Mersy DJ. Recognition of alcohol and substance abuse. American Family Physician. 2003; 67: 1529-1532. Available at: http://www.aafp.org/afp/2003/0401/p1529.html Accessed on: 2013-10-24.
 

Information gained through the following gives the "big picture" regarding a patient's substance use:

  • Screening
  • History and physical
  • Lab tests (if any)
  • Interview

This gives enough information to proceed with a brief intervention, if warranted, during the same appointment. A brief intervention can usually be initiated without definitive lab results as long as you have some knowledge of the patient's possible substance use disorder.

Brief interventions are covered in the next module in this training activity

Keep In Mind

Determine whether an intervention is needed based on the level of risk determined by screening:

  • No intervention necessary
  • Brief intervention in primary care
  • Brief intervention in primary care plus referral
Staff Role

Keep in mind that many of the SBIRT steps can be completed by multiple staff: medical assistant, physician assistant, nurse practitioner, social worker, or counselor. Throughout this activity, dialogue examples will be given for different medical staff. The various screening tools are designed for simple administration and scoring while the later steps simply require an understanding of the brief intervention steps and motivational interviewing.

Flow of Information

Each standardized screening tool includes instructions for administration and scoring so they can be administered and scored by staff with minimal training. If initial screening is completed via a self-administered, computer or paper, standardized health assessment or by staff interview, a system for flagging responses of concern, such as those that suggest unhealthy alcohol use, needs to be in place. "Flagging" of positive responses can be achieved by a note in the patient record or use of alerts in certain electronic medical records for this purpose. It can be a very quick, simple process once it is set up and becomes part of the routine.

Examples of Screening Results

Significant results on admission screening:

Blood pressure 160/90; CAGE-AID positive: 2 out of 4 questions

Vital signs and substance use

BP: 120/90, Pulse: 68, Temp. 98.0, Substance use: NIDA Quick Screen - Negative

Practice Tip

Use of Electronic Health Records (EHR). Select an electronic medical record that has an expectation to screen for all substances: tobacco, alcohol, illicit drugs, or misuse of drugs. Choose EHRs where the user must go through this step in admitting a new patient and in periodic updating of the medical history. Also, the electronic record should have some mechanism of reminding the provider of any positive screening results.

Appropriate use of drug testing to improve patient care

For patients who are abusing drugs other than alcohol, there are a few instances when drug testing may be useful:

  • When you suspect the presence of drugs but the patient denies use
  • When the patient has unexplained physical signs of drug use
  • When treating patients who have a history of substance use disorder and/or relapse
  • When the patient needs medication prescribed that has serious contraindications with alcohol or drugs that are used
  • To confirm information that the patient provided during the interview about his/her substance use
  • (SAMHSA, 2005)

A special note regarding alcohol: Interviews and questionnaires have greater sensitivity and specificity than urine tests that measure biochemical markers for alcohol (NIAAA, 2005).

Administering an on-site drug test

In a primary care setting, urine drug testing (UDT) is the most commonly used method of drug testing, because of the ease of obtaining the sample and the potential for high concentration of the substance for up to four days post-drug use. "Point of care" tests are increasingly being used to provide quick results – in as little as five minutes. A point-of-care urine drug test will typically only reveal a specific class of drug but not a single drug or the concentration of the substance in the specimen (Gialamas et al., 2010). These tests are getting increasingly sensitive and specific.

Interpreting urine drug test results

Providers should not immediately assume that the patient with a positive test result has a substance use disorder (Compton, 2009); many factors need to be considered. For example, ask patients what prescription, over-the-counter, and herbal medications they are taking, because they might cause false positives or negatives. Consider following up a positive or unexpected result with a confirmatory laboratory-based test to confirm a positive point-of-care test or to get more information, such as on specific drugs. Discuss positive lab test results with the laboratory to learn the possibility of false negative and false positive results. Include all urine test results and interpretation in the patient's chart. If the results point to a substance use disorder after other possibilities are ruled out, meet with the patient to discuss.

View ReferencesHide References
Compton P. Urine toxicology screening: a case study. Emerging Solutions in Pain. 2009.
Gialamas A, St John A, Laurence CO, Bubner TK, PoCT Management Committee. Point-of-care testing for patients with diabetes, hyperlipidaemia or coagulation disorders in the general practice setting: a systematic review. Fam Pract. 2010; Feb 27(1): 17-24. Available at: https://fampra.oxfordjournals.org/content/27/1/17.long Accessed on: 2013-10-24.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping Patients Who Drink Too Much: A Clinician's Guide. Bethesda, Md. 2005 (Updated 2007). Available at: https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf Accessed on: 2013-10-24.
Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 43, Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2005. Available at: https://www.ncbi.nlm.nih.gov/books/NBK64164/ Accessed on: 2013-10-24.
Communication to Build Patient Rapport

Effective communication skills can improve the effectiveness of screening. Patients who are abusing alcohol or drugs may be reluctant to tell the truth. The following techniques from motivational interviewing may help establish rapport and get the patient to open up:

Ask Open-Ended Questions
 

Tell me more about your marijuana use

 

This is more effective than asking the patient if their marijuana use is a problem, which is likely to be answered, "No."
 

