Addressing the Needs of Patients Presenting with Substance Abuse or Suicide Risk in the Emergency Department

Transcription

1 Addressing the Needs of Patients Presenting with Substance Abuse or Suicide Risk in the Emergency Department A Toolkit for Emergency Department Staff Arizona Department of Health Services Division of Behavioral Health Services Emergency Department Initiative

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3 Table of Contents Dear Emergency Department Professional:... 6 Section 1: Addressing Alcohol Use in ED Patients... 9 Screening Patients for Alcohol Description of Screening Tools for Alcohol NIAAA Prescreen The Alcohol Use Disorders Identification Test (AUDIT) RAPS4-QF Alcohol Screening Tools for Use in the ED Decision Tree for Addressing Patients with Alcohol-Related Issues Using the SBIRT Model Brief Interventions for Patients with Problematic Drinking The FLO Brief Intervention Referral to Treatment for Patients with Possible Alcohol Dependence Aftercare Materials for Patients with Identified Alcohol Problems Section 2: Addressing Drug Use in ED Patients Screening Patients for Illicit Drug Use Description of Screening Tools for Drug Use NIDA-Modified ASSIST CRAFFT Screening Tool for Children and Adolescents Drug Use Screening Tools for Use in the ED Decision Tree for Addressing the Needs of Patients with Drug-Related Issues Using the SBIRT Model Brief Interventions for Patients with Drug Abuse Referral to Treatment for Patients with Drug Abuse Aftercare Materials for Patients with Identified Drug Problems Section 3: Addressing Suicide Risk in ED Patients Guidelines for Addressing the Needs of Suicidal Patients in EDs Decision Tree for Addressing the Needs of Suicidal Patients in the ED Assessing Patients for Suicidality P a g e

4 Description of Assessment Tools for Suicidality Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Suicide Assessment Tool for Use in the ED Means Restriction Brief Intervention: Speaking with the Patient s Family and Loved Ones about Firearms and Prescription Medications Referral to Treatment for Patients Presenting with Attempted Suicide Aftercare Materials for Patients and Caregivers Dealing with Suicide References Decision Tree for Determining Referral to Treatment Options for Patients Presenting with Substance Abuse Referral Information For more information about this Tookit, please contact: Lisa Shumaker Arizona Department of Health Services Division of Behavioral Health Office of Prevention 150 N. 18th Ave, Suite 220 Phoenix, AZ (602) Lisa.Shumaker@azdhs.gov These materials were funded through an initiative by the Arizona Department of Health Services and produced in 2011 by Pima Prevention Partnership, statewide contract #EPS P a g e

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6 Addressing the Needs of Patients Presenting with Substance Abuse or Suicide Risk in the Emergency Department: A Toolkit for Emergency Department Staff Dear Emergency Department Professional: Thank you for being on the front line of helping the people of Arizona who are in the most urgent need of help and services! This toolkit was created to guide emergency department (ED) personnel in addressing the needs of Arizona s adults and adolescents who present to EDs with behavioral health emergencies related to substance abuse problems, suicide risk, or both. Adherence to the guidelines in this toolkit can help EDs more successfully identify and connect patients to services according to the individual s level of need. The tools included have been selected as reliable and easy to deliver in the ED. Successful implementation of these guidelines can reduce return visits by these patients, ultimately minimizing the workload (and costs) placed on EDs by behavioral health emergencies. Who is this toolkit for? This toolkit was written for use by a range of ED personnel. It may be a particularly useful resource for staff working in EDs that have few or no onsite behavioral health professionals, and those that have not yet instituted screening protocols for substance abuse or suicide risk. What information does this toolkit contain? This toolkit contains materials that will assist ED personnel in performing screenings for alcohol abuse, drug abuse, and suicide risk and, where appropriate, conducting brief interventions in the ED. It also contains recommended protocols, resources that can be used to facilitate referrals to treatment, and supplemental aftercare materials for patients or their caregivers. How should this toolkit be used? The toolkit has been divided into individual sections addressing the needs of patients presenting with possible alcohol abuse, drug abuse, or suicide risk. Because co-occurrence of these issues is common, more than one section may relate to an individual patient. In instances where a patient presents with only one issue, it may also be appropriate to supplement screening with tools from another section. The materials in this toolkit are valuable additions to service delivery. However, it is important to recognize that they are not sufficient for making psychiatric diagnoses nor are they a substitute for evaluation by mental health professionals. 6 P a g e

7 What steps can be taken to integrate this toolkit into your ED? This toolkit is intended to be integrated into existing ED systems. It is not a replacement for working systems nor is it expected to be shoe-horned into an ED system in a way that does not make sense. Consider the following steps as a way to integrate elements of this toolkit into your ED: Identify ED Staff: Identify staff who have training in Screening and Brief Interventions (SBI). Identify staff who will oversee the integration of this toolkit into existing systems. Define the Target Population of Patients Who Will Be Assessed: Identify how patients will be identified who present with specific indicators. Select the Protocol for Assessment: Identify and select which assessment protocols provided in this toolkit will be implemented by the ED staff. Identify a Protocol to Provide Brief Interventions: Identify which ED or hospital staff will deliver the intervention. Identify the training that will be received. Develop a Record-Keeping Protocol: Identify which measures of implementation and effectiveness will be tracked, such as percentage of patients screened. Determine how those records will be kept. Ensure that Mechanisms for Patient Protection and Confidentiality are in Place: Ensure that all staff members are aware of existing ED practices and protocols. Develop a Reimbursement Strategy: Identify Medicaid, Medicare, and commercial insurance billing codes for Screenings and Brief Interventions. Identify methods for reimbursement for the ED. Finally, please encourage all staff to photocopy or print out any of the tools or materials included as part of this Toolkit. Thank you for using this toolkit to provide help to Arizonans who are in the most urgent need of support and services! Note: The checklist above was adapted from Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: Committee on Trauma Quick Guide produced by the U.S Department of Health and Human Services 7 P a g e

8 Section 1: Addressing Alcohol Use in Emergency Department Patients 8 P a g e

9 Section 1: Addressing Alcohol Use in ED Patients Alcohol Dependency is Widely Misunderstood Treatment for alcohol dependency can be initiated in a hospital setting and even in an emergency department (ED). However, many misconceptions persist about substance addiction and may interfere with successful treatment initiation in the ED. The following are some of the most common misconceptions: Misconception: Alcohol experimentation is a normative part of childhood and adolescence. Reality: Underage drinking can undermine normative development. It can cause damage to areas of the brain that affect judgment, impulse control, learning, and memory. Underage drinking can also disrupt the hormone balance necessary for normal pubertal development and predispose the individual to alcoholism. Misconception: Addiction is a willpower problem. People can stop, if they really want to. Reality: A person starts out as an occasional drug user, and that is a voluntary decision. But as time passes, something happens, and that person goes from being a voluntary alcohol user to being a compulsive alcohol user. Over time, continued use of addictive substances changes your brain -- some times in dramatic, toxic ways, at other times in more subtle ways, but virtually always in ways that result in compulsive and even uncontrollable use. Misconception: Addicts should be punished, not treated. Reality: Science is demonstrating that addicts have a brain disease that causes them to have impaired control over their use. Addicts need treatment for their changed brain chemistry, to learn to cope with triggers, and to learn to re-socialize without chemicals. Some people get into cycles of criminal behavior precisely because they must sustain their drug or alcohol use. Their bodies and brain tell them they will not survive without the substance. Misconception: People don't need treatment. They can stop using if they really want to. Reality: It is extremely difficult for people addicted to alcohol or drugs to achieve and maintain long-term abstinence. Research shows that long-term alcohol and other drug use actually changes a person's brain function, causing them to crave the substance even more, making it increasingly difficult for the person to quit. 9 P a g e

10 Misconception: Treatment just doesn't work. Reality: Treatment can help people. Studies show treatment reduces relapse by 40 to 60 percent and can significantly decrease criminal activity during and after treatment. Misconception: Addicts who continue to abuse alcohol/drugs after treatment are hopeless. Reality: Addiction is a chronic disorder; occasional relapse does not mean failure. Stress from work or family problems, social cues (i.e., meeting individuals from one's substance-using past), or their environment (i.e., encountering streets, objects, or even smells associated with alcohol or other drug use) can easily trigger a relapse. Addicts are most vulnerable to alcohol or drug use during the few months immediately following their release from treatment. 1 Many Patients Presenting with Alcohol Issues in EDs Are Not Alcohol Dependent Many ED patients presenting with alcohol issues are not in fact alcohol dependent. Contrary to popular belief (as the pyramid below illustrates) the percentage of U.S. adults who are dependent on alcohol (4%) is small compared with the percentage of adults who drink in a hazardous way that puts themselves and others at risk (25%). 2 Pyramid of Alcohol Problems 2 Drinking Type Intervention Type Hazardous or At-Risk Use Dependent Use 4% 25% Brief Intervention and Referral Brief Intervention Low-Risk Use or Abstention 71% No Intervention Note: The prevalence estimates in this figure are non-institutionalized U.S. Population, not trauma or ED patients. Hazardous or at-risk drinkers often do not know how much alcohol they can drink safely or that their drinking is hazardous to their health and the health of others. 2 Research has shown that when these drinkers are guided by medical practitioners to consider their drinking behavior as problematic, many of them can and will change their drinking habits P a g e

