.nlm.nih.gov/pubmed/18279535?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ ResultsPanel.Pubmed_RVDocSum. 2 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H34, DHHS Publication No. SMA 084343). Rockville, MD, 2008. Available at http://www.oas.samhsa.gov/nsduh/2k7nsduh/AppG.htm#TabG-11. 3 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H34, DHHS Publication No. SMA 084343). Rockville, MD, 2008. Available at http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#7.2 4 Madras, B.K. ; Compton, W.M. ; Avula, D. ; Stegbauer, T.; Stein, J.B.; and Clark, W.H. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Depend [e-pub ahead of print], 2008. 5 Bernstein, J.; Bernstein, E.; Tassiopoulos, K.; Heeren, T.; Levenson, S.; and Hingson, R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend 77(1):4959, 2005. Available at http://www.ncbi.nlm.nih.gov/pubmed/15607841?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ ResultsPanel.Pubmed_RVDocSum. 6 Humeniuk, R.; Dennington, V.; Ali, R.; and WHO ASSIST Phase III Study Group. The Effectiveness of a Brief Intervention for Illicit Drugs Linked to the ASSIST Screening Test in Primary Health Care Settings: A Technical Report of Phase III Findings of the WHO ASSIST Randomized Controlled Trial (Draft). Geneva, Switzerland, 2008. 7 Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance abuse. Substance Abuse. 28: 7-30. 8 Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: Committee on Trauma Quick Guide, Substance Abuse and Mental Health Services Administration, DHHS Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing Office, 2007. Available at http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf. 9 Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Treatment Improvement Protocol (TIP) Series, No. 24. Substance Abuse and Mental Health Services Administration, DHHS Publication No. (SMA) 973139. Washington, DC: U.S. Government Printing Office, 1997. 10 Rossi, P.; Di Lorenzo, C.; Faroni, J.; Cesarino, F.; and Nappi, G. Advice alone vs. Structured detoxification programmes for medication overuse headache: a prospective, randomized, open-label trial in transformed migraine patients with low medical needs. Cephalalgia. 26:10971105, 2006. 11 Vicens, C.; Fiol, F.; Llobera, J.; Cpoamor, F.; Mateu, C.; Alegret, S.; and Socias, I. Withdrawal from long-term benzodiazepine use: randomised trial in family practice. Br J Gen Pract 56:958963, 2006.
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