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Provider Guidelines

BRIEF SCREENING, INTERVENTION, AND REFERRAL FOR ALCOHOL AND OPIATE DISORDERS

Alcohol and Drug Screening and Brief Intervention: A Three-Step Process

  • Screen
  • Brief Intervention
  • Follow-up
The Problem
  • According to the National Institute on Alcohol Abuse and Alcoholism 3 in 10 adults drink at levels that elevate their risk of physical, mental health, and social problems.1
  • Heavy drinking increases the risk of gastrointestinal bleeding, hypertension, hemorrhagic stroke, cirrhosis of the liver, major depression, sleep disorders, and cancers of the head and neck, digestive tract, and breast.2
  • The misuse (use of prescription-type drugs not prescribed for the individual by a physician or used only for the experience or feeling they caused) of opioid pain relievers is a growing public health problem.
  • An estimated 48 million people have used prescription drugs for nonmedical reasons in their lifetime.3

The Solution

Primary care physicians and behavioral health care providers are in the best position to identify and begin address hazardous drinking and drug misuse.

The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

The USPSTF found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence but place them at risk for increased morbidity and mortality, and good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over six- to 12-month periods or longer.

1 National Institute on Alcohol Abuse and Alcoholism. Unpublished data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationwide survey of 43,093 U.S. adults aged 18 or older, 2004.

2 Rehm j, Room R, Graham K, Monteiro M, GmelG, Sempos CT. The relationship of average volumn of alcohol consumption and patterns of drinking to burden of disease: An overview. Addiction, 98 (9), 1209-1228, 2003.

3 National Institute on Drug Abuse (2005). Research Report Series – Prescription Drugs: Abuse and Addiction: NIH Publication No. 01-4881, Revised August 2005.

SCREEN

Routine screening is a quick and simple way to identify patients who are engaged in risky or dependent drinking or drug misuse.  Screening allows the care provider to educate their patients about the hazards of heavy drinking or drug misuse, identify problems before serious dependence develops, and motivate their patient to change their behavior.1

 Screening Tools for Alcohol and Drugs

 Alcohol Use Disorders Identification Test (AUDIT) — a screening tool developed by the World Health Organization to identify persons with hazardous or harmful alcohol consumption.2  The AUDIT consists of 10 items that can be administered quickly either verbally, written, or by computer in ~5 minutes. The AUDIT-C (AUDIT items 1-3) can be administered in ~1-2 minutes as a prescreener to determine if further screening (items 4-10) is needed.

 The Drug Abuse Screening Test (DAST) — The DAST was designed to provide a brief and simple method for identifying individuals who are abusing psychoactive drugs and to provide an assessment of the degree of problems related to drug use or misuse. 

 AUDIT AND DAST PRESCREENER

AUDIT C

0

1

2

3

4

Score

1. How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4 or more times per week

 

2. How many drinks containing alcohol do you have on a typical day of drinking?

 

1 or 2

 

3 or 4

 

5 or 6

 

7 to 9

 

10 +

 

3. How often do you have five or more drinks on one occasion?

Never

Less than monthly

Monthly

Wkly

Daily or

almost daily

 

A standard drink in the US is any drink that contains about 14 grams of pure alcohol.  One drink=12oz. beer, 5oz. wine, 1.5 oz. liquor

 

AUDIT-C Score (add items 1-3)

 

Recommended Level and Focus of Brief Intervention based on Screening Results:

·         NEGATIVE SCREEN < 4 for men/ 3 for women – Inform client that they are at low risk. Congratulate clients at low risk and encourage them to remain that way. Simple Advice can be offered.

·         POSITIVE SCREEN ≥ 4 for men/ 3 for women - Inform client that they screen positive for hazardous alcohol use and are at risk for health and other problems – continue with the full AUDIT.

DAST Pre-screener

Score

1. In the past 12 months, have you used drugs other than those required for medical reasons?

Yes or No

A yes response to the DAST pre-screener indicates a positive drug prescreen – continue with full DAST.