11 EDs Are Ideal Settings for Screening and Brief Interventions for Alcohol Use Studies show that 40% of ED visits are injury-related and that approximately 50% of these visits are alcohol-related. 4 In addition, patients presenting to the ED are more likely to have alcoholrelated problems than those presenting to primary care or in the general population. Past research has estimated that if screening was a routine practice, approximately 25% of all adult ED patients would screen positive for hazardous or harmful drinking. 5 Teachable Moments May Provide Motivation for Behavior Change Serious injuries have been shown to serve as important motivators for patients to reduce drinking and may serve as teachable moments during an ED visit. 6 Medical professionals in EDs have an opportunity to assess these individuals for excessive drinking and to provide, where appropriate, brief interventions. Research has shown that when the motivating aspects of injury are coupled with a targeted intervention, patients have been shown to change their substance abuse behavior. 7 One strategy for capitalizing on the teachable moment to promote behavior change that has gained widespread support is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model. The SBIRT Service Delivery Model Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a three-tiered public health risk reduction approach to the delivery of early intervention and treatment services for people with substance use problems. SBIRT consists of: S BI RT Screening to identify risky or problematic drinking patterns using a short, well-tested questionnaire Brief Intervention featuring a short, structured conversation that provides personalized feedback and harnesses the patient s selfefficacy to alter harmful alcohol-related behaviors Referral to Treatment for additional services, where necessary to fully address the patient s alcohol risk level 11 P a g e

12 Reasons for Supporting SBIRT in EDs Reason #1: SBIRT can help reduce substance abuse. Utilization of the SBIRT model had demonstrated successful reduction of substance abuse in various healthcare populations, including primary care, emergency department, and trauma centers. Screening and brief intervention (SBI) in EDs specifically has demonstrated positive outcomes such as reduced consumption and reduced injury, with both adults and adolescents, in a variety of studies. 8,9 Reason #2: Many agencies support SBIRT. The American College of Emergency Physicians (ACEP) as well as the following federal agencies have endorsed SBIRT as an effective healthcare practice and promote routine screening and brief interventions to reduce the harm of risky substance use: Did you know? Arizona T/RBHAs (Tribal/Regional Behavioral Health Authorities) received Federal funds in Substance Abuse Prevention and Treatment (SAPT) Block Grant funding to cover the cost of substance abuse treatment for individuals who have an addiction to alcohol or other drugs. For more information on SAPT Block Grant Funding, visit: azdhs.gov/bhs/pdf/saptfaqs.pdf Substance Abuse and Mental Health Services Administration (SAMHSA) Centers for Disease Control and Prevention (CDC) National Institute of Alcohol Abuse and Alcoholism (NIAAA) National Institute on Drug Abuse (NIDA) National Highway Transportation Safety Administration (NHTSA) Reason #3: SBIRT can save money. Findings from the Center for Substance Abuse Treatment (CSAT) demonstrated that the implementation of an SBIRT model in Washington State EDs resulted in Medicare savings of $185 per member per month, primarily due to declines in costs associated with inpatient hospitalizations from ED admissions. 10 A study of trauma patients who were screened, and received a brief intervention where indicated, demonstrated a savings of $3.81 for every $1.00 spent on screening and intervention. 3 Reason #4: Over time, SBIRT can reduce workload for ED staff. Gentilello (1999) found that ED patients who received a brief intervention for alcohol in the ED were significantly less likely than control group members to incur a subsequent injury that required medical attention P a g e

13 Screening Patients for Alcohol Who should be screened? At a minimum, all patients who present with alcohol issues or related injuries in the ED should be screened. This practice would help ensure that hazardous drinkers are identified during the course of an ED visit. Some hospitals may choose to screen a broader segment of their patient population; experts suggest that the ideal may be to screen virtually all ED patients. Alternatively, some hospitals may consider screening populations considered at particular risk such as patients presenting with drug abuse issues or suicide risk. Specific criteria for determining who to screen should be decided by an individual hospitals clinical supervisors and risk management professionals. 12 How long does screening take? Prescreening can take as little as 1 minute. Screening and scoring an assessment can take as little as 10 minutes. When should patients be screened? Appropriate times to screen for alcohol are when a patient s anesthetics have worn off, when heavy doses of pain medication are no longer needed, and when the patient is stabilized. As a general rule of thumb, screening should not be performed until a patient can comfortably discuss other subjects. 2 Who should deliver screenings? Screening practices in EDs vary in terms of who provides screening (physicians, nurses, etc.). Screening can be provided by existing clinical staff or existing behavioral health specialist. What method for delivering screenings is most effective? Screening practices in EDs vary in terms of how screening is provided (written, verbally, by computer, etc.). No method has been determined to be more effective than another. 5 Written or computer delivery may at first appear to save time for ED personnel. However, verbal delivery has the advantage of avoiding incorrect responses due to low reading skills or language limitations. In addition, verbal delivery can help foster trust between the provider and the patient that may facilitate the delivery of additional services such as brief interventions. 13 P a g e

14 Description of Screening Tools for Alcohol There are numerous screening tools for alcohol. Some widely-used tools that are succinct and easy to score are listed below. Further details for each tool, including an example of each tool, are provided in the following section. Screening Tools Patient Population Adults Adolescents NIAAA Prescreen X X AUDIT X X RAPS4-Q4 X NIDA-Modified ASSIST X Notes Recommended as a Prescreen for use with the AUDIT Assesses alcohol consumption and presence of at-risk drinking More reliable with men and with some cultural minority groups Screens for alcohol and other drugs; may be helpful in identifying patients presenting with co-occurring substance abuse issues Included in the drug abuse section of this toolkit Note: A Blood Alcohol Concentration (BAC) test is sometimes conducted to identify patients who are currently under the influence of alcohol. Under ARS Section , insurance companies in Arizona can preclude reimbursement for treatment for patients who are under the influence of alcohol at the time they sustained the injury that caused them to require care, which may discourage the use of the BAC. The screening tools in this toolkit are sufficient to determine the need to address substance abuse issues without a BAC test; they are designed to assess overall substance use. How are the results of screening tools useful? Screening tools are useful for identifying patients who engage in problematic patterns of drinking and guiding the patient to appropriate treatment. Screening tools such as those included in this toolkit can identify patients who can benefit from a brief intervention delivered in the ED. To best benefit the patient, any brief intervention should occur shortly after the screening. For more information on delivering brief interventions, see the next section of this toolkit. 14 P a g e

15 NIAAA Prescreen The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that patients be prescreened to determine whether they require further assessment (e.g., the AUDIT). NIAAA Prescreen 13 Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages? NO YES Ask the screening question about heavy drinking days: Screening Complete How many times in the past year have you had. 5 or more drinks in a day (for men)? 4 or more drinks in a day (for women)? Scoring and Interpreting the NIAAA Prescreen Negative Screen: Patients who answers NO to the prescreen question should be applauded for not engaging in at-risk drinking and provided positive reinforcement. Patients who indicate that in the past year they have NOT consumed 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women) should be applauded for not engaging in at-risk drinking and provided positive reinforcement. Positive Screen: Patients who indicate that in the past year they have on at least one occasion consumed 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women) should be given the AUDIT screen, which is described in more detail on page 14. Please remember that the NIAAA Prescreen approach is not sufficient in and of itself for patients who screen positive. These patients should be provided with further screening. 15 P a g e

16 The Alcohol Use Disorders Identification Test (AUDIT) The AUDIT 14 was developed to screen for excessive drinking and to help medical practitioners identify patients who would benefit from reducing or ceasing drinking. It can be used with adults or adolescents. The AUDIT can help distinguish types of alcohol use: Abstinence Low risk drinking: characterized by modest rates of consumption and absence of unsafe behaviors Risky drinking o Hazardous drinking: increases the risk of harmful consequences for the user or others o Harmful use: results in consequences to physical and mental health Alcohol dependence: disorder that may develop after repeated alcohol use and includes characteristics such as impaired control over drinking and persistent drinking despite harmful consequences Scoring and Interpreting the AUDIT Higher scores on the AUDIT indicate greater likelihood of hazardous and harmful drinking. Such scores may also reflect greater severity of alcohol problems and dependence, as well as a greater need for referrals for more intensive treatment. Patient s Score Patient s Risk Level Suggested Intervention <8 <7 if female or age No use or low risk use Provide positive reinforcement is if female or age is 65+ Moderate risk use Moderate-high risk use Perform brief intervention* and consider referral based on clinical judgment Perform brief intervention* and arrange referral for further diagnostic evaluation for alcohol dependence Note: Scores on items 4, 5, and 6 relate to specific symptoms of alcohol dependence and may cue the provider that further diagnostic evaluation for alcohol dependence is warranted despite a lower overall score. *For information on how to conduct a brief intervention in the ED, see guidelines starting on page P a g e

