U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857DHHS Publication No. (SMA) 97-3139 Printed 1997
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number ADM 270-95-0013. Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT Government project officer. Writers were Paddy Cook, Constance Grant Gartner, M.S.W., Lise Markl, Randi Henderson, Margaret K. Brooks, Esq., Donald Wesson, M.D., Mary Lou Dogoloff, Virginia Vitzthum, and Elizabeth Hayes. Special thanks go to Daniel Vinson, M.D., M.S.H.P., Mim J. Landry, Mary Smolenski, C.R.N.P., Ed.D., MaryLou Leonard, Pamela Nicholson, Annie Thornton, Jack Rhode, Cecil Gross, Niyati Pandya, and Wendy Carter for their considerable contributions to this document.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem.
The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are communicated to a Consensus Panel, non-Federal experts on the topic who have been nominated by their peers. This Panel participates in discussions over 5 days; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov". The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
The objective of this TIP, A Guide to Substance Abuse Services for Primary Care Clinicians, is to help physicians, nurses, physician assistants, and advanced practice nurses (nurse practitioners and clinical nurse specialists) screen their patients for substance use disorders, conduct brief interventions for patients in the early stages of problem development, and appropriately refer more severely affected patients for in-depth assessment and treatment. The TIP also gives an overview of the types of treatment available and outlines a primary care clinician's role in aftercare.
This document gives primary care clinicians specific guidance on identifying indications of substance abuse, how to broach the subject with a patient, and what screening and assessment instruments to use. It explains how to perform an office-based brief intervention in which patient and clinician set mutually agreed upon goals and "contract" to stop or cut back the alcohol or other drug use. The elements of in-depth assessments, appropriate referrals, and specialized treatment are discussed. The appendixes to the document include discussions by experts on leading pharmacotherapies for alcohol and other drugs and legal issues of patient confidentiality.
This TIP equips primary care clinicians who may not have any knowledge of the substance abuse field to address this pervasive disease. The physicians, nurses, social workers, researchers, certified alcohol counselors, program directors, and pharmacologists on the Consensus Panel pooled years of research and practice to devise recommendations that can be readily implemented in a busy primary care setting. This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve substance abuse treatment.
Other TIPs may be ordered by contacting The National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
Nelba Chavez, Ph.D.
Administrator
Substance Abuse and Mental Health Services Administration
David J. Mactas
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
The goal of this TIP is to recommend guidelines for primary care clinicians to follow in caring for patients with alcohol and other drug use disorders. These guidelines were developed by a Consensus Panel of clinicians, researchers, and educators who work on the prevention and treatment of substance use disorders. Protocols are based partly on research evidence, partly on Panel members