Screening and Brief Intervention for Unhealthy Alcohol and Other Drug Use in Primary Care

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1 Screening and Brief Intervention for Unhealthy Alcohol and Other Drug Use in Primary Care Richard Saitz MD MPH FACP FASAM Professor of Medicine & Epidemiology Clinical Addiction Research and Education (CARE) Unit Section of General Internal Medicine Boston Medical Center is the primary teaching affiliate of the Boston University School of Medicine.

2 WHAT CAN BE DONE? SCREENING/IDENTIFICATION ADVICE/REFERRAL TREATMENT/PHARMACOTHERAPY FOLLOW-UP/REASSESSMENT

3 UNHEALTHY USE: The condition of interest (*includes dependence) Saitz, R. N Engl J Med 2005;352:

4 What should be done in primary care? Screening (unhealthy alcohol use) We have brief valid tools Also important to identify any alcohol and drug USE to diagnose and treat health conditions appropriately Assessment for severity (includes dependence, withdrawal) Limited evidence for best choices; but clinically necessary Brief counseling (and treatment) when unhealthy use identified Evidence for other drug SBI limited Motivate, refer and/or treat (Rx for alcohol/opioid) dependence when patient agrees Limited evidence for those identified by screening

5 How? System for screening/identification and assessment Pre-visit self-administered (paper, electronic) Health professional administered (designated roles) Role of electronic health record Intervention Health professional (designated roles) or electronic Brief advice, motivational counseling Withdrawal management Initiation of pharmacotherapy Referral with coordination (information releases) Care management (follow-up, measurement based care)

6 VALIDITY OF KEY TOOLS Screening test Against appropriate reference standard (unhealthy use) Risk assessment/diagnosis Against appropriate reference standard (dependence) In general health setting In the way it will be used for intervention (screen, risk assess)

7 ALCOHOL-SASQ Do you sometimes drink beer wine or other alcoholic beverages? How many times in the past year have you had 5 (4 for women) or more drinks in a day? + test =>0 82% sensitive, 79% specific NIAAA. Clinicians Guide to Helping Patients Who Drink Too Much, Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. J Gen Intern Med :783-8 and erratum. DOI: 1007/s

8 Audit-(c) option, and assessment 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 6 (4/5) or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? 6. How often during the last year have you been unable to remember what happened the night before because you had been drinking? 7. Have you or someone else been injured as a result of your drinking? 8. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 9. How often during the last year have you had a feeling of guilt or remorse after drinking? 10. Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested that you should cut down? Sensitivity 57-95%; specificity 78-96%. >8 (>4-7 more sens, less spec); >15-20DEP AUDIT-C >3F, >4M, >7-10DEP Fiellin DA, O Connor PG. Ann Intern Med 2000;133:815-27

9 OTHER DRUGS-SDSQ How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? If asked to clarify the meaning of non-medical reasons, add for instance, because of the experience or feeling it caused. + test = >0 100% sensitive for disorder; 74% specific 93%, 94% for past year use Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Arch Intern Med 2010;170:1155.

10 DAST-10 - ASSESSMENT 1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you unable to stop using drugs when you want to? 4. Have you ever had blackouts or flashbacks as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parents) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)? Skinner HA. Addict Behav 1982;7:363-71, Bohn MJ et al. NIDA Res Monogr 119, 1992, Gavin DR et al. Br J Addict 1989;84:301-7, Maisto SA et al. Psychol Assess 2000;12:186-92, Smith PC et al. Arch Intern Med 2010;170:1155. >3 problem/dep

11 We need to know: Dependence Risk stratification vs. Diagnosis AUDIT-C, AUDIT DAST CAGE-brief, alcohol (CAGE-AID, CAGE-D) ASSIST Dependence checklists/questions (CIDI SF, Rethinking Drinking) 2-item-brief (Vinson et al. AUD)

12 VALIDITY Tool REF Unhealthy REF Depend GEN Health As risk strat in BI RCT Actionable SASQ-A yes* no** yes* no yes AUDIT/C yes yes yes no*** yes SASQ-D yes* no** yes* no yes DAST10 yes* no** yes* no*** +/- *1 study (though >1 other for similar SASQ-A item) **yes in 1 study vs. abuse/dependence ***have been used in BI RCTs as screener and/or to exclude, and for DAST, in service projects

13 FOLLOW-UP Best measures not yet determined Responsive, valid, related to clinical outcomes Options Screening or assessment tools with continuous results Face validity? days of (heavy) use HRQOL measures Track in electronic record and respond accordingly

14 Summary Screen, assess, intervene Brief tools exist, with varying degrees of utility and validation Electronic systems with standard measures to support practice

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