Be Sensitive to the Patient's Own Perspective
 

Anything you say about your drinking stays between us and I only use to understand your needs and how I might help, so please feel free to be open and honest when answering my questions. 

 

 

Listen Reflectively

Paraphrase what you heard from them to let them know you are listening carefully.

 

I lost all my friends. It seems like no one wants to be close to me since I started using a lot of drugs.

 
 

It sounds like your drug use makes you feel pretty isolated.

 

 

Convey a Non-Judgmental Attitude
 

I am not here to judge you. Instead, I want to help you make the best possible decisions about your use of alcohol.

 

 

Empathize with the Patient
 

I know this is not the easiest topic to talk about, and I appreciate that you are willing to talk with me about it.

 

(Sobell & Sobell, 2008)

Note: Additional Motivational Interviewing skills are covered later in the training.

Practice Tip
Pauses are a powerful way to draw people out without asking further questions. After making a simple question or a reflective statement, pause and wait patiently. Most people will fill the pause.
View ReferencesHide References
Sobell, Sobell. Motivational interviewing strategies and techniques: Rationales and examples. Nova Southeastern University. 2008. Available at: http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf Accessed on: 2015-06-16.
CAGE-AID Brief Description

CAGE-AID (Adapted to Include Drugs) is a quick screening tool with four questions that takes approximately 1 minute. It is like CAGE but adapted to include drug use. It does not ask about tobacco or assess the severity of the problem (Brown et al., 1998).

CAGE-AID Questions

The CAGE or CAGE-AID should be preceded by these two questions:

  1. Do you drink alcohol?
  2. Have you ever experimented with drugs?

If the patient only drinks alcohol, then ask the CAGE questions. If the patient has experimented with drugs, ask the CAGE-AID questions. The CAGE questions are simply the CAGE-AID questions seen below without the mention of drug use.

CAGE-AID questions:

C

Cut down – Have you ever felt you ought to cut down on your drinking or drug use?

A

Annoyed – Have people annoyed you by criticizing your drinking or drug use?

G

Guilty – Have you ever felt bad or guilty about your drinking or drug use?

E

Eye-opener – Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Reprinted with permission from Brown & Rounds, 1995.

Purpose & Evidence
  • Purpose: The CAGE-AID is a version of the CAGE alcohol screening questionnaire, adapted to include drug use. It assesses likelihood and severity of alcohol and drug use disorder.
  • Target population: Adults and adolescents
  • Advantages/Limitations

    Advantages

    • Well suited for use in a primary care facility.
    • Quick and easy to administer.
    • Screening for alcohol and drug usage conjointly rather than separately.
    • Easily incorporated into a medical history protocol or intake procedure.

    Limitations

    • Not created for pain patients (Butler, 2008).
    • Be cautious in prescribing to a patient who answers yes to any one question. Individuals who answer yes to 2 or more questions should be subject to a psychosocial assessment prior to prescription (Fine and Portenoy, 2004).

  • Evidence
    • Easy to administer, with good sensitivity and specificity (Leonardson et al., 2005).
    • More sensitive than original CAGE questionnaire for detecting substance use disorder (Brown & Rounds, 1995).
    • Less biased in term of education, income, and sex then the original CAGE questionnaire (Brown & Rounds, 1995).

Test Features
  • Estimated time: Brief, approximately 1 minute to administer and score
  • Length: 4 items
  • Administered by: Patient Interview or Self-Report
  • Intended settings: Primary care
  • Scoring and Interpretation: Of the 4 items, one or more positive responses (a "yes" answer) is considered a positive screening result, and substance use should be further addressed with the patient.
View ReferencesHide References
Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorder among inpatients ages 18 to 49: an opportunity for prevention. Preventive Medicine. 1998; 27(1): 101-110. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9465360 Accessed on: 2013-10-24.
Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995; 94(3): 135-40. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7778330 Accessed on: 2013-10-24.
An Introduction to Screening

Screening can be:

  • a quick interview question asking about tobacco, alcohol and drug use (both illicit drugs and misuse of prescription drugs)
  • use of one of the screening tools covered in this section that, if positive, can be followed up with longer screening questionnaires.

In short, all adolescent and adult patients should be screened for tobacco, alcohol and/or drug use for risk and clinical substance use disorders.

Who

Substance abuse screening as a standard part of every adolescent and adult patient interview is supported by several other professional organizations (AMA, ASAM, CSAT, AAP, NIAAA). Screening all patients for all substances is recommended by the United States Preventive Services Task Force due to the efficacy of the approach (Azari et al., 2015).

Screening should be universally applied: What you see without screening is just the tip of the iceberg   the VAST majority of risky use goes undetected without universal screening.

In addition to screening for substance use, the USPSTF has indicated that all adults should be screened for depression. This recommendation has been expanded from past suggestions to now include pregnant and postpartum women, as well as those who do not indicate prior evidence of depression (USPSTF, 2016).