17 RAPS4-QF The RAPS4 15 is a measure of alcohol dependence that was developed specifically for delivery in ED settings. It was enhanced with a question about quantity (Q) and a question about frequency (F) to broaden its relevance for identifying alcohol abusers and to improve its prediction ability. RAPS4-QF is a mnemonic acronym of first letters of key words in the 6 screening questions. R A P S - Q F 1. During the last year have you had a feeling of guilt or Remorse after drinking? 2. During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? (Amnesia) 3. During the last year have you failed to do what was normally expected from you because of drinking? (Perform) 4. Do you sometimes take a drink in the morning when you first get up? (Starter/Eye opener)? 5. During the last year have you had five or more drinks on at least one occasion? (Quantity) 6. During the last year did you drink as often as once a month? (Frequency) Scoring and Interpreting the RAPS4-QF At risk for alcohol dependence: The patient is considered at risk of having alcohol dependency if he/she answers yes to any of the items 1-4 (RAPS4 items). These patients warrant a brief intervention * and further diagnostic evaluation for alcohol dependence. At risk for hazardous drinking: The patient is considered at risk for hazardous drinking if he/she answers yes to Question 5 (the Quantity question) but no to all of Questions 1-4. These patients warrant a brief intervention. * At low risk: The patient is considered low risk if they answer yes to none of the questions or they answer yes to only Question 6 (the Frequency question). These patients should be provided with positive reinforcement. *For information on how to conduct a brief intervention in the emergency department, see guidelines starting on page P a g e

18 Alcohol Screening Tools for Use in the ED 18 P a g e

19 NIAAA Prescreen Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages? NO Screening Complete YES Ask the screening question about heavy drinking days: How many times in the past year have you had. 5 or more drinks in a day (for men)? 4 or more drinks in a day (for women)? Scoring and Interpreting the NIAAA Prescreen Negative Screen: Patients who answers NO to the prescreen question should be applauded for not engaging in at-risk drinking and provided positive reinforcement. Patients who indicate that in the past year they have NOT consumed 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women) should be applauded for not engaging in at-risk drinking and provided positive reinforcement. Positive Screen: Patients who indicate that in the past year they have one at least one occasion consumed 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women) should be given the AUDIT screen,. Remember that the NIAAA Prescreen approach is not sufficient in and of itself for patients who screen positive. These patients should be provided with further screening. 19 P a g e

20 The Alcohol Use Disorders Identification Test (AUDIT) Read questions as written. Record answers carefully. Begin the AUDIT by saying Now I am going to ask you some questions about your use of alcoholic beverages during the past year. Explain what is meant by alcoholic beverages by using local examples of beer, wine, vodka, etc. Code answers in terms of standard drinks. * Place the correct answer number in the box at the right. * A standard drink is typically considered one beer, one glass of wine (5oz.), or one standard mixed drink (one shot or 1.5 oz. of 80 proof spirits) 1. How often do you have a drink containing alcohol? (0) Never [Skip to Qs 9-10] (1) Monthly or less (2) 2 to 4 times a month (3) 2 or 3 times a week (4) 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more 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 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 Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0 4. How often during the last year have you found that you were not able to stop drinking once you 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 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 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 another 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 Record total of specific items here 20 P a g e

21 RAPS4-QF Questions Directions: Begin by explaining what constitutes a drink, i.e., one beer, one glass of wine (5oz.), or one standard mixed drink (one shot or 1.5 oz. of 80 proof spirits). Ask the following questions: 1 During the last year have you had a feeling of guilt or remorse after drinking? No Yes 2 During the last year has a friend or family member ever told you about No Yes things you said or did while you were drinking that you could not remember? 3 During the last year have you failed to do what was normally expected from No Yes you because of drinking? 4 Do you sometime take a drink in the morning when you first get up? No Yes 5 During the last year have you had five or more drinks on at least one occasion? No Yes 6 During the last year did you drink as often as once a month? No Yes Scoring and Interpreting the RAPS4-QF Questions The following guidelines can be used to distinguish likely low risk drinkers, hazardous drinkers, and alcohol dependents: At risk for alcohol dependence: The patient is considered at risk of having alcohol dependency if he/she answers yes to any of the items 1-4 (RAPS4 items). These patients warrant a brief intervention and further diagnostic evaluation for alcohol dependence. At risk for hazardous drinking: The patient is considered at risk for hazardous drinking if he/she answers yes to Question 5 (the Quantity question) but no to all of Questions 1-4. These patients warrant a brief intervention. At low risk: The patient is considered low risk if they answer yes to none of the questions or they answer yes to only Question 6 (the Frequency question). These patients should be provided with positive reinforcement. 21 P a g e

22 Decision Tree for Addressing Patients with Alcohol-Related Issues Using the SBIRT Model Patient is medically cleared and lucid Determine eligibility for screening according to individual hospital criteria Not Eligible Eligible No screening occurs Positive Administer NIAAA Prescreen Negative Administer full screening (e.g. AUDIT, RAPS4-QF) Screening complete No or low risk drinker based on score Risky or hazardous drinker based on score Likely alcohol dependent based on score Provide praise and encouragement Provide brief intervention Provide brief intervention AND referral to treatment or additional assessment This screening process makes no determination whether the patient is under the influence of alcohol in the ED. Clinical judgment may take the place of conclusions drawn from screening tools. 22 P a g e

23 Brief Interventions for Patients with Problematic Drinking What constitutes a brief intervention for alcohol? A brief intervention for alcohol typically consists of a short, non-confrontational counseling session between a health professional and a patient that drinks in ways that are potentially harmful or abusive. Ideally, brief interventions immediately follow a positive screening and can take as little as five minutes. They are intended to reduce patients alcohol consumption and minimize harmful drinking practices. Which patients can benefit most from a brief intervention? While traditional alcohol treatment is focused on helping people who are alcohol dependent, brief interventions were developed to address the larger population of patients with mild to moderate alcohol problems. These patients are ideally positioned to benefit from a brief intervention, in part because the occurrence of an injury can serve as a teachable moment that may help motivate the patient to change. Patients who are alcohol dependent will likely need services beyond a brief intervention; however, providing a brief intervention to these patients may result in reduction in alcohol use and may encourage them to seek additional help sooner. Who can perform brief interventions? Brief interventions can be delivered by a wide range of health professionals, including but not limited to physicians, psychologists, physician assistants, nurses, social workers, mental health or substance abuse counselors, and spiritual care workers. 12 Some factors that may help EDs decide who will perform brief interventions include time availability, interpersonal skills, and knowledge and experience (although background in substance abuse treatment is NOT required). 2 The ability to show empathy may be considered the most necessary skill of the individual who delivers a brief intervention. What are some brief interventions that can be used in the ED? There are various recommended formats for delivering a brief intervention in the ED for alcohol misuse. In general, they are motivational interviewing (MI) strategies for helping the patient identify for themselves reasons to change their behavior and giving them the resources to do so. This toolkit includes instructions for conducting a motivational interview using the FLO framework. The FLO is one of many models for brief intervention delivery. Other models that have been used in ED settings include the Brief Negotiated Interview (BNI) and FRAMES. 23 P a g e

24 The FLO Brief Intervention The goal of a brief intervention is to help the patient decide to lower their risk for substancerelated problems. There are various techniques for delivering a brief intervention. At a minimum, many authorities recommend a framework represented by the acronym FLO. The FLO framework is based on the following elements: F Feedback on screening L Looking for patients reasons for change O Discussing options for change Steps for Conducting a Brief Intervention Based on the FLO Elements * *These recommendations are adapted from Screening, Brief Intervention, and Referral to Treatment for Substance Abuse: A training manual for staff in acute medical settings Use a transition statement to move from the screening to the brief intervention. Example: Thank you for answering all these questions. If it s ok with you, I d like to go over your scores on the questionnaire with you. 2. Set the stage for feedback. F Provide feedback on screening Assure the patient that you are not judging them nor trying to get them to change anything that they are not ready to change. Tell the patient the following to help them understand their score: The range of possible scores on the screening tool (e.g., 0-40 on the AUDIT). Ask the patient what they think their score might be. Tell the patient what normal (low risk) scores are. 3. Give the patient their score. Elicit patient reaction and avoid arguments by asking them what they think about their score. Do not argue that the test is correct or valid. Do not get into debates about whether the patient is an alcoholic or addict. It is not necessary for patients to accept a label before they can change. They just have to become concerned with the status quo to become motivated to change. I m less concerned about labels and more concerned about whether you think your use of alcohol is hurting you at all. 24 P a g e

25 L - Elicit change talk with a positive approach Ask the following Importance questions: On a scale of 1 to 10, how important is it to you to make a change in your drinking? Why didn t you give it a lower number? What would make you give it a higher number? 4. Ask the following Confidence questions: If you decided to make a change in your drinking, on a scale of 1-10, how confident are you that you would succeed? Why didn t you give it a lower number? What would make you give it a higher number? Asking the Importance and Confidence questions will help: Keep the conversation positive; reduce pushback from the patient Help the patient identify things they value that may be threatened by their alcohol use such as physical health, staying out of legal trouble, keeping a job, maintaining relationships 5. Summarize both sides of the patient s view. Example: On one hand, you don t think you re addicted.on the other hand, your legal problems make you think you will do something different fairly soon Useful questions for summarizing the patient s point of view: Ask about the link between what is precious and alcohol: I heard you say that the most important thing for you now is keeping a paycheck coming in. How does your alcohol use fit in with your ability to get up on time for work? Ask about the future: How would you like your drinking to look 5 years from now? Be gone? Be less? Be the same? 25 P a g e

