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Screening for Drug uSe in general MeDical SettingS

Resource Guide

This guide is designed to assist clinicians serving adult patients in screening for drug use. This screening tool was adapted from the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Version 3.0, developed and published by WHO (available at http://www.who.int/substance_abuse/ activities/assist_v3_english.pdf).

This pamphlet is in the public domain and may be reproduced.

Screening for Drug Use in General Medical Settings: A Resource Guide for Providers

Table of Contents Introduction BeforeYouBeginScreeningPatients TheNIDAModifiedASSISTScreeningTool Step1:Ask ConductingaBriefIntervention Step2:Advise Step3:Assess Step4:Assist Step5:Arrange Appendices RecommendationsToAddressPatientResistance SampleProgressNotes ChangePlanWorksheet BiologicalSpecimenTesting AdditionalResources

Introduction
ThisResourceGuideisintendedtoprovide cliniciansservingadultpopulations in generalmedicalsettingswiththescreening toolsandproceduresnecessarytoconduct screening,briefintervention,and/or treatmentreferralforpatientswhomay haveorbeatriskofdevelopingasubstance usedisorder.Screeningandbrief interventionprovidesanopportunityfor clinicianstointerveneearlyandpotentially enhancemedicalcarebyincreasing awarenessofthelikelyimpactofsubstance useonapatientsoverallhealth. Why screen for drug use (including tobacco, alcohol, illicit [i.e., illegal], and nonmedical use of prescription drugs)? Druguse(licitorillicit)isharmfuland hasmanyadverseconsequences. Multiplephysicalhealth,emotional,and interpersonalproblemsareassociated withillicitdruguse.Cardiovascular disease,stroke,cancer,HIV/AIDS, anxiety,depression,sleepproblems,as wellasfinancialdifficultiesandlegal, work,andfamilyproblemscanallresult fromorbeexacerbatedbydrugabuse. 1 Theuseofillicitdrugsismorecommon thanyoumightthink.In2007,an estimated19.9millionAmericansaged 12orolder(~8.0percentofthe population)werecurrentillicitdrug users,whichmeanstheyhadusedan illicitdrugduringthemonthpriortothe survey.Nearly1in5Americansaged 1825hadusedillicitdrugsinthepast month. 2 Onlyafractionofindividualswhoneed specialtytreatmentfordrugoralcohol
This resource guide does not specifically address the unique considerations that must be taken into account when screening adolescents or pregnant women.

addictionactuallyreceiveiteachyear. In2007,ofthemorethan23million personsaged12orolderwhoneeded specializedtreatmentforadrugor alcoholproblem,mostalmost21 milliondidnotreceiveit. 3 Routine screeningforsubstanceusedisorders couldalterthisstatisticandgetmore peoplethehelptheyneed. Usingscreeningandbriefintervention proceduresingeneralmedicalsettings canmakeadifferenceindruguse behaviors.Researchhasdemonstrated thatscreeningandbriefinterventioncan promotesignificantreductionsinalcohol andtobaccouse. 4,5,6 Agrowingbodyof literaturealsosuggestsbenefitsof screeningandbriefinterventionforillicit ornonmedicalprescriptiondruguseas well. 7 How do you screen and provide feedback? Asamedicalprovider,youareanimportant figureinyourpatientslives.Inaveryshort conversation,youhaveawonderful opportunitytoletyourpatientsknowifand howtheirdrugusemaybeputtingtheir healthatrisk. TheFiveAsofIntervention(Ask,Advise, Assess,Assist,Arrange)canbeauseful frameworkforencouragingpatientstoquit smokingandmayalsobeusefulfor screeningandprovidingfeedbackrelatedto otherdruguse. ASKScreeningisthefirstAbecauseitasks oneormorequestionsrelatedtodruguse. ADVISEThesecondAinvolvesstrong directpersonaladvicebytheprovidertothe patienttomakeachange,ifitisclinically indicated. 2

ASSESSThethirdAreferstodetermining ARRANGEThefinalAistoreferthe howwillingapatientistochangehisorher patientforfurtherassessmentand behaviorafterhearingtheprovidersadvice. treatment,ifappropriate,andtosetup followupappointments. ASSISTThefourthAreferstohelpingthe patientmakeachangeifhe/sheappears ready. Ifyouarenotalreadydoingso,weencourageyoutoincorporatedrugusescreeningand briefinterventionintoyourpractice.TheremainderofthisResourceGuideprovidesdetailed informationtobeginscreeningfor:

Tobacco

Alcohol

Illicit Drugs

Nonmedical Prescription Drug Use

Before you begin screening patients


Whilemosthealthcaresettingshave establishedprocessesandproceduresfor patientscreeningofhealthconditionssuch ashighbloodpressure,cholesterol,breast orprostatecancer,etc.,drugabuse screeningingeneralmedicalsettings involvesadditionalpractical considerations: 8,9 Determinestaffingroles,includingwho willadministerthescreeninginstrument; discussresultswithpatients;and interveneand/orreferwhennecessary. Traindesignatedstafftoconduct screening,intervention,andreferral. Decidehowscreeningresultswillbe usedanddevelopaprocedurefor handlingpositiveandnegativeresults. Note:Screeningisnotafullassessment; referpatientsforafullassessmentifa problemisindicatedbythescreenor throughdiscussionwiththepatient. Applyexistingofficeproceduresto screeningpractices,includingpatient documentation,consentprocedures, confidentialityandHIPAAprocedures, storageofrecords,andpatientflow. Obtainreimbursementinformationfor yourState. o In2007,theCentersforMedicare andMedicaidServices(CMS) adoptednewcodesforalcoholand substanceabuseassessmentand interventionservicesinthe HealthcareCommonProcedure CodingSystem(HCPCS). o InJanuary2008,theAmerican MedicalAssociation(AMA)adopted CurrentProceduralTerminology (CPT)codesforscreeningandbrief intervention,andnewMedicareG codesbecameavailablethatparallel theCPTcodes(see http://sbirt.samhsa.gov/coding.htm formoreinformation). Establishrelationshipsandlinkageswith externalproviderswhowillaccept referralsforadditionalassessment and/ordrugtreatment. Considerpatientreadinglevelwhen providingeducationalandsupport materials.Becauseitisoftendifficultto determinereadinglevel,particularlyin emergencyroomsituations,consider usingmaterialsdevelopedforan8th gradereadinglevel. Dealwithsevere,immediatelylife threateningmedicalconsequencesof substanceabuseasyouwouldanyother medicalemergency. o Ifsamedaysubstanceabuse treatmentassessmentisnot available,transferpatienttothe emergencyroomoradmittothe hospital. o Arrangealternativetransportation forpatientsundertheinfluenceof drugs,alcohol,ormedicationthat wouldimpairtheirdriving.Forthese patients,thebriefintervention shouldfocusoncrisismanagement.

The NIDA-Modified ASSIST

Step 1: ASK about drug use.


Thisscreeninginstrumentisappropriateforpatientsage18orolder.Youmaydeliveritasan interviewandrecordpatientresponses,orreadthePrescreenquestionaloudandhavethe patientcompletetheremainingquestions(ifapplicable)asawrittenquestionnaire.Itis recommendedthatthepersonadministeringthescreeningreviewthesamplescriptto introducethescreeningprocess.Thescriptoffershelpfullanguageforintroducingwhatcan beasensitivetopicforpatients. A. Introduce yourself and establish rapport. Step 1: ASK about drug use. A. Introduce yourself and establish rapport. B. Ask about lifetime drug use. C. Begin the NIDA-Modified WHO ASSIST. D. Score the ASSIST and identify patients risk level.

