Pringle JL, Kowalchuk A, Meyers JA, Seale JP. Equipping residents to address alcohol and drug abuse: The national SBIRT residency training project. Journal of Graduate Medical Education. 2012; 4: 58-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23451308 Accessed on: 2017-07-27.
Miller W, Carroll K. Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It. Guilford Publications. 2011. Available at: https://www.amazon.com/Rethinking-Substance-Abuse-Science-Should/dp/1606236989 Accessed on: 2017-07-26.
American Public Health Association. Alcohol Screening and Brief Intervention: A guide for public health practitioners. Substance Abuse and Mental Health Services Administration. 2008. Available at: https://www.integration.samhsa.gov/clinical-practice/alcohol_screening_and_brief_interventions_a_guide_for_public_health_practitioners.pdf Accessed on: 2017-07-26.

Next...

Continue the dialogue using techniques from motivational interviewing (MI), plus the 7 steps taught in the module on brief interventions.Basic steps in a brief intervention:
  1. Confirm that the patient's screening answers indicate a concern
  2. Ask about the patient's view of the situation -- Includes identifying barriers to quitting and risk factors for relapse
  3. Discuss the patient's personal responsibility, health effects and other consequences of substance misuse
  4. Provide the patient with non-judgmental advice and the benefits of quitting
  5. Mention treatment options if appropriate and gauge patient's reaction
  6. Encourage and support the patient -- Includes soliciting patient commitment to a clear goal
  7. Provide patient education and resources
A plan for followup is also important!

Counseling techniques are labeled in parentheses in the following sample dialogue:



You became more ready to quit drinking after thinking about drinking while driving. How responsible would you be if you did have an accident while drinking and someone got hurt? (Step 2: Ask the patient's view of the situation. Step 3: Discuss personal responsibility.)

It would be all me -- I get that. It's just that when I'm drinking I don't care as much or I think I can get away with it just this once.

It sounds like you sometimes drink enough to impair your judgment about this important issue and possibly others (Step 3 Discuss personal responsibility). As your medical provider, I recommend you never drink and drive and that you reduce your drinking to within the guidelines we discussed, so that you can count on yourself to make sound decisions (Step 4: Non-judgmental advice).

I would like to do that. It might be hard, though, because I might lose some friends.

That may be. You may lose some friends (MI: Roll with the resistance) On the one hand you want to keep drinking to excess so you can keep your friends, even those who want you to drink too much, and on the other hand, you want to reduce your drinking so you know that you'll be making responsible decisions (MI: Resolving ambivalence). Can we talk about the importance of each one for you? (MI: Asking rather than telling.)

When you put it that way, not very important. I do have other friends who don't drink too much.

Continue the dialogue using techniques from motivational interviewing (MI), plus the 7 steps taught in the module on brief interventions.Basic steps in a brief intervention:
  1. Confirm that the patient's screening answers indicate a concern
  2. Ask about the patient's view of the situation -- Includes identifying barriers to quitting and risk factors for relapse
  3. Discuss the patient's personal responsibility, health effects and other consequences of substance misuse
  4. Provide the patient with non-judgmental advice and the benefits of quitting
  5. Mention treatment options if appropriate and gauge patient's reaction
  6. Encourage and support the patient -- Includes soliciting patient commitment to a clear goal
  7. Provide patient education and resources
A plan for followup is also important!

Counseling techniques are labeled in parentheses in the following sample dialogue:



Another thing I'd like to make you aware of is the very likely possibility that your sleeping problems are related to your alcohol use. In fact, the first treatment I'd like to recommend to address your sleeping problems is addressing your alcohol use. (Step 7: Patient education.)

Is that right? I suppose I really should think about drinking less.

Since you've agreed that you think you should cut down on your drinking, what step are you ready to take toward that goal? (Step 5: Mention goals. MI: Plan for change)

I'll try really hard to stay within the limits. And I'll ask my friends who don't drink too much to do the driving until I get this under control.

I think that's great! When would you start? (Step 6. Encourage and support the patient, including eliciting commitment to a clear goal.)

I could start today while I'm inspired! I hope I can do it.

We will support you in this. Mrs. Green will give you a list of 12 step programs in the area. I highly recommend you consider going to them. Getting support from others who have been through the same thing can make a big difference. We've also got an educational brochure she'll give you to read over that offers tips to help you be successful. We'll give you a call next week to see how it's going, if that's ok (Step 7: Provide patient education and resources and plan for follow-up.)

Thank you.