26 O Option for change discussion Following these FLO guidelines will: Ask about the future. So what do you think you will do? So what are your options for the future? Note: Discuss one substance at a time as patients sometimes choose different options for different substances. ( It seems like you are most concerned about alcohol and less concerns about marijuana.is it ok if we just focus on alcohol for now? ) Reduce push-back from patients who often get told they must abstain from all substances Guide patients to explore options that they have never before considered Reduce status quo talk ( I m not an addict, therefore I don t need to change ) Encourage patient to consider each substance that they use separately, and avoid the quit everything or quit nothing conflict 8. Provide the patient a menu of options. M Manage your use: [Cut down to within low use guidelines for alcohol] One thing you might try is cutting down on how often you drink, like try doing it only on weekends instead of on workdays E Eliminate use: [Quit alcohol] Another option might be to stop using alcohol N Never take certain risks: [Drive after drinking, mix drugs and alcohol] altogether. Some people don t want to cut down or quit, but they are willing to take a look at some of the risks they incur when they do use. U Utterly no change: [Don t quit, don t You might decide not to make any changes at all cut down. Don t avoid harm] in your lifestyle right now. S Seek help Some people decide they need to get help. What to do with patients high in CONFIDENCE but low in IMPORTANCE ( I can change if I want to but it s not important. ): Ask hypothetically: If for some reason you someday decided to change, what would you do? Manage your use? Eliminate use? Never take certain risks? Utterly no change? Seek help? Prove to them that you respect their choice not to take action yet: I can see that although you re taking this seriously, you re not entirely ready to take action right away. 26 P a g e

27 Try to leave a pebble in their shoe by planting doubt about the status quo: I hear that you don t think that alcohol caused you to be stabbed, but I can t help but wonder if you would even be here if you weren t drinking that night, because you might have gone somewhere else instead of the club. What do you think? Remind patient of their autonomy: Nobody can decide for you. It s completely up to you to choose what you will do. What to do with patients low in CONFIDENCE ( I need to change but it s too hard. ): Be optimistic; loan patients your confidence until they have their own: I believe that your chances are actually better than you think. Tell them about the success of others: I can tell you that many people have successfully quit drinking alcohol, despite not believing at first that they could do it. They tell me they enjoy life much more compared to when they were drinking. Tell them that most people have to try to change several times before it sticks: The fact that you ve tried several times to quit bodes well for your success. Actually, it s the people who fail once and never try again that don t make it. 9. Close the brief intervention on good terms. Why it is so important to close on good terms? So the next interventionist will have it easier than you did Because of you close on bad terms, they will remember the conversation as unpleasant and therefore discount your message Because you will enjoy your work more It will promote better relationships within the ED if you re seen as a positive addition, and not someone who angers/upsets patients Examples for closing on good terms: I think you did a great job talking about this, under very tough circumstances. Thanks for taking the time to discuss this matter. You really kept an open mind throughout. I admire your honesty and determination. I believe that you will know what the right thing to do is, once you make up your mind. People are most likely to change if they feel that you value and like them! 27 P a g e

28 Referral to Treatment for Patients with Possible Alcohol Dependence Identifying Patients for Referral to Treatment Many patients who present to EDs with alcohol-related issues are hazardous or risky drinkers and may benefit from the screening and brief intervention tools included in previous sections of this toolkit. A smaller portion of adults who present to the ED, however, are alcohol dependent. For this population, brief interventions in the ED are recommended, but it is less likely that such interventions will be enough to change their behavior. These patients may benefit from additional counseling or treatment. It is important to remember that screening tools are not diagnostic tools; patients for whom there is evidence of alcohol dependency should be referred for a diagnostic evaluation by a behavioral health professional. Determining Referral Guidelines Results from screening tools can help ED staff determine when a referral is appropriate. The table below summarizes how each screening tool included in this toolkit can be used to identify patients who may be alcohol dependent or at high risk for alcohol dependency that may benefit from additional counseling or treatment services. ED staff should use their discretion in relying solely on screening tools for identifying patients with alcohol dependence. Referral to Treatment Guidelines Based on Alcohol Screening Results Provide brief intervention in the ED and referral to treatment Provide brief intervention in the ED Provide positive reinforcement AUDIT: Age 65+ Female AUDIT: Age <65 Male RAPS4-QF Less than Less than No to all Qs or yes to Q6 only Yes to Q5, but no to Qs 1-4 Yes to Qs 1,2,3, or 4 Referral Resources for Emergency Department Personnel Section 4 of this toolkit contains a decision tree and resource lists that can assist ED personnel in locating referral and treatment services for patients: 28 P a g e

29 Aftercare Materials for Patients with Identified Alcohol Problems ED staff may want to provide aftercare materials to patients with identified alcohol problems or to their caregivers and family members. The materials listed below may be accessed and downloaded from the Arizona Department of Health Services (ADHS) Department of Behavioral Health Services (DBHS) website Materials for Patients Resources for Arizona Patients Tips for Drinking in Moderation (For adults and older adolescents) Drinking Risks for Older Adults (For older adults) Understanding Addiction (For adults and older adolescents) Recovery Strategies and Coping Skills (For adults and older adolescents) Alcohol Addiction Treatment and Self Help (For adults) Older Adults and Alcohol: You Can Get Help (For older adults) Rethinking Drinking: Alcohol and Your Health (For adults) Drinking and Your Pregnancy (For pregnant women) Alcohol: A Women s Health Issue (For women) Beyond Hangovers: Understanding Alcohol s Impact on Your Health (For adults) Materials for Patients in Spanish Understanding Addiction (For adults and older adolescents) Drinking and Your Pregnancy (For pregnant women) Materials for Family Members or Caregivers Tips for Talking about Another s Alcohol Issues (For caregivers of adults with alcohol issues) Discouraging Your Child From Continued Alcohol Use (For parents or caregivers of children and adolescents with alcohol issues) Tips for Talking with Your Child about Alcohol Use (For parents or caregivers of children and adolescents with alcohol issues) Hope, Help, and Healing: A guide to helping someone who might have a drug or alcohol problem (For family members or caregivers of adults) Suspect Your Teen is Using Drugs or Drinking? A brief guide to action for parents (For parents of teens) Make a Difference: Talk to your child about alcohol (For parents of children ages 10-14) What is Substance Abuse Treatment: A booklet for families It Feels So Bad (For teens with family members with alcohol issues) 29 P a g e

30 Materials for Family Members or Caregivers in Spanish Hope, Help, and Healing: A guide to helping someone who might have a drug or alcohol problem (For family members or caregivers of adults) What is Substance Abuse Treatment: A booklet for families 30 P a g e

31 Section 2: Addressing Drug Use in Emergency Department Patients 31 P a g e

32 Section 2: Addressing Drug Use in ED Patients Misconceptions about Drug Addiction Many misconceptions persist about drug addiction and which may interfere with successful initiation of substance abuse treatment in the ED. The following are some of the most common misconceptions about addiction: Misconception: Addiction is a willpower problem. People can stop, if they really want to. Reality: A person starts out as an occasional drug user, and that is a voluntary decision. But as time passes, something happens, and that person goes from being a voluntary drug user to being a compulsive drug user. Over time, continued use of addictive drugs changes a person s brain -- some times in dramatic, toxic ways, at other times in more subtle ways, but virtually always in ways that result in compulsive and even uncontrollable use. Misconception: Addicts should be punished, not treated. Reality: Science is demonstrating that addicts have a brain disease that causes them to have impaired control over their use. Addicts need treatment for their changed brain chemistry, to learn to cope with triggers, and to learn to re-socialize without chemicals. Some people get into cycles of criminal behavior precisely because they must sustain their drug or alcohol use. Their bodies and brain tell them they will not survive without the substance. Misconception: People don't need treatment. They can stop using if they really want to. Reality: It is extremely difficult for people addicted to drugs to achieve and maintain long-term abstinence. Research shows that long-term alcohol and other drug use actually changes a person's brain function, causing them to crave the drug even more, making it increasingly difficult for the person to quit. Misconception: Treatment just doesn't work. Reality: Studies show drug treatment reduces drug use by 40 to 60 percent and can significantly decrease criminal activity during and after treatment. 32 P a g e