Beforeyoubegintheinterview,pleasereadthefollowing tothepatient: Hi,Im__________,nicetomeetyou.Ifitsokaywith you,Idliketoaskyouafewquestionsthatwillhelpme giveyoubettermedicalcare.Thequestionsrelateto yourexperiencewithalcohol,cigarettes,andother drugs.Someofthesubstanceswelltalkaboutare prescribedbyadoctor(likepainmedications).ButIaminterestedinthoseonlyifyouhave takenthemforreasonsorindosesotherthanprescribed takenthemforreasonsorindosesotherthanprescribed.Illalsoaskyouaboutillicitor illegaldrugusebutonlytobetterdiagnoseandtreatyou. Ifthepatientdeclinesscreening,advisethepatientthatyourespectthatdecisionbut wouldliketoinformhim/heraboutthepotentialharmsofdruguse. B. Ask patients about lifetime drug use using the Prescreen Question of the NIDA-Modified ASSIST.
Reminder: Patients should be advised of the limits of Withoutbeingjudgmentalorconfrontational,askthe confidentiality and patientifheorshehaseverusedanyofthesubstances insurance coverage for listedseethePrescreenquestionontheNIDAModified conditions occurring ASSIST under the influence of alcohol or illicit drugs ( http://www.drugabuse.gov/nidamed/screening/nmassist.p (these vary by State and df)foralist.Note:Ifthepatientmentionsadrugnoton provider). thelist(e.g.,steroids),pleaseenteritintheother category. Bepreparedtogentlyprobecertainquestions.Forexample,ifthepatientanswers Notoeverysubstance,askaprobingquestionsuchasNotevenwhenyouwere younger,perhapsinhighschoolorcollege? IfthepatientsaysNoforalldrugsinPrescreen,reinforceabstinence.Forexample, youmaysayItisreallygoodtohearyouarentusingdrugs.Thatisaverysmart healthchoice.Screeningiscomplete. IfthepatientsaysYestoanyofthedrugs,gotoC.

Begin the NIDA-Modified ASSIST (Link to PDF of tool). ForpatientswhoanswernevertoQuestion1(Inthepastthreemonths,howoften haveyouusedthesubstancesyoumentioned?):SkiptoQuestions57todetermineif theyhavesymptomsofapriorsubstanceuseproblem.Providefeedback(seeStep2) andreinforceabstinence.

For patients who report use of tobacco: Any tobacco use in the past three months placesapatientatrisk. o Advisealltobaccouserstoquit.Formoreinformationonsmokingcessation, pleaseseeHelpingSmokersQuit:AGuideforCliniciansat http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm. Forpatientswhoreportuseofalcohol:Questionthepatientinmoredetailabout frequencyandquantityofuse: Iftheansweris: None:Advisepatienttostaywithintheselimits. Forhealthymenundertheageof65:Nomorethan4drinksperdayANDno morethan14drinksperweek. Reminder: Forhealthywomenundertheageof65andnot pregnant(andhealthymenovertheageof65): Many people dont know Nomorethan3drinksperdayANDnomorethan what counts as a standard drink (e.g., 12 oz beer, 5 oz 7drinksperweek. wine, 1.5 oz liquor). Recommendlowerlimitsorabstinenceas medicallyindicatedforpatientswho: For information, please see http://pubs.niaaa.nih.gov/publ Takemedicationsthatinteractwith ications/Practitioner/Clinician alcohol sGuide2005/clinicians_guide Haveahealthconditionexacerbatedby 13_p_mats.htm alcohol Arepregnant(adviseabstinence). Encouragepatientstotalkopenlyaboutalcoholandanyconcernsthatmay arise,rescreenannually. Oneormoretimesofheavydrinking(5formen;4forwomen):Patientis anatriskdrinker. 7

PleaseseetheNationalInstituteonAlcoholAbuseandAlcoholism(NIAAA) WebsiteHelpingpatientswhodrinktoomuch:Acliniciansguideat http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clini cians_guide.htmforadditionalinformationtoAsk,Assess,Advise,Assist,and Arrangehelpforatriskdrinkersorpatientswithalcoholusedisorders. For patients who report any illicit or nonmedical prescription drug use, go to Questions2through7.Note:AskQuestion7ifthepatientreportstheuseofanydrug that might be injected, including those that might be listed in the other category (e.g.,steroids).

Forpatientswhoreportalcoholaswellasanyillicitornonmedicalprescriptiondrug use,askalcoholfollowupquestionsandthengotoQuestions27. D. Score the full NIDA-Modified ASSIST for illicit and nonmedical prescription drug use. Foreachsubstance,addupthescoresreceivedforQuestions16.Thisisthe SubstanceInvolvement(SI)score.DonotincludetheresultsfromeitherStep1 (Prescreen)orQuestion7inyourSIscore.ThepatientwillreceiveanSIscoreforeach substanceendorsed,notacumulativescore.Therefore,thepatientsrisklevelmay differfromdrugtodrug. UsetheresultantSIscoretoidentifypatientsrisklevel.Ifmorethanonesubstanceis reported,focusinterventiononthesubstancewiththehighestscore.

Reminder: Use clinical judgment if the patient reports use of multiple drugs but does not score highly on any of them (i.e., consider an intervention).