1 Babor, 1992

2  Ibid

 

AUDIT and DAST Full Screens

 

AUDIT - Continued

Questions

0

1

2

3

4

Score

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

 

Never


Less than

monthly

 

Monthly

 

Weekly

 

Daily or

almost daily

 

 

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

 

Never

 

Less than

monthly

 

Monthly

 

Weekly

 

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?

 

Never

 

Less than monthly

 

Monthly

 

Weekly

 

Daily or

almost daily

 

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

 

Never

Less than monthly

 

Monthly

 

Weekly

Daily or

almost daily

 

 

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

 

Never

 

 

Less than monthly

 

Monthly

 

Weekly

 

 

Daily or

almost daily

 

9. Have you or someone else been injured because of your drinking?

 No

 

 

Yes, but not in the last year

 

Yes, during the last year

 

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

 

No

 

Yes, but not in the last year

 

Yes, during the last year

 

 

 

 

 

AUDIT Score (add items 1-10)

 

 

Scoring: Questions 1–8 are scored 0, 1, 2, 3, or 4 points. Questions 9 and 10 are scored 0, 2, or 4 only. A score of 8+ on the AUDIT generally indicates at-risk, harmful, or hazardous drinking.

AUDIT Scores and Recommended Level of Intervention:

AUDIT score

Risk Level

Intervention

0-7

Zone I

Alcohol Education

8-15

Zone II

Simple Advice

16-19

Zone III

Simple Advice plus Brief Intervention and Follow-up (Continued Monitoring, if possible)

20-40

 

Zone IV

Referral to Specialist for Diagnostic Evaluation and Treatment.

DAST-10©

The questions included in the DAST-10 concern information about possible involvement with drugs not including alcoholic beverages during the past 12 months.

In the statements, “drug use” refers to (1) the use of prescribed or over the counter drugs in excess of the directions and (2) any non-medical use of drugs.

In the past 12 months: Circle response

1

Have you used drugs other than those required for medical reasons?

Yes or No

2

Do you abuse more than one drug at a time

Yes or No

3

Are you always able to stop using drugs when you want to?

Yes or No

4

Have you had “blackouts” or “flashbacks” as a result of your drug use

Yes or No

5

Do you ever feel bad or guilty about your drug use?

Yes or No

6

Does your spouse (or parents) ever complain about your involvement with drugs?

Yes or No

7

Have you neglected your family because of your use of drugs?

Yes or No

8

Have you engaged in illegal activities in order to obtain drugs?

Yes or No

9

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes or No

10

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Yes or No

SCORING THE DAST-10©1

       Score:____________

Score 1 point for each question answered “yes,” except for question 3 for which a “no” receives 1 point.

AUDIT/DAST Scores and Recommended Level of Intervention

DAST-10 Interpretation

Score

Degree of problems related to drug abuse

Suggested Action

0

No problems reported

None at this time

1-2

Low level Monitor

re-assess at a later date

3-5

Moderate level

Further investigation

6-8

Substantial level

Intensive assessment

9-10

Severe level

Intensive assessment

 


        11982 by the Addiction Research Foundation. Author: Harvey A. Skinner Ph.D. Developed on 07/15/2008.

      BRIEF INTERVENTION

Brief intervention is effective and efficient way to intervene with patients who report risky or hazardous alcohol and/or drug use.  Patients with alcohol and drug misuse problems typically appreciate health care providers who express concern about their drinking and drug use.

Brief intervention, which usually happens in a single session immediately following a positive screen, consists of a motivational discussion with the patient. This discussion is focused on increasing insight and awareness regarding the impact of substance use and motivation for behavior change. For patients identified as needing more extensive treatment than just a brief intervention, the provider can refer the patient to specialized substance use treatment. 

In a brief intervention, the health provider expresses medical concern about a patient's drinking; advises the patient to cut down his or her drinking or drug use, or in the case of a person with alcoholism, to stop drinking.

       Brief Intervention Method

FLO: Feedback, Listen and Understand, Options explored7

“F”  FEEDBACK USING AUDIT-C, AUDIT, DAST (1-2 minutes)       

______ Range: AUDIT-C can range from 0 (non-drinkers) to 12 (hazardous, harmful, risk use of alcohol); AUDIT can range from 0 (non-drinkers) to 40 (hazardous, harmful, risk use of alcohol); DAST can range from 0 (non drug misuse) to 10 (serious drug misuse).