Assessing Ms. Cosgrove Using the AUDIT

You further assess Ms. Cosgrove's alcohol use by using the AUDIT. A nurse provides Ms. Cosgrove with a tablet computer, and Ms. Cosgrove fills out an electronic version of the AUDIT. This takes her about 4 minutes to complete.

Ms. Cosgrove's AUDIT Responses

Q1: How often do you have a drink containing alcohol?
__Never (0 points)
__Monthly or less (1 point)
__2 to 4 times a month (2 points)
__2 to 3 times a week (3 points)
X 4 or more times a week (4 points)

Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?
X 1 or 2 (this is actually an underestimate – she does not “count” the middle-of-night drinks) (0 points)
__3 or 4 (1 point)
__5 or 6 (2 points)
__7 to 9 (3 points)
__10 or more (4 points)

Q3: How often do you have six or more drinks on one occasion?
__Never (0 points)
__Less than monthly (1 point)
X Monthly (2 points)
__Weekly (3 points)
__Daily or almost daily (4 points)

Q4: How often during the last year have you found that you were not able to stop drinking once you had started?
__Never (0 points)
X Less than monthly (1 point)
__Monthly (2 points)
__Weekly (3 points)
__Daily or almost daily (4 points)

Q5: How often during the last year have you failed to do what was normally expected of you because of drinking?
__Never (0 points)
__Less than monthly (1 point)
X Monthly (2 points)
__Weekly (3 points)
__Daily or almost daily (4 points)

Q6: How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
X Never (0 points)
__Less than monthly (1 point)
__Monthly (2 points)
__Weekly (3 points)
__Daily or almost daily (4 points)

Q7: How often during the last year have you had a feeling of guilt or remorse after drinking?
__Never (0 points)
__Less than monthly (1 point)
__Monthly (2 points)
X Weekly (She feels bad when she has trouble getting up with the kids in the morning) (3 points)
__Daily or almost daily (4 points)

Q8: How often during the last year have you been unable to remember what happened the night before because of your drinking?
__Never (0 points)
X Less than monthly (1 point)
__Monthly (2 points)
__Weekly (3 points)
__Daily or almost daily (4 points)

Q9: Have you or someone else been injured because of your drinking?
X No (0 points)
__Yes, but not in the last year (2 points)
__Yes, during the last year (4 points)

Q10: Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down?
__No (0 points)
__Yes, but not in the last year (2 points)
X Yes, during the last year (Her mom mentioned a few times that drinking wine was not a cure for insomnia, and that's part of what prompted her to come to the doctor today) (4 points)

Add total points:


Interpreting the AUDIT

Questions 1 through 8 = 0, 1, 2, 3, or 4 points. Questions 9 and 10 are scored as 0, 2, or 4.

Using the total points you calculated above, interpret Ms. Cosgrove's AUDIT responses. Remember your interpretation because we will ask you in a poll on the next page.

Risk Level Intervention AUDIT Score
Zone I Alcohol Education 0-7
Zone II Simple Advice 8-15
Zone III Simple Advice plus Brief Intervention and Follow-up (Continued Monitoring, if possible)16-19
Zone IVReferral to Specialist for Diagnostic Evaluation and Treatment 20-40
Case Info

Patient Name: Joanne Cosgrove   Age: 44 y/o

Height: 5' 4"   Weight: 144 lbs   

BP: 124/84   Pulse: 93    Respiration: 14/min  

Chief Complaint: Fatigue, low energy, insomnia

History of Present Illness: Onset of fatigue about 4 months ago, insomnia for the past 2 months. Nothing has changed in her life, so she is not sure what caused these symptoms "out of nowhere." Reports no pain, no depression or anxiety symptoms, no other health problems or changes.

Medical History: Placenta previa resulting in healthy live birth (1999), cholecystectomy, rhinoplasty, childhood asthma. Family history of lung cancer, skin cancer, high blood pressure, and osteoarthritis.

Medications: No prescription medication. Vitamin D 500 IU, fish oil 1000mg bid, women's multivitamin, loratadine (as needed for seasonal allergies), diphenhydramine (as needed for insomnia).

Laboratory Results: There are currently no laboratory results available.

Case Objectives
The goals for this case are to apply the following skills learned earlier in the activity:

  1. Select an appropriate screening/assessment tool
  2. Screen Ms. Cosgrove for substance use problems
  3. Interpret the screening results from a widely used screening tool for alcohol use
  4. Discuss screening results and concerns with Ms. Cosgrove
  5. Determine if brief intervention or other treatment is warranted

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