Conducting a Brief Intervention

Step 2: ADVISE patient according to screening results.


Thisbriefinterventiongivespatientsachancetolearnabouttheirdruguseespeciallyasit pertainstotheirhealthfromanobjectivethirdpartywithmedicaltraining.Itreliesonthe premisethatadvicefromanexperthasbeenshowntopromotechange. 10,11 A. Review screening results with the patient. Step 2: Discuss screening results. Askpermissiontohaveashortdiscussionabout A. Review screening results. thescreeningresults. B. Provide medical advice. Reportbackthetypesandamountsofuse reported(givingpatientstheNIDAModifiedASSISTtallysheetmaybehelpful). Allowthepatienttocorrectomissionssoyougetthefullpictureofuse.Promptthe patient:TellmemoreaboutyouruseofdrugXandY(foreachdrugthepatient reported). Ifthepatienthasusedwithinthepast3months,reviewotherASSISTresponses. B. Provide medical advice about Reminders to improve patient rapport: the patients drug use. Avoid tone that the patient might think is judgmental or Explainthatitisyourroleas confrontational. his/hermedicalproviderto Show an interest in what the patients life is like. conveyhealthrecommendations. Acknowledge the patients current view of his/her drug use. Recommendquittingbefore Signal to the patient that having mixed feelings about a drug use problem is normal. s problems(ormoreproblems) develop.Givespecificmedical reasons. o Medicallysuperviseddetoxificationmaybenecessaryfordiscontinuinguseof somedrugs(e.g.,benzodiazepines).

Whenappropriate,educatepatientsonthefollowing: Reminder: o Useofevensmallamountsofdrugsortobacco maynegativelyimpacthealthandperformance The screen is only one indicator of a patients potential drug use (e.g.,drivingoroperatingmachinery). problem. It is not a substitute o Becausedrugintoxicationcanleadtoimpaired for clinical judgment, which judgmentandriskybehaviors,referallsexually you should use to determine activepatientsforconfidentialtestingforHIVand when an intervention is warranted. othersexuallytransmitteddiseasesorprovidean onsitetestingopportunity,iftheydonotknow theirstatusorhavenotbeentestedrecently.Encourageallpatientstopractice safesex. o Referallpatientswithpastorcurrentinjectiondruguse(Question7)forHIVand HepatitisB/Ctestingiftheyhavenotbeentestedtwiceovera6monthspan followingtheirlastinjection. 10

Makereferralstoevaluatesuspectedcooccurringconditions(e.g.,psychiatric consultationfordepressed,inattentive,oranxiouspatientsorpainspecialist consultationforpatientsseekingnarcoticprescriptionsforchronicnonmalignant pain). Providerecommendationsbasedonrisklevel:


Risk level High risk Recommendation Astrongrecommendationtochangesubstanceuseisessential.Considermakinga statementsuchas:Basedonthescreeningresults,youareathighriskofhaving ordevelopingasubstanceusedisorder.Itismedicallyinyourbestinterestto stopyouruseof[insertspecificdrugshere].Iamconcernedthatifyoudonot makeachangequickly,theconsequencestoyourhealthandwellbeingmaybe serious.Includeareferralforadditionalassessment(theNIDAModifiedASSIST providesarisklevel,butnotadiagnosisofabuseordependence).Letthepatient knowthattheassessmentwilldeterminewhethertheyhaveadiagnosisof substanceabuseordependenceandifsubstanceabusetreatmentisindicated. Whethertoattendtreatmentwillbethepatientsdecision. Specificexamplesofharmfordifferentproblemdrugcategoriesmaybe helpful. Emphasizethattherearemanywaystochangesubstanceusebehavior(e.g., communitytreatmentprograms,selfhelpgroups,medications,etc.). Emphasizethattreatmentisoftenonanoutpatientbasisandprogramsare oftenaccommodatingofconcernslikemaintainingemployment,insurance reimbursement,childcare,etc.,dependingonthepatientsconcerns. Considerbeginningthediscussionbysaying,Basedonthescreeningresults,you areatmoderateriskofhavingordevelopingasubstanceusedisorder.Itis medicallyinyourbestinteresttochangeyouruseof[insertspecificdrugshere]. Addinformationthatisspecifictothedrugsthepatientuses. Expressyourconcernaboutspecificwaysdrugsmightnegativelyimpactyour patientslife(e.g.,health,relationships,work,etc.). Emphasizethattherearemanywaystochangesubstanceusebehavior(e.g., communitytreatmentprograms,selfhelpgroups,medications,etc.). Considerhavingadiscussionaboutacceptablelevelsofuseandthepotentialfor futureproblems.YoumaybeginthediscussionbysayingYourscreeningresults showyouareunlikelytohaveasubstanceusedisorder.However,peoplewith anyhistoryofsubstanceusecanbeatsomeriskofadverseconsequencesand developingadisorderespeciallyintimesofstressoriftheyhavejuststartedto userecently.Itisimpossibletoknowinadvancewhetherornotapersonwill becomeaddicted.AsyourphysicianIencourageyoutoonlyusealcohol moderatelyandresponsiblyandtoavoidusingothersubstances. Interventiondurationmaybeminimal Useyourclinicaljudgmentbasedonthemedicalstatusofthepatientanddrug beingused.Forexample,pregnantwomen,*youth,peoplewithhistoriesof substanceusedisorders,andothersforwhomanydrugusecouldpotentially poseaseriousriskmaybenefitfromacompleteinterventionregardlessof apparentrisklevel.