For What

Substance Use Disorder "A medical illness caused by repeated misuse of a substance or substances...characterized by clinically significant impairments in health, social function, and impaired control over substance use and are diagnosed through assessing cognitive, behavioral, and psychological symptoms" (USDHHS, 2016). A person who meets 2-3 of the criteria outlined in the APA's DSM-5 is diagnosed as having mild substance use disorder, while those who meet 4-5 have moderate, and 6-7 have severe substance use disorder (APA, 2013).

Note: The diagnoses of Substance Abuse and Substance Dependence formerly found in the DSM-IV TR, have been combined to form a single diagnosis, Substance Use Disorder, in the DSM-5, which was published in May 18, 2013.

Practice Tip

"At-risk" is a clinical descriptor useful in identifying a need for prevention, rather than a diagnosis. It means significant risk factors for substance use disorders or unhealthy substance use that falls short of a clinical diagnosis. It includes any use of tobacco, illicit drugs, or misuse of prescription drugs and excessive use of alcohol short of addiction (any alcohol use for adolescents). Health and/or other personal risks are still a problem, even if substance use is less than a clinical syndrome.

All "At Risk" substance use should be the target of at least a brief intervention.

View ReferencesHide References
Azari S, Lum P, Ratanawongsa N, et al. A Skills-Based Curriculum for Teaching Motivational Interviewing-Enhanced Screening, Brief Intervention, and Referral to Treatment (SBIRT) to Medical Residents. MedEdPORTAL Publications. 2015. Available at: https://www.mededportal.org/publication/10080 Accessed on: 2015-06-16.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping Patients Who Drink Too Much: A Clinician's Guide. Bethesda, Md. 2005 (Updated 2007). Available at: https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf Accessed on: 2013-10-24.
U.S. Preventative Services Task Force. Final Recommendation Statement - Depression in Adults: Screening. U.S. Preventative Services Task Force Website. 2016. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1 Accessed on: 2016-02-02.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: https://addiction.surgeongeneral.gov/ Accessed on: 2016-11-17.
Using General Billing Codes

When insurance does not pay for SBIRT, one can "upcode" if the office visit meets the criteria, such as additional time or 3 chronic conditions (tobacco and alcohol use disorder could be two of those conditions). For example, you could use the 99214 code if you spend 25 minutes on the visit, and half is spent in health education (SAMHSA, 2008). This is used instead of code 99213, which is the code for a regular 15-minute office visit. The 99214 code is about 40 dollars more than a 99213.

Behavioral Health Providers

For Medicaid, the following conditions must be met in order to bill when a behavioral health provider (BHP) sees the patient rather than a Medicaid qualified medical provider:

  • Medical provider has initially seen patient
  • Medical provider must be able to provide evidence of management of the patient’s care
  • Medical provider employs the BHP or BHP employed by same entity as medical provider
  • Medical provider must be readily accessible by phone or pager and able to return to office

Professionals who can apply as behavioral health providers include nurse practitioners, counselors, and social workers.

ICD Codes for Substances

When a diagnosis code is needed, ICD-10 codes in the F10 to F19 section for mental and behavioral disorders due to psychoactive substances are used, for example:

  • F10 is for alcohol
  • F11 is for use of opioids
  • F14 for use of cocaine
  • F17 for use of nicotine

A modifier code is applied after a decimal point according to subtype: F1x.1 is for harmful use, F1x.2 is for dependence syndrome, F1x.3 is for withdrawal state. For example, F10.2 is the code for "Alcohol Dependence Syndrome"

The ICD-10 version of codes is the current one and must be used by October, 2015.

(WHO, 2013)

View ReferencesHide References
SAMHSA. Coding for SBI Reimbursement . SAMHSA. 2008. Available at: http://www.integration.samhsa.gov/clinical-practice/sbirt/Detailed_information_about_coding_for_SBI_reimbursement.pdf Accessed on: 2011-11-01.
World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. . 2013. Available at: http://www.who.int/substance_abuse/terminology/ICD10ClinicalDiagnosis.pdf Accessed on: 2015-06-10.
Encourage and Support the Patient

Encouraging and supporting patients as individuals is an important part of brief interventions. Remember that changing habits can be very difficult, but small failures can be reframed as opportunities to learn from mistakes. For example:

Don't get discouraged that you drank more than your limit a few times. Try to learn from it instead and remember your goals. Think about what factors were involved and how important it is to you and your family that you lower the risks that are associated with a high level of alcohol use.

Solicit Patient Commitment

Facilitate patient commitment to goals that are set. For example:

Since it seems you are in agreement that cutting back on your drinking to keep it within the healthy limits is a good idea, how would you feel about making a commitment to doing that for the next few weeks until we meet again?

Practice Tips

Capitalize on past successes and strengths. Successful weight loss, following a diabetic diet, getting a new job, etc. are all positive past goals that you can relate to treatment for substance use disorder, while still emphasizing the relative seriousness of the disorder. Explore and capitalize on the patient's strengths and existing resources, such as a supportive spouse or partner, family, or friendship network.

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