33 Misconception: Addicts who continue to abuse alcohol/drugs after treatment are hopeless. Reality: Addiction is a chronic disorder; occasional relapse does not mean failure. Stress from work or family problems, social cues (i.e. meeting individuals from one's drug-using past), or their environment (i.e. encountering streets, objects, or even smells associated with alcohol or other drug use) can easily trigger a relapse. Addicts are most vulnerable to drug use during the few months immediately following their release from treatment. 1 The ED: A Viable Setting for Intervening with Patients with Drug Use Issues Some but not all ED patients presenting with drug issues are drug dependent. Interventions for patients who present with drug issues at various levels can be initiated in hospital and ED settings. Serious injuries may serve as teachable moments during an ED visit. 6 Medical professionals in EDs have an opportunity to assess these individuals for drug use and to provide, where appropriate, brief interventions. Research has shown that when the motivating aspects of injury are coupled with a targeted intervention, patients have been shown to change their substance abuse behavior. 7 One strategy for capitalizing on the teachable moment to promote behavior change that has gained widespread support is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model. The SBIRT Service Delivery Model Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a three-tiered public health risk reduction approach to the delivery of early intervention and treatment services for people with substance use problems. SBIRT consists of: S BI RT Screening to identify risky or problematic substance use patterns using a short, well-tested questionnaire Brief Intervention featuring a short, structured conversation that provides personalized feedback and harnesses the patient s selfefficacy to alter harmful substance-related behaviors Referral to Treatment for additional services, where necessary to fully address the patient s risk level 33 P a g e

34 Reasons for Supporting SBIRT in EDs Reason #1: SBIRT can help reduce substance abuse. Utilization of the SBIRT model has demonstrated successful reduction of substance abuse in various healthcare populations, including primary care, emergency department, and trauma centers. SBI is recommended for patients who may be abusing drugs and has demonstrated success in recent research 5,17 Reason #2: Many agencies support SBIRT. The American College of Emergency Physicians (ACEP) as well as the following federal agencies have endorsed SBIRT as an effective healthcare practice and promote routine screening and brief interventions to reduce the harm of risky substance use: Did you know? Arizona T/RBHAs (Tribal/Regional Behavioral Health Authorities) received Federal funds in Substance Abuse Prevention and Treatment (SAPT) Block Grant funding to cover the cost of substance abuse treatment for individuals who have an addiction to alcohol or other drugs. For more information on SAPT Block Grant Funding, visit: azdhs.gov/bhs/pdf/saptfaqs.pdf Substance Abuse and Mental Health Services Administration (SAMHSA) Centers for Disease Control and Prevention (CDC) National Institute of Alcohol Abuse and Alcoholism (NIAAA) National Institute on Drug Abuse (NIDA) National Highway Transportation Safety Administration (NHTSA) Reason #3: SBIRT can save money. Findings from the Center for Substance Abuse Treatment (CSAT) demonstrated that the implementation of an SBIRT model in Washington State EDs resulted in Medicare savings of $185 per member per month, primarily due to declines in costs associated with inpatient hospitalizations from ED admissions. 10 A study of trauma patients who were screened, and received a brief intervention where indicated, demonstrated a savings of $3.81 for every $1.00 spent on screening and intervention. 3 Reason #4: Over time, SBIRT can reduce workload for ED staff. Researchers have found that ED patients who received a brief intervention for alcohol in the ED were significantly less likely than control group members to incur a subsequent injury that required medical attention P a g e

35 Screening Patients for Illicit Drug Use Who should be screened? At a minimum, all patients who present with illicit drug use or related injuries in the ED should be screened to help ensure that patents using drugs are identified during the course of an ED visit. Some hospitals may choose to screen a broader segment of their patient population. Some hospitals may consider screening populations considered at particular risk such as patients presenting with alcohol issues or suicide risk. Specific criteria for determining who to screen should be decided by an individual hospitals clinical supervisors and risk management professionals. 12 When should patients be screened? Appropriate times to screen for illicit drug use are when a patient s anesthetics have worn off, when heavy doses of pain medication are no longer needed, and when the patient is stabilized. As a general rule of thumb, screening should not be performed until a patient can comfortably discuss other subjects. 2 Who should deliver screenings? Screening practices in EDs vary in terms of who provides screening (physicians, nurses, etc.). Screening can be provided by existing clinical staff or existing behavioral health specialists. 4 What method for delivering screenings is most effective? Screening practices in EDs vary in terms of how screening is provided (written, verbally, by computer, etc.). No method has been determined to be more effective than another. 5 Written or computer delivery may at first appear to save time for ED personnel. However, verbal delivery has the advantage of avoiding incorrect responses due to low reading skills or language limitations. In addition, verbal delivery can help foster trust between the provider and the patient that may facilitate the delivery of additional services such as brief interventions. 35 P a g e

36 Description of Screening Tools for Drug Use What screening tools for drug use can be delivered in EDs? Some widely-used tools that are succinct and easy to score are listed below. Further details for each tool, including an example of each tool, are provided in the following section. Screening Tools NIDA-Modified ASSIST CRAFFT Patient Population Adults Adolescents X X Notes Screens for individual drugs, alcohol, and tobacco use A general screen for alcohol and drug use by adolescents How are the results of screening tools useful? Screening tools are useful for identifying patients who engage in illicit drug use and identifying appropriate treatment. Screening tools such as those included in this toolkit can identify patients who can benefit from a brief intervention delivered in the ED. *For information on how to conduct a brief intervention in the ED, see guidelines starting on page P a g e

37 NIDA-Modified ASSIST The NIDA-Modified ASSIST 18 (Alcohol, Smoking and Substance Involvement Screening Test) was originally developed by the World Health Organization (WHO) and is designed for use with adults who are at least 18 years of age. The tool, which includes a short series of screening questions, is used to generate a Substance Involvement (SI) score that helps identify a patient s risk of having or developing a substance use disorder. In addition, the SI score suggests the level of addiction recovery treatment (if any) that a patient may need. Scoring and Interpreting the NIDA-Modified ASSIST To calculate the Substance Involvement (SI) score for the NIDA-Modified ASSIST, add up the scores received for Questions 1-6. Do not include the results from either Step 1 (Prescreen) or Question 7 in the SI score. The patient will receive an SI score for each substance endorsed, not a cumulative score. The patient s risk level may differ from drug to drug. Use the SI score to identify the patient s risk level and identify if conducting a brief intervention with the patient is warranted: Patient s SI Score Patient s Risk Level Suggested Intervention 27 High Risk Perform brief intervention* and arrange referral to treatment 4-26 Moderate Risk Perform brief intervention* and consider referral based on clinical judgment 0-3 Lower Risk Reinforce abstinence and provide positive reinforcement Note: If more than one substance is reported, focus a brief intervention on the substance with the highest score. *For information on how to conduct a brief intervention in the ED, see guidelines starting on page P a g e

38 CRAFFT Screening Tool for Children and Adolescents The CRAFFT 19 is a six question screening tool designed to screen adolescents ages for high-risk alcohol and other drug use disorders simultaneously. The tool, which is recommended by the American Academy of Pediatrics Committee on Substance Abuse, can help determine whether a longer conversation (or brief intervention) about substance use is warranted. It has been shown to work well for boys and girls, for younger and older adolescents, and among youth from diverse racial backgrounds. CRAFFT is a mnemonic acronym of first letters of key words in the 6 screening questions. C R A F F T Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? Do you ever use alcohol or drugs while you are by yourself, or ALONE? Do you ever FORGET things you did while using alcohol or drugs? Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or drugs? Note: The CRAFFT is accompanied by three consumption questions about substance use. Scoring and Interpreting the CRAAFT Each Yes response to the CRAFFT questions is scored 1 point. Adolescents who report no use of alcohol or drugs and have a CRAFFT score of 0 should receive praise and encouragement. Those who report any use of alcohol or drugs and have a CRAFFT score of 0 or 1 should be encouraged to stop and receive brief advice regarding the adverse health effects of substance use. For information on how to conduct a brief intervention in the ED, see guidelines starting on page 48. A CRAFFT score of 2 or greater is a positive screen and indicates that the adolescent is at high-risk for having an alcohol or drug-related disorder and requires further assessment. 38 P a g e

39 Drug Use Screening Tools for Use in the ED 39 P a g e

40 NIDA-Modified ASSIST Name:.. Sex ( ) F ( ) M Age:.. Interviewer:.. Date:./ /. Sample Introduction (Please convey to patient): Hi, I m, nice to meet you. If it s okay with you, I d like to ask you a few questions that will help me give you better medical care. The questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we ll talk about are prescribed by a doctor (like pain medications). But I will only record those if you have taken them for reasons or in doses other than prescribed. I ll also ask you about illicit or illegal drug use but only to better diagnose and treat you. Instructions: For each substance, mark in the appropriate column. For example, if the patient has ever used cocaine in their lifetime, put a mark in the Yes column in the cocaine row. Prescreen Question: In your lifetime, which of the following substances have you ever used? For prescription medications, please report nonmedical use only. 1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) 2. Alcoholic beverages (beer, wine, liquor, etc.) 3. Cannabis (marijuana, pot, grass, hash, etc.) 4. Cocaine (coke, crack, etc.) 5. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) 6. Methamphetamine (speed, crystal meth, ice, etc.) 7. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) 8. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) 9. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) 10. Street opioids (heroin, opium, etc.) 11. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) 12. Other specify: No Yes If the patient says NO for all drugs in Prescreen, reinforce abstinence. Screening is complete. If the patient says YES to any of the drugs, ask Question 1 of the NIDA-Modified ASSIST tool (on the following page). Page 1 40 P a g e