Moderate risk

Lower risk

* Providers should be aware that many States mandate reporting of drug use during pregnancy and that failure to do so may be a prosecutable offense.

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Step 3: ASSESS the patients readiness to quit.


Haveaconversationaboutwhetherthepatientisreadytoquit.Forexample,youmight saysomethinglike,Givenwhatwevetalkedabout,doyouwanttochangeyourdrug use? Ifthepatientisunwillingtoquit,raiseawareness Steps 3 and 4: aboutdrugsasahealthproblem.Letpatientswho A. Assess patients readiness arenotreadyknowthatyouwillrevisittheissueat to quit. futurevisitsandhaveresourcesavailablewhen B. Assist patient in making a he/shedecidestopursuemakingachange. change. Ifthepatientisreadytoquit,reinforcecurrent effortsandmovetoStep4.

Step 4: ASSIST patient in making a change.


Jointlycompleteaprogressnoteform(Appendix2)withthepatienttodocumentthe screeningresultsandcreateafollowupplan. Helpsetconcrete(andreasonable)goalsformakingachange(seeAppendix3:Change PlanWorksheet,formoreinformation). o Askinterestedpatientstocompleteachangeplanbeforetheygohome. o Makeacopywithouttheirnameorthenameofyourofficeonit,giveittothemto takehome,andtellthemyouwillcheckinontheirprogressatthenextvisit. o Forpatientswhodonotcompleteachangeplan,scheduleasecondappointmentto continuethediscussionandtocompletethechangeplan.Youmayprovideablank copyforthemtotakehomeandaskthemtoreturnwithit,butsomepatientsmay needtostartagainwithafreshcopyduringtheirsecondappointment. o Forpatientsnotinterestedincompletingachangeplan,encouragethemtosetafew briefchangegoals(e.g.,cuttingback,tryingaselfhelpgroup);recordthegoalsto checkprogressatthenextvisit. Prescribemedicationsforofficebasedtreatmentoftobacco,alcohol,oropiateaddiction, asappropriate.

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Step 5: ARRANGE specialty assessment, drug treatment, followup visit.


A. Refer patients as appropriate. Becausethescreeningdoesnotprovidea Step 5: Offer continuing diagnosisofabuseordependence,referhigh support at followup visits. riskpatientsforafullassessment.For A. Refer patients as moderateriskpatientsandlowriskpatients appropriate. withspecialconcerns(e.g.,pregnantwomen, B. Schedule followup. edule pastinjectiondrugusers),useclinical C. Offer continuing support at judgmenttodeterminewhetheradditional followup. assessmentisnecessary.UseSAMHSAs treatmentlocator(seeAppendix5, http://dasis3.samhsa.gov/)orNIDAsNationalDrugAbuseTreatmentClinicalTrials NetworkListofAssociatedCommunityTreatmentPrograms(seeAppendix5, http://www.drugabuse.gov/CTN/ctps.html)tolocateassessmentresources. Ifnearbytreatmentresourcesarenotavailable,considerprovidingsupportgroup contactinformationandselfchangematerials(seeAppendix5),aswellascounseling resourcesclergyormentalhealthreferrals. Obtainawritteninformationreleasetosendthescreeningresultstoallproviderswho willreceivereferrals. B. Schedule a followup appointment within 12 weeks for moderate- and highrisk patients and low -risk patients in certain groups. C. Offer continuing support at followup visits. Annualrescreeningisindicatedforpatientswhoreportanydruguseatbaseline(even withscoresof03)andforanyotherpatientsaboutwhomyouremainconcerned.For moderateandhighriskpatients,rescreenatnextappointment. Atfollowup,maketargetedrecommendationstomoderate,highandselectlower riskpatientsaccordingly:

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Risk level High risk Targeted Recommendations Offer Make Obtainrecords additional additional ofassessment brief referralsfor and/or intervention patientswho treatmentfor forpatients missed patientswho whodidnot referral. attended attendthe referraland/or referral. treatment.

Determine whetherthe patient followed throughwith thereferral.

Discussways tohelp support recommenda tionsof referral source.

Moderate risk Determine whetherthe patient reducedor abstained fromuse. Forpatients whodidnot makeprogress withchange efforts, acknowledge changeishard, repeatbrief intervention, anddiscuss additional waysto supportthe patients efforts. Ifthepatient Encourage indicatedthat abstinence he/shewanted fromtobacco tomakea andillicit change,ask drugsand what,if adviselowrisk anything,the alcoholusers patient toremain decidedtodo within about acceptable substanceuse. drinkinglevels. Forpatients whohave madechanges, reinforce effortsand encourage additional goalsetting.

Followupat subsequent visits.

Lower risk

Onevidenceof escalationof use,conduct brief intervention.

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Appendix 1Recommendations to Address Patient Resistance (may not be applicable in every case)
PatientResistanceScenario Patientanswersno,seeminglywithout consideringitthoughtfullyorisreluctant togivedetails. Patientisuncomfortabledisclosing personalsubstanceuseonaform. Patientappearsashamedorembarrassed aboutrecommendationstochange substanceusebehaviors. Atriskpatientappearsambivalenttothe ideaofchanginghis/hersubstanceuse behavior. Patientbecomesupset,argumentative. PhysicianResponse Gentlyprobewithaquestionlike:Notevenwhenyouwere inschool? Encouragediscussionbysayinggoonortellmemore. Letthepatientknowyouwillfollowupinpersonaboutthe screening. Reinforcethatallinformationprovidedwillbekept confidentialwhenpossible. Ifpatientisstilluncomfortable,skipscreeningbutprovide informationaboutharmsassociatedwithdruguse. Statethatthisisahealthrelatedmedicalrecommendation andisnotmeanttojudgeorstigmatizethem. Remindthepatientofyourrolethatphysicianshaveaduty tosharetestresultswiththeirpatients. Acknowledgethepatientsambivalenceandthefactthat ambivalenceiscommon. Stateyourconcernaboutspecificwaysthatdrugsmay negativelyaffectyourpatientshealthorpersonallife. Donotarguewiththepatient.Givethepatienttimetomake adecision(unlesstheconditionislifethreatening). Discusshis/herconcernsandreflectthemback(e.g.,convey thatyouunderstandthepatientsclaimthatdrugsmake themfeelbetterorthattheirpeersusethem). Exploreconcernsabouttheassessment. Emphasizethatreferralforanassessmentmaynotmean enteringsubstanceabusetreatmentandthattreatment,if recommended,likelywillincludedifferentoptions. Problemsolveaboutbarriersandoffersupport,suchas remindercalls,assistancearrangingtransportation,andchild care. Clearlystatethatyouarenotinsistingonformaltreatment. Explainthattreatmentisofteneasierthanquittingcold turkeyandthatstoppingtheuseofcertaindrugs(e.g., alcohol,benzodiazepines)withoutmedicalsupervisioncan bedangerous. Acknowledgethatchangeisdifficult. Repeatthebriefinterventionanddiscussotherwaysto supportthepatientsefforts. Makeadditionalreferralsforpatientswhodidnotattendthe referral.

Patientresistsreferralforadditional assessment

Patientcitesbarrierstoattendingthe referralappointment. Patientresiststheideaofgoinginto formalsubstanceabusetreatment.

Infollowupvisits,patientshowsno progresswithchangeefforts.

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Appendix 2Sample Progress Note


DATE: Timewithpatient(min): Performedby:PrimaryPhysician: SCREENING:Circleeachsubstanceusedand IFALCOHOLUSE(circlebelow): recordSubstanceInvolvementScore
SubstanceList: a.tobacco_________________g.Inhalants________ b.alcohol_________________h.Sedatives_______ c.cannabis________________i.Hallucinogens____ d.cocaine_________________j.streetopioids_____ e.prescription k.prescription amphetamines_____________opioids_________ f.methamphetamine________l.Other__________

Past3months(list substances):_______________

BiologicalTestResults:_______________

PLAN: Discussedscreeningresultswithpatient (checkifcompleted)______ ProvidedaBriefIntervention(checkifcompleted)______ Howreadyispatienttochangebehavior?Unwilling_____Tentative______Ready_______ ChangePlancompleted?Yes____(attach)No____N/A____ ChangePlanappointment?Yes____No___N/A____ REFERRALSTATUS: Referforfurtherassessment?__________Refused?____________N/A_______ Refertodetox?_________Refused?___________N/A_______ FOLLOWUPPLANS: Dateofnextappointmenttocheckprogress______ Orforlowriskpatients,rescreenonnextRTC________,oroneyear(ifnegative). ProviderSignature:________________________PatientSignature:_____________________

Level of risk associated with different Substance Involvement Score ranges for illicit or nonmedical prescription drug use 03 Low Risk 426 Moderate Risk 27+ High Risk

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Appendix 3Change Plan Worksheet


Seehttp://www.motivationalinterview.org/clinical/changeplan.PDFformoreinformationand examples.
The changes I want to make (or continue making) are:

The reasons why I want to make these changes are:

The steps I plan to take in changing are:

The ways other people can help me are:

I will know that my plan is working if:

Some things that could interfere with my plan are:

What I will do if the plan isnt working:

As my doctor, you can help me keep these changes by:

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Appendix 4Biological Specimen Testing


Introduction to Biological Testing Urinedrugtestingisthemostcommontoxicologicaltestofbodyfluidsamplesingeneral medicalsettings,butyoudonotneedtohaveabiologicaltestingprogramtoimplementa drugscreeningprogram.Thepurposeofabiologicaltestingprogramisto: Confirmthepresenceofadrugortheuseofmultipledrugs. Augmentscreeningandfollowupconversations(i.e.,biologicaltestingshouldnot precludescreening). Users of biological tests should be aware that: Biologicaltestshavedifferentwindowsofdetection.Forexample: o Apositiveurineorsalivascreenforcocaineand/orheroinlikelyindicatesvery recentuse(pastfewdays/pastweek),whereasoneformarijuanacoulddetect marijuanauseonemonthormoreinthepast. o Itisalmostimpossibletodeterminethetimeofusefromhairsamples. Notallbiologicalscreenstestforallcommonlyabuseddrugs(e.g.,MDMA, methadone,fentanyl,andothersyntheticopioidsarenotincludedinmanydrug screens,andthesetestsmustbeorderedseparately). Biologicaltestsexamineasamplewithadrugconcentrationataspecificcutofflevel (seeSAMHSADrugCutoffConcentrations).Therefore,anegativeresultdoesnot meandrugshavenotbeenused,andapositiveresultmayattimesreflect consumptionofothersubstances(suchashemporpoppyproducts). Iftamperingisaconcern,specimensshouldbemonitoredfortemperatureor adulterants;andprogramsshouldimplementandfollowaccuratechainofcustody procedures. Feedback for biological screening results: PresentresultsinamatteroffactwayinconjunctionwithNIDAModifiedASSIST feedback. Readministerthetestifthepatientbelievestheresultshowedafalsepositive. Ifthesecondbiologicaltestresultsarepositive,categorizethepatientashighriskand offerabriefinterventionandreferralforadditionalassessmentandpossible treatment. 18

Appendix 5Additional Resources


Screening Information:
HenryEdwards,S.;Humeniuk,R.;Ali,R.;Poznyak,V.;andMonteiro,M.TheAlcohol,Smokingand SubstanceInvolvementScreeningTest(ASSIST):GuidelinesforUseinPrimaryCare.Geneva, Switzerland:WorldHealthOrganization(WHO),2008.Availableat http://www.who.int/substance_abuse/activities/en/Draft_The_ASSIST_Guidelines.pdf.

CenterforSubstanceAbuseTreatment.AlcoholScreeningandBriefIntervention(SBI)forTrauma Patients:CommitteeonTraumaQuickGuide.SubstanceAbuseandMentalHealthServices Administration,DHHSPublicationNo.(SMA)074266.Washington,DC:U.S.GovernmentPrinting Office,2007.Availableathttp://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf. CenterforSubstanceAbuseTreatment.AGuidetoSubstanceAbuseServicesforPrimaryCare Clinicians.TreatmentImprovementProtocol(TIP)Series,Number24.SubstanceAbuseandMental HealthServicesAdministration,DHHSPublicationNo.(SMA)973139.Washington,DC:U.S. GovernmentPrintingOffice,1997.Availableat http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.45293.

Brief Intervention Instruction and Additional Information:


WorldHealthOrganization.BriefInterventionforSubstanceUse:AManualforUseinPrimaryCare http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf .

National Institute on Alcohol Abuse and Alcoholisms Helping Patients Who Drink Too Much: A Clinicians Guide:
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm.

SAMHSAs Treatment Facility Locator:


Searchabledirectoryofdrugandalcoholtreatmentprogramsaroundthecountrythattreatdrug abuse,alcoholism,andalcoholabuseproblems. Simplyenteranaddressintothequicksearchfeature,andyouwillseealistofsubstanceabuse treatmentfacilitiesclosesttotheaddress.Additionalinstructionsavailableat http://findtreatment.samhsa.gov/images/loc_short.pdf.

NIDAs National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs: http://www.drugabuse.gov/CTN/ctps.html. Resources on Certification in Office-Based Buprenorphine: http://buprenorphine.samhsa.gov/howto.html.

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Devlin, R.J,, and Henry, J.A. Clinical review: Major consequences of illicit drug consumption. Crit Care. 12(1):202, 2008. Available at http://www.ncbi.nlm.nih.gov/pubmed/18279535?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ ResultsPanel.Pubmed_RVDocSum. 2 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H34, DHHS Publication No. SMA 084343). Rockville, MD, 2008. Available at http://www.oas.samhsa.gov/nsduh/2k7nsduh/AppG.htm#TabG-11. 3 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H34, DHHS Publication No. SMA 084343). Rockville, MD, 2008. Available at http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#7.2 4 Madras, B.K. ; Compton, W.M. ; Avula, D. ; Stegbauer, T.; Stein, J.B.; and Clark, W.H. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Depend [e-pub ahead of print], 2008. 5 Bernstein, J.; Bernstein, E.; Tassiopoulos, K.; Heeren, T.; Levenson, S.; and Hingson, R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend 77(1):4959, 2005. Available at http://www.ncbi.nlm.nih.gov/pubmed/15607841?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ ResultsPanel.Pubmed_RVDocSum. 6 Humeniuk, R.; Dennington, V.; Ali, R.; and WHO ASSIST Phase III Study Group. The Effectiveness of a Brief Intervention for Illicit Drugs Linked to the ASSIST Screening Test in Primary Health Care Settings: A Technical Report of Phase III Findings of the WHO ASSIST Randomized Controlled Trial (Draft). Geneva, Switzerland, 2008. 7 Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance abuse. Substance Abuse. 28: 7-30. 8 Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma Patients: Committee on Trauma Quick Guide, Substance Abuse and Mental Health Services Administration, DHHS Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing Office, 2007. Available at http://sbirt.samhsa.gov/documents/SBIRT_guide_Sep07.pdf. 9 Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Treatment Improvement Protocol (TIP) Series, No. 24. Substance Abuse and Mental Health Services Administration, DHHS Publication No. (SMA) 973139. Washington, DC: U.S. Government Printing Office, 1997. 10 Rossi, P.; Di Lorenzo, C.; Faroni, J.; Cesarino, F.; and Nappi, G. Advice alone vs. Structured detoxification programmes for medication overuse headache: a prospective, randomized, open-label trial in transformed migraine patients with low medical needs. Cephalalgia. 26:10971105, 2006. 11 Vicens, C.; Fiol, F.; Llobera, J.; Cpoamor, F.; Mateu, C.; Alegret, S.; and Socias, I. Withdrawal from long-term benzodiazepine use: randomised trial in family practice. Br J Gen Pract 56:958963, 2006.
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health