Substance Use Disorder

General Substance Use Disorder

Single Item Drug abuse question:
NIDA Single-Item Drug Use
"How many times in the past year have you used an illegal drug or prescription medication for non-medical
reasons?”
• Identifies overall drug use
• Positive screen = 1 or more times
• Provide BI/RT if positive

Alcohol Use Disorder:

Single Question Alcohol Screening:
Each “standard” drink contains 13.6 grams of alcohol.

NIAAA Single-Item Alcohol Use Question-

“How many times in the past year have you had X or more drinks in a day?”
• X = 5 for men, 4 for women
• Identifies unhealthy alcohol use
• Positive Scree = score 1 or more (= positive screen) will need a BI
(=> BI, Brief Intervention – See below)
o My follow up for +ve screen à AUDIT-C
AUDIT-C
(another screening test) better than CAGE questionnaire – see App. 1 for the full table.
3 questions: (Determine drink equivalence before asking, see above diagram and App. 3 below)
Q1: How often did you have a drink containing alcohol in the past year? (>2-3 times/wk)
Q2: How many drinks did you have on a typical day when you were drinking in the past year? (>5-6)
Q3: How often did you have six or more drinks on one occasion in the past year? (>Monthly)

In men, a score of 4 or more is considered positive; in women, a score of 3 or more is considered positive.
Generally, the higher the AUDIT-C score, the more likely it is that the patient's drinking is affecting his/her
health and safety. (Any answer on the Yellow marks or beyond is high risk)
Determine functional impact
Determine functional impact of alcohol use by asking:
(From SADD questionnaire, see App. 2 below)
1. Do you find you find thinking of drinking most of the time?
2. Do you plan your day around when and where you can drink?
3. Do you drink as much as you want irrespective of what you are doing the next day?
4. Do you know that you won’t be able to stop drinking once you start?
5. The morning after a heavy drinking session do you need your first drink to get yourself going?
6. The morning after a heavy drinking session do you wake up with a definite shakiness of your hands?
7. The morning after a heavy drinking session do you go out of your way to avoid people?
My addition to above list – Ever failed to fulfill your duties at work or at home?
Ever got into trouble with police/legal issues for drinking?