41 Never Once or Twice Monthly Weekly Daily or Almost Daily Question 1 Instructions: Patients may fill in the following form themselves but screening personnel should offer to read the questions aloud in a private setting and complete the form for the patient (circle number in appropriate row/column). 1. In the past three months, how often have you used the substances you mentioned (first drug, second drug, etc.)? a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) b. Alcoholic beverages (beer, wine, liquor, etc.) c. Cannabis (marijuana, pot, grass, hash, etc.) d. Cocaine (coke, crack, etc.) e. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) f. Methamphetamine (speed, crystal meth, ice, etc.) g. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) h. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) i. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) j. Street opioids (heroin, opium, etc.) k. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) l. Other specify: For patients who report Never having used any drug in the past 3 months: Go to Question 5-7. For any recent illicit or nonmedical prescription drug use, go to Question 2. For tobacco and alcohol, see next page. Page 2 41 P a g e

42 For Tobacco and Alcohol Use a. For patients who report use of tobacco: Any current tobacco use places a patient at risk. Advise all tobacco users to quit. For more information on smoking cessation, please see Helping Smokers Quit: A Guide for Clinicians at b. For alcohol: Question patient in more details about frequency and quantity of use: c. For men: How many times in the past year have you had 5 or more drinks in a day? d. For women: How many times in the past year have you had 4 or more drinks in a day? If the answer is: None: Advise patient to stay within these limits For healthy men under the age of 65: No more than 4 drinks per day AND no more than 14 drinks per week. For healthy women under the age of 65 and not pregnant (and healthy men over the age of 65): No more than 3 drinks per day AND no more than 7 drinks per week. Recommend lower limits or abstinence as medically indicated; for example for patients who: a. Take medications that interact with alcohol b. Have a health condition exacerbated by alcohol c. Are pregnant (advise abstinence) Encourage talking openly about alcohol and any concerns it may raise, re-screen annually. One or more times of heavy drinking ( 5 for men; 4 for women): Patient is an at-risk drinker. Page 3 42 P a g e

43 Never Once or Twice Monthly Weekly Daily or Almost Daily Never Once or Twice Monthly Weekly Daily or Almost Daily Questions 2-7 Instructions: Patients may fill in the following form themselves but screening personnel can offer to read the questions aloud in a private setting and complete the form (circle number in appropriate row/column). To preserve confidentiality, a protective sheet should be placed on top of the questionnaire so it will not be seen by other patients after it is completed but before it is filed in the medical record. 2. In the past three months, how often have you had a strong desire or urge to use (first drug, second drug, etc.)? a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: In the past three months, how often has your use of (first drug, second drug, etc.) led to health, social, legal or financial problems? a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: Page 4 43 P a g e

44 Never Once or Twice Monthly Weekly Daily or Almost Daily 4. In the past three months, how often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc.)? a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: Instructions: Ask Questions 5 & 6 for all substances ever used (i.e., those endorsed in the Prescreen). 5. Has a friend or relative or anyone else ever expressed concern about your use of (first drug, second drug, etc.)? No, never Yes, but not in the past 3 months Yes, in the past 3 months a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: Page 5 44 P a g e

45 6. Have you ever tried and failed to control, cut down or stop using (first drug, second drug, etc.)? No, never Yes, but not in the past 3 months Yes, in the past 3 months a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: Instructions: Ask Question 7 if the patient endorses any drug that might be injected, including those that might be listed in the other category (e.g., steroids). Circle the appropriate response. 7. Have you ever used any drug by injection (NONMEDICAL USE ONLY)? No, never Yes, but not in the past 3 months Yes, in the past 3 months Recommend to patients reporting any prior or current intravenous drug use that they get tested for HIV and Hepatitis B/C. If patient reports using a drug by injection in the past three months, ask about their pattern of injecting during this period to determine their risk levels and the best course of intervention. If patient responds that they inject once weekly or less OR fewer than 3 days in a row, provide a brief intervention including a discussion of the risks associated with injecting. If patient responds that they inject more than once per week OR 3 or more days in a row, refer the patient for further assessment. Note: Recommend to patients reporting any current use of alcohol or illicit drugs that they get tested for HIV and other sexually transmitted diseases. Page 6 45 P a g e

46 Tally Sheet for scoring the full NIDA-Modified ASSIST Instructions: For each substance (labeled a-j), add up the scores received for questions 1-6 above. This is the Substance Involvement (SI) score. Do not include the results from either the Prescreen or Q7 (above) in your SI scores. Substance Involvement Score Total (SI Score) a. Cannabis (marijuana, pot, grass, hash, etc.) b. Cocaine (coke, crack, etc.) c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) d. Methamphetamine (speed, crystal meth, ice, etc.) e. Inhalants (nitrous oxide, glue, gas, etc.) f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) h. Street opioids (heroin, opium, etc.) i. Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) j. Other specify: Use the Substance Involvement (SI) Score to identify patient s risk level. To determine patient s risk level based on his or her SI score, see the table below: Level of risk associated with different Substance Involvement Score ranges for Illicit or nonmedical prescription drug use 0-3 Lower Risk 4-26 Moderate Risk 27+ High Risk Page 7 46 P a g e

47 CRAFFT Screening Tool for Children and Adolescents Screening using the CRAFFT begins by asking the adolescent to Please answer these next questions honestly; reminding him/her of your office confidentiality policy; and then asking 3 opening questions. During the past 12 months, did you: 1. Drink any alcohol (more than a few sips)? 2. Smoke any marijuana or hashish? 3. Use anything else to get high? Anything else includes illegal drugs, over the counter and prescription drugs, and things that you sniff or huff. If the adolescent answers No to all 3 opening questions, the provider only needs to ask the adolescent the first question the CAR question. If the adolescent answers Yes to any 1 or more of the 3 opening questions, the provider asks all 6 CRAAFT questions. (See Figure Below) CRAFFT is a mnemonic acronym of first letters of key words in the 6 screening questions. The questions should be asked exactly as written. C Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? R A F Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? Do you ever use alcohol or drugs while you are by yourself, or ALONE? Do you ever FORGET things you did while using alcohol or drugs? F T Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into TROUBLE while you were using alcohol or drugs? Scoring and Interpreting the CRAAFT Each Yes response to the CRAFFT questions is scored 1 point. Adolescents who report no use of alcohol or drugs and have a CRAFFT score of 0 should receive praise and encouragement. Those who report any use of alcohol or drugs and have a CRAFFT score of 0 or 1 should be encouraged to stop and receive brief advice regarding the adverse health effects of substance use. A CRAFFT score of 2 or greater is a positive screen and indicates that the adolescent is at highrisk for having an alcohol or drug-related disorder and requires further assessment. 47 P a g e

48 Decision Tree for Addressing the Needs of Patients with Drug-Related Issues Using the SBIRT Model Patient is medically cleared and lucid Determine eligibility for screening according to individual hospital criteria Not Eligible Eligible No screening occurs Conduct screening (e.g. ASSIST, CRAFFT) No or low risk drug user based on score Moderate drug user based on score High risk drug user based on score Provide praise and encouragement Provide brief intervention and consider referral to treatment Provide brief intervention AND referral to treatment or additional assessment Clinical judgment may take the place of conclusions drawn from screening tools. 48 P a g e

49 Brief Interventions for Patients with Drug Abuse What constitutes a brief intervention for drug use? A brief intervention for drug use typically consists of a short, non-confrontational counseling session between a health professional and a patient that uses drugs in ways that are potentially harmful or abusive. Ideally, brief interventions immediately follow a positive screening and can take as little as five minutes. They are intended to reduce patients consumption and minimize harmful drug use practices. Which patients can benefit most from a brief intervention? Patients who present to EDs and who have mild to moderate drug problems are ideally positioned to benefit from a brief intervention, in part because the occurrence of an injury can serve as a teachable moment that may help motivate the patient to change. Patients who are chemically dependent will likely need services beyond a brief intervention; however, providing an intervention to these patients is recommended as it may result in reduction of use and may also encourage them to seek additional help sooner. Who can perform brief interventions? Brief interventions can be delivered by a wide range of health professionals, including but not limited to physicians, psychologists, physician assistants, nurses, social workers, mental health or substance abuse counselors, and spiritual care workers. 12 Some factors that may help EDs decide who will perform brief interventions include time availability, interpersonal skills, and knowledge and experience (although background in substance abuse treatment is NOT required). 2 The ability to show empathy may be considered the most necessary skill of the individual who delivers a brief intervention. What are some brief interventions that can be used in the ED? There are various recommended formats for delivering a brief intervention in the ED for drug misuse. In general, they are motivational interviewing (MI) strategies for helping the patient identify for themselves reasons to change their behavior and giving them the resources to do so. This toolkit includes instructions for conducting a motivational interview using the FLO framework. The FLO is one of many models for brief intervention delivery. Other models that have been used in ED settings include the Brief Negotiated Interview (BNI) and FRAMES. 49 P a g e