______  AUDIT and DAST has been given to thousand of patients in medical settings, so you can compare your drinking to others.

______ Normal AUDIT-C scores are 0-4 for men and 0-3 for women, which is low-risk drinking; Normal DAST score is 0.

______ Give result: Your score was…which places you in the category for higher risk of harm.

_______ Elicit reaction: What do you make of that?

‘L’   LISTEN AND ELICIT (1-5 minutes)

_______ Explore pros and cons of drinking or drug use (What do you like about drinking? What do like less about drinking?)

_______ Summarize both sides (On the one handOn the other hand…)

_______ Ask about importance. (circle #) On a scale of 1-10, how important is it to you to… (change)? Why did you give it that number and not a lower number? What would it take to raise that number?  

1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Not at all Important       Very Important

_______ Ask about confidence. (circle #) On a scale of 1-10, how confident are you that you can change successfully? Why did you give it that number and not a  lower number?  What would it take to raise that number? 

1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Not at all Important       Very Important

“O” OPTIONS (Goal Setting)        1-5 minutes

_______ Ask key questions about what they want to change, what is their goal

(Where does this leave you? Do you want to quit? Cut down? Make no change?)

_______ Manage your drinking/drug use

_______ Eliminate drinking/drug use from your life

_______ Never drink/use drugs and drive

_______ Utterly nothing

_______ Seek help

_______ Other goals ________________________________________________________________
________________________________________________________________

_______   (If appropriate) ask about the plan (How will you do that?  If you wanted to…how would you? Who will help you? What might get in the way?)

CLOSE ON GOOD TERMS     <1 minute

______ Summarize Patient’s statements in favor of change

______ Emphasize their strengths

______ What agreement was reached

EDUCATION AND REFERRAL

______ Give patient brochures “Alcohol: It may be legal but it can hurt your health” and/or “When pain medications become another problem”

______ Circle Behavioral Health Service Provider on back of brochure “Alcohol: How much is too much?”- select based on payor (i.e., health plan, self/uninsured)

FOLLOW-UP

Patient outcomes improve when follow up is provided.  A phone call soon after the brief intervention to assess patient progress will reinforce the intervention. In cases where a referral is given to the patient, the physician or clinician should check to see if the patient initiated contact.

ADDITIONAL RESOURCES

National Hotlines

  • Alcohol and Drug Helpline (public and private resources…………800-821-4357
  • National Council on Alcoholism and Drug Dependence Hopeline…800-622-2255
  • Alcohol and Drug Abuse Hotline (literature and private programs)..800-729-6686

Alcoholics Anonymous (AA)

Moderation Management: National support group network for people concerned about their drinking and seek to moderate their drinking.  Intended for problem drinkers who have experienced mild to moderate levels of alcohol related problems.

425-483-5293

www.moderation.org

National Council on Alcoholism and Drug Dependence, Inc (NCADD): Operates a network of affiliates with advocacy, education, prevention and treatment programs.

12 West 21st Street
New York, NY 10010
212-206-6770/800-NCA-CALL
www.ncadd.org

National Institute of Alcohol Abuse and Alcoholism (NIAAA)
Pamphlets and brochures are available
www.niaaa.nih.gov.

Salvation Army
Salvation Army is the largest residential substance abuse rehabilitation program in the US. Locations are listed on their website. The Salvation Army has spiritually-based residential programs.
USA National Headquarters
P.O.Box 269
Alexandria, VA 22312
703-684-5500
www.salvationarmy.org

Locating treatment providers in your area: Substance Abuse and Mental Health Services Administration (SAMHSA) compiles the National Directory of Drug Abuse and Alcoholism Treatment Programs – www.findtreatment.samhsa.gov

Veterans Health Administration, National Center for Health Promotion and Disease Prevention (NCHP).
VA Medical Center
508 Fulton Street
Durham, NC 27705
919-416-5879
http://www.prevention.va.gov/


   
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