Elements of BI:
(From SBIRT Webiner presentation)
Ø Screening score feedback
o Using a non-judgmental voice: “From your responses, your drinking puts you at higher risk for
many health and emotional concerns than those who drink at lower ranges. These questions
have been given to thousands of people, so you can compare your drinking to others. Your score
was [#]...on a scale of 0-12 (for AUDIT-C) which places you in the category of [moderate or high]
risk.”
Ø Education (Risks, Guidelines)
o Discuss health risk of Alcohol or other substances:
§ “Unhealthy alcohol use can put you at risk for injury, accident, and health problems such
as depression, diabetes, cancer, insomnia, High blood pressure, stroke, heart and
gastrointestinal problems, and other conditions.”
o Review drinking guidelines
§ “The recommended guidelines for healthy adults are no more than 1 drink/day (or 7
drinks/weeks) for women and adults over the age 65, and no more than 2 drinks/day (or
14 drinks/week) far men.”
o Education is done using Normative Feedback
§ Personalized Normative Feedback
• Like social marketing, personalized normative feedback approaches use information designed to
correct normative misperceptions to reduce heavy drinking. Based on this, personalized
normative feedback has a few initial requirements. If personalized normative feedback is
theoretically based on the premise of correcting normative misperceptions, then these
misperceptions must be present. Three pieces of information are necessary when providing
personalized normative feedback: information about a student’s own drinking, information
about the student’s perceptions of others’ drinking, and information about others’ actual
drinking. The presentation of this information is designed to change students’ perceptions of
“normal” drinking by exposing their misperceptions of the norm as well as by comparing their
behavior with “normal” behavior. In contrast to social marketing interventions, normative
feedback that is personalized and presented individually is likely to have a greater impact
because it is more salient3 and explicit in revealing discrepancies among individual behavior,
perceived “typical” student behavior, and actual “typical” student behavior.
§ Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2459316/
Ø Simple advice and expression of clinical concern
o “Reducing your consumption to safer drinking levels can decrease your risk of health problems.”
o “I advise you to cut back your alcohol/drugs consumption.”
o 10 to 30% of clients would significantly reduce alcohol/tobacco/diabetic risky behavior
 Ø Provide Resources
o Provide booklets regarding cutting down the mountain thinking and also mixing alcohol with
other medications
Ø Exploring motivation using MI and CBT strategies
o Explore ambivalence
§ Pros and cons of alcohol use
• What are the good things about your alcohol/tobacco?
• What are some of the less good things?
• What concerns do you have about your alcohol/tobacco use?
• If you would change, what would it be like?
• Where does this leave you now?
(Does it make you willing to change your substance/EtOH use now? = my version)
o Explore readiness
§ Importance and confidence rulers
• How important it is too you to quit using alcohol/tobacco/Begin treatment?
o If 0 was not important and 10 was very important what number would
you give yourself?
o Why are you not at X and not Y? (always start with the higher number)
o What would have to happen for each to become much more important
for you to change?
• If you decided right now to stop drinking/tobacco, how confident do you feel
about succeeding with this?
o If 0 was not confident and 10 was very confident, what number would
you give yourself?
o What would make you more confident about making these changes?
o Why have you given yourself such a high score on confidence?
o How could you move up higher, so that your score goes from X to Y?
o How can I help you succeed?
o Explore goals
§ If you were to decide to change, what might your option be?
§ What is your next step?
§ How would you do that?
§ Are there anyways you know about that have worked for other people?
§ Is there anything you found it helpful in any previous attempt to change?
o Elicit change talk – “I really want to cut back on drinking with the guys after work.”
Ø Close on good terms
o Say “Thank you”: “Thank you for taking a few minutes to talk with me about your alcohol/drug
use. I appreciate your openness and sharing your experiences/ thoughts with me today.”
Ø Make referral linkage for high risk of dependency, or complicated cases
o “Based on the information you provided, I would encourage you to concentrate getting
additional help for dealing with issues related to alcohol/drugs.”
o “I would like to refer for you to….”
Video examples
• http://www.youtube.com/watch?v=TGhj06- sM2Y&feature=player_embedded
• http://www.youtube.com/watch?v=4smHqphkBgs (4:25-5:00)
FRAMES Intervention Protocol:
• Feedback is given to the individual about personal risk or impairment.
• Responsibility for change is placed on the participant.
• Advice to change is given by the provider.
• Menu of alternative self-help or treatment options is offered to the participant.
• Empathic style is used in counseling.
• Self-efficacy or optimistic empowerment is engendered in the participant.
(Source: https://www.ncbi.nlm.nih.gov/books/NBK64942/)
Appendix
Appendix 1
AUDIT-C
The Alcohol Use Disorders Identification Test (AUDIT-C) is an alcohol screen that can help identify patients
who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence).
AUDIT-C
The Alcohol Use Disorders Identification Test is a publication of the World Health Organization, @ 1990
Q1: How often did you have a drink containing alcohol in the past year?
Answer Points
Never 0
Monthly or less 1
Two to four times a month 2
Two to three times a week 3
Four or more times a week 4
Q2: How many drinks did you have on a typical day when you were drinking in the past year?
Answer Points
None, I do not drink 0
1 or 2 0
3 or 4 1
5 or 6 2
7 to 9 3
10 or more 4
Q3: How often did you have six or more drinks on one occasion in the past year?
Answer Points
Never 0
Less than monthly 1
Monthly 2
Weekly 3
Daily or almost daily 4
The AUDIT-C is scored on a scale of 0-12 (scores of 0 reflect no alcohol use). In men, a score of 4 or more is considered
positive; in women, a score of 3 or more is considered positive. Generally, the higher the AUDIT-C score, the more
likely it is that the patient's drinking is affecting his/her health and safety.
Source: https://www.hepatitis.va.gov/provider/tools/audit-c.asp#S1X
Appendix 2
Severity Assessment EtOH:
SHORT ALCOHOL DEPENDENCE DATA QUESTIONNAIRE (SADD)

Source: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.331.5207&rep=rep1&type=pdf
Appendix 3
Drink Equevalence:
1 Drink equivalent:

A pint is either a British ("imperial") pint of 20 imperial fluid ounces (568 ml) or an American pint of 16 US fluid
ounces (473 ml). Measurement is typically used to serve beer, and also often for cider.
ABV = Alcohol by Volume

ABV stands for Alcohol By Volume and is usually listed as a percentage. By law in the United States, the ABV must be listed on each
beer to give customers an idea about how much alcohol is in each brew.
This percentage lets you know how much of your beer is alcohol and how much is other stuff, like water. Simply put, the higher the
ABV, the more drunk you’ll get. Beer can be anywhere between 2% to 12% ABV, though you’ll generally find it in the 4% to 6%
range. (Source: http://berghoffbeer.com/blog/what-do-abv-and-ibu-mean/)
ABV for different drinks:
Drink Typical ABV
Fruit juice (naturally occurring) 0%-0.09%
Low-alcohol beer 0.05%–1.2%
Beer 2.0%–12% (usually 4%–6%)
Cider 2.0%–12% (usually 4%–8%)
Malt liquor 5.0%+
Wine 9%–16% (most often 12.5%–14.5%)[5]
Liqueurs 15%–55%
Fortified wine 15.5%–20%[6] (in the European Union, 18%–22%)
Vodka 35%–95% (usually 40%, minimum of 37.5% in the European Union)
Rum 37.5%–80% (usually 40%)
Brandy 35%–60% (usually 40%)
Gin 37.5%–50%
Whisky 40%–68% (usually 40%, 43% or 46%)
Scotch 40%–63.5%
Rectified spirit 95% up to a practical limit of 95.6%
Source: Wikipedia