50 The FLO Brief Intervention The goal of a brief intervention is to help the patient decide to lower their risk for substancerelated problems. There are various techniques for delivering a brief intervention. At a minimum, many authorities recommend a framework represented by the acronym FLO. The FLO framework is based on the following elements: F Feedback on screening L Looking for patients reasons for change O Discussing options for change Steps for Conducting a Brief Intervention Based on the FLO Elements * *These recommendations are adapted from Screening, Brief Intervention, and Referral to Treatment for Substance Abuse: A training manual for staff in acute medical settings Use a transition statement to move from the screening to the brief intervention. Example: Thank you for answering all these questions. If it s ok with you, I d like to go over your scores on the questionnaire with you. 7. Set the stage for feedback. F Provide feedback on screening Assure the patient that you are not judging them nor trying to get them to change anything that they are not ready to change. Tell the patient the following to help them understand their score: The range of possible scores on the screening tool (e.g., 0-40 on the AUDIT). Ask the patient what they think their score might be. Tell the patient what normal (low risk) scores are. 8. Give the patient their score. Elicit patient reaction and avoid arguments by asking them what they think about their score. Do not argue that the test is correct or valid. Do not get into debates about whether the patient is an alcoholic or addict. It is not necessary for patients to accept a label before they can change. They just have to become concerned with the status quo to become motivated to change. 50 P a g e

51 I m less concerned about labels and more concerned about whether you think your use of alcohol is hurting you at all. L - Elicit change talk with a positive approach Ask the following Importance questions: On a scale of 1 to 10, how important is it to you to make a change in your drinking? Why didn t you give it a lower number? What would make you give it a higher number? 9. Ask the following Confidence questions: If you decided to make a change in your drinking, on a scale of 1-10, how confident are you that you would succeed? Why didn t you give it a lower number? What would make you give it a higher number? Asking the Importance and Confidence questions will help: Keep the conversation positive; reduce pushback from the patient Help the patient identify things they value that may be threatened by their alcohol use such as physical health, staying out of legal trouble, keeping a job, maintaining relationships 10. Summarize both sides of the patient s view. Example: On one hand, you don t think you re addicted.on the other hand, your legal problems make you think you will do something different fairly soon Useful questions for summarizing the patient s point of view: Ask about the link between what is precious and alcohol: I heard you say that the most important thing for you now is keeping a paycheck coming in. How does your alcohol use fit in with your ability to get up on time for work? Ask about the future: How would you like your drinking to look 5 years from now? Be gone? Be less? Be the same? 51 P a g e

52 O Option for change discussion Following these FLO guidelines will: Ask about the future. So what do you think you will do? So what are your options for the future? Note: Discuss one substance at a time as patients sometimes choose different options for different substances. ( It seems like you are most concerned about alcohol and less concerns about marijuana.is it ok if we just focus on alcohol for now? ) Reduce push-back from patients who often get told they must abstain from all substances Guide patients to explore options that they have never before considered Reduce status quo talk ( I m not an addict, therefore I don t need to change ) Encourage patient to consider each substance that they use separately, and avoid the quit everything or quit nothing conflict 9. Provide the patient a menu of options. M Manage your use: [Cut down to within low use guidelines for alcohol] One thing you might try is cutting down on how often you drink, like try doing it only on weekends instead of on workdays E Eliminate use: [Quit alcohol] Another option might be to stop using alcohol N Never take certain risks: [Drive after drinking, mix drugs and alcohol] altogether. Some people don t want to cut down or quit, but they are willing to take a look at some of the risks they incur when they do use. U Utterly no change: [Don t quit, don t You might decide not to make any changes at all cut down. Don t avoid harm] in your lifestyle right now. S Seek help Some people decide they need to get help. What to do with patients high in CONFIDENCE but low in IMPORTANCE ( I can change if I want to but it s not important. ): Ask hypothetically: If for some reason you someday decided to change, what would you do? Manage you use? Eliminate use? Never take certain risks? Utterly no change? Seek help? Prove to them that you respect their choice not to take action yet: I can see that although you re taking this seriously, you re not entirely ready to take action right 52 P a g e

53 away. Try to leave a pebble in their shoe by planting doubt about the status quo: I hear that you don t think that alcohol caused you to be stabbed, but I can t help but wonder if you would even be here if you weren t drinking that night, because you might have gone somewhere else instead of the club. What do you think? Remind patient of their autonomy: Nobody can decide for you. It s completely up to you to choose what you will do. What to do with patients low in CONFIDENCE ( I need to change but it s too hard. ): Be optimistic; loan patients your confidence until they have their own: I believe that your chances are actually better than you think. Tell them about the success of others: I can tell you that many people have successfully quit drinking alcohol, despite not believing at first that they could do it. They tell me they enjoy life much more compared to when they were drinking. Tell them that most people have to try to change several times before it sticks: The fact that you ve tried several times to quit bodes well for your success. Actually, it s the people who fail once and never try again that don t make it. 10. Close the brief intervention on good terms. Why it is so important to close on good terms? So the next interventionist will have it easier than you did Because of you close on bad terms, they will remember the conversation as unpleasant and therefore discount your message Because you will enjoy your work more It will promote better relationships within the ED if you re seen as a positive addition, and not someone who angers/upsets patients Examples for closing on good terms: I think you did a great job talking about this, under very tough circumstances. Thanks for taking the time to discuss this matter. You really kept an open mind throughout. I admire your honesty and determination. I believe that you will know what the right thing to do is, once you make up your mind. People are most likely to change if they like you and feel that you value them. 53 P a g e

54 Referral to Treatment for Patients with Drug Abuse Identifying Patients for Referral to Treatment Many patients who present to EDs with substance abuse issues may benefit from the screening and brief intervention tools included in previous sections of this toolkit. A portion of adults who present to the ED, however, are chemically dependent. For this population, brief interventions in the ED are recommended, but it is less likely that such interventions will be enough to change their behavior. These patients may benefit from additional counseling or treatment. It is important to remember that screening tools are not diagnostic tools; patients for whom there is evidence of chemical dependency should be referred for a diagnostic evaluation by a behavioral health professional. Determining Referral Guidelines Results from screening tools can help ED staff determine when a referral is appropriate. The table below summarizes how each screening tool included in this toolkit can be used to identify patients who may be chemically dependent or at high risk for chemical dependency that may benefit from additional counseling or treatment services. ED staff should use their discretion in relying solely on screening tools for identifying patients with drug addiction(s). Other indicators may also need to be taken into account in the decision making process. Referral to Treatment Guidelines Based on Drug Screening Results Provide positive reinforcement Provide brief intervention in the ED and referral to treatment Provide brief intervention in the ED NIDA-Modified ASSIST CRAFFT Report no use and have CRAFFT score of 0 Report any use and have CRAFFT score of 0 or 1 CRAFFT score 2 Referral Resources for Emergency Department Personnel Section 4 of this toolkit contains a decision tree and resource lists that can assist ED personnel in locating referral and treatment services for patients. 54 P a g e

55 Aftercare Materials for Patients with Identified Drug Problems ED staff may want to provide aftercare materials to patients with identified drug problems or to their caregivers and family members. The materials listed below may be accessed and downloaded from the Arizona Department of Health Services (ADHS) Department of Behavioral Health Services (DBHS) website Materials for Patients Resources for Arizona Patients Consequences of Drug Use for Young Adults (For young adults) Consequences of Drug Use for Youth (For adolescents and young adults) Short and Long Term Health Consequences of Drug Use (For adults) Abuse of Prescription Drugs: Effects and Prevention (For adults of all ages) Recovery Strategies and Coping Skills (For adults and older adolescents) Understanding Addiction (For adults and older adolescents) Materials for Patients in Spanish Understanding Addiction (For adults and older adolescents) Materials for Family Members or Caregivers Warning Signs a Friend or Family Member May be Abusing Drugs (For caregivers) Hope, Help, and Healing: A guide to helping someone who might have a drug or alcohol problem (For family members or caregivers of adults) Suspect Your Teen is Using Drugs or Drinking? A brief guide to action for parents (For parents of teens) What is Substance Abuse Treatment: A booklet for families (For families) Materials for Family Members or Caregivers Hope, Help, and Healing: A guide to helping someone who might have a drug or alcohol problem (For family members or caregivers of adults) What is Substance Abuse Treatment: A booklet for families (For families) 55 P a g e

56 Section 3: Addressing Suicide Risk in Emergency Department Patients 56 P a g e

57 Section 3: Addressing Suicide Risk in ED Patients Suicide: A Serious Public Health Concern in Arizona According Arizona Department of Health Services (ADHS) Vital Statistics, suicide has been one of the top ten causes of death in Arizona every year for over a decade. The median charge for a self-inflicted injury-related hospitalization was $14,614 and hospital charges for self-inflicted injury-related hospitalizations in 2009 alone totaled over $116.8 million. Misconceptions about Suicidality Although patients presenting with issues of suicidality or deliberate self harm (DSH) come to emergency departments every day, some EDs may feel underprepared to fully address the immediate needs of these individuals. Many misconceptions persist about suicidal individuals that may undermine effective patient care. Below are some common misconceptions: Misconception: Asking about suicide would plant the idea in my patient's head. Reality: Asking how your patient feels doesn t create suicidal thoughts any more than asking how your patient s chest feels would cause angina. Misconception: There are talkers and there are doers. Reality: Most people who die by suicide have communicated some intent. Any person who talks about suicide provides an opportunity for health professionals to intervene before suicidal behaviors occur. Misconception: Anyone who tries to kill him/herself must be crazy. Reality: Most suicidal people are not psychotic or insane. They may be upset, griefstricken, depressed or despairing, but extreme distress and emotional pain are always signs of mental illness and are not signs of psychosis. Misconception: If somebody wants to die by suicide, there is nothing you can do about it. Reality: Most suicidal ideas are associated with the presence of underlying treatable disorders. Providing a safe environment for treatment of the underlying cause can save lives. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and the strong intent to die by suicide, then you will have gone a long way towards promoting a positive outcome. 57 P a g e

58 Misconception: He/she really wouldn't kill themselves since..she has young children at home.he signed a No Harm Contract.he knows how dearly his family loves him Reality: The intent to die can override any rational thinking. In the presence of suicidal ideation or intent, the physician should not be dissuaded from thinking that the patient is capable of acting on these thoughts and feelings. No Harm or No suicide contracts have been shown to be essentially worthless from a clinical and management perspective. The anecdotal reports of their usefulness can all be explained by the strength of the alliance with the care provider that results from such a collaborative exchange, not from the specifics of the contract itself. Misconception: People who die by suicide are people who were unwilling to seek help. Reality: Studies of suicide victims have shown that more than half had sought medical help within six months before their deaths. Misconception: Multiple and apparently manipulative self-injurious behaviors mean that the patient is just trying to get attention and are not really suicidal. Reality: Suicide gestures require thoughtful assessment and treatment. Multiple prior suicide attempts increase the likelihood of eventually dying by suicide. The task is to empathically and non-judgmentally engage the patient in understanding the behavior and finding safer and healthier ways of asking for help. 20,21 58 P a g e

59 Guidelines for Addressing the Needs of Suicidal Patients in EDs Below are some guidelines 22 that can help the ED respond appropriately to patient presenting with issues of suicidality: 1. Restrict the means of a suicide attempt in the ED. The patient presenting with issues of suicidality should not be left alone. The patient should be checked for weapons, pills, and other threats to safety. Suicide means such as unguarded window, electric cords, etc., should be removed from the patient s access. 2. The patient should be medically cleared. Patients presenting with suicide issues who arrive at the ED with physical injuries or other immediate health needs (e.g., drug overdose) should have these issues addressed before a risk assessment is performed. A physical exam may help rule out underlying medical explanations for mental health symptoms. A patient who cannot reach medical stability at the ED should be referred for inpatient admission to medical services with psychiatric consult or transferred to an inpatient psychiatry unit. 3. Once medically cleared a preliminary suicide risk assessment should be conducted to determine immediate risk. This determination may involve the following: Intention Plan Previous attempts Available means 4. The patient who is identified as at immediate or high risk for suicide should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold. The patient at low or ambiguous risk according to a preliminary assessment should receive a more comprehensive assessment before being released. 5. If mental health staff are not available to assess, trained ED personnel can assess using the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) included in this toolkit. Screening tools alone should not be relied upon in making an assessment; the whole picture should be taken into account. A patient who is determined to be at immediate or high risk should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold. 59 P a g e

60 6. A patient presenting with suicide issues should be screened for risky or problematic substance use. Substance abuse is a risk factor for suicide. If substance abuse issues are identified, they can be addressed in the ED, often with a brief intervention (See earlier sections of this guide.) 7. A patient who is medically cleared and is determined to be at less than high or immediate risk for suicide can be released under certain circumstances: A supervising adult has been identified who will maintain close monitoring until scheduled outpatient follow up appointment A supervising adult has been identified and informed how to respond should the patient s condition deteriorate (e.g., return to ED) A supervising adult has been instructed how to reduce means in the home of the patient (e.g., securing of firearms, removal of lethal medications, etc.) (See Brief Intervention below) Did you know? In Arizona, firearms and poisoning are the most frequently used mechanisms for death by suicide A referral for urgent outpatient follow-up should be arranged for every patient presenting with suicidality who is released from the ED. 60 P a g e

61 Decision Tree for Addressing the Needs of Suicidal Patients in the ED Restrict the means of a suicide attempt in the ED Medically clear the patient Immediate/ High risk Preliminary assessment to determine immediate risk Mental health consultation and/or admission to an inpatient psychiatric unit; take suicide precautions Immediate/ High risk Low/ ambiguous risk More comprehensive assessment such as the SAFE-T Moderate risk Low risk Consider admission If released: develop crisis plan; referral for urgent outpatient follow up with a mental health professional; symptom reduction; give emergency/crisis numbers Referral for urgent outpatient follow up with a mental health professional; symptom reduction; give emergency/crisis numbers A supervising adult should be instructed how to reduce suicide means in the home of the patient Can be released in accordance with careful guidelines with social supports established Assessment tools should support the decision but the whole picture needs to be taken into account in determining level of risk Suicidal patients should be assessed for risky substance use 61 P a g e

62 Assessing Patients for Suicidality Which patients should be assessed? At a minimum, patients who present to the ED with a suicide attempt or suicidal ideations should be assessed for current level of risk. Patients presenting with drug overdose may also be considered for assessment, even if the overdose in not recognized as a suicide attempt. Evidence has suggested that a fairly high percentage of people who die by suicide had a visit with a healthcare provider in the previous year, 23 indicating that it also could be lifesaving to screen a broader patient population for suicide risk. Is your patient suicidal? 1 in 10 suicides are by people seen in an ED within 2 months of dying, yet many patients are never assessed for suicide risk. When should patients be assessed? Once medically cleared, a preliminary suicide risk assessment to determine immediate risk should be conducted with all patients who present in the ED having attempted suicide or with suicidal ideations. This preliminary assessment may contain elements such as intention, plan, previous attempts, and available means, and should identify individuals at current high risk for suicide attempt, who should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold. The patient at low or ambiguous risk according to a preliminary assessment should receive a more comprehensive assessment to support the findings from the preliminary screening and to provide further services as indicated. Who should deliver assessments? It is important to remember that suicide risk assessment tools are not diagnostic tools, which should be delivered by mental health professionals. Assessment tools are designed to be delivered by ED personnel, including physicians, nurses, social workers, and mental health staff. 62 P a g e

63 Will assessing for suicide be sufficient? Some suicide assessment tools may require screening for other issues that increase the risk for suicide, such as substance abuse and depression. Screening tools for substance abuse are described early in this toolkit. A common screening tool for assessing depression is the Beck Depression Inventory (BDI). Details regarding the BDI can be found in the following publication: Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (June 1961). "An inventory for measuring depression." Arch. Gen. Psychiatry 4: Can assessment tools adequately assess suicide risk? Screening tools are not considered sufficient alone to assess suicide risk. Many suicide risk assessment tools, including the one included in this toolkit, do not have a scoring system because they are intended to help the assessor identify relevant risk factors while leaving the assessment of actual risk to the assessor. Each patient should be evaluated on a case-by-case basis taking the whole picture into account. 63 P a g e

64 Description of Assessment Tools for Suicidality What assessment tool for suicidality can be delivered in EDs? Many tools to assess suicidality have been developed, typically for screening general populations. A tool that can be used to help assess suicide risk in ED patients is the Suicide Assessment Five-step Evaluation and Triage (SAFE-T). This tool has been endorsed by the American College of Emergency Physicians (ACEP), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Suicide Prevention Resource Center (SPRC). Further details, including the tool itself, are provided in the following section of this toolkit. Patient Population Screening Tools Adults Adolescents SAFE-T (2009 version) X X Notes Evidence-based Assessment of adolescents includes consultation with parent or guardian 64 P a g e

65 Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) 24 was conceived of by Douglas Jacobs, a doctor of psychiatry at Harvard Medical School, and developed in collaboration with the Suicide Prevention Resource Center (SPRC). It is based on the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors and designed for use with adults and adolescents. Implementing this tool with adolescents assumes the inclusion of parents or guardians, consulting them in Step 3 (Suicide Inquiry) and providing them with a role in the treatment plan in Step 5 (Documentation). The SAFE-T tool is comprised of the following steps: 1. Identify risk factors 2. Identify protective factors 3. Conduct a suicide inquiry (current suicidal thoughts, plan, behavior and intent) 4. Determine risk level and need for intervention (based on Steps 1-3). Reassess and redetermine risk level and appropriate intervention level as the patient or environmental circumstances change 5. Document risk level, rationale, treatment plan, means restriction instruction, and follow-up plan. Documentation should continue throughout each reassessment Interpreting the SAFE-T Determining risk level and appropriate level of intervention using the SAFE-T tool is based on Steps 1-3 (identifying risk factors, identifying protective factors, and conducting a suicide inquiry): Risk/Protective Factors Suicidality Patient s Risk Level Psychiatric disorder with Potentially lethal High Risk severe symptoms, or suicide attempt or acute precipitating event; persistent ideation protective factors not with strong intent of relevant suicide rehearsal Multiple risk factors; few protective factors Modifiable risk factors; strong protective factors Suicidal ideation with plan but no intent or behavior Thoughts of death; no plan intent, or behavior Moderate Risk Low Risk Suggested Intervention Admission generally indicated unless a significant change reduces risk. Take suicide precautions Admission may not be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers Outpatient referral. Symptom reduction. Give emergency/crisis numbers 65 P a g e

66 Suicide Assessment Tool for Use in the ED 66 P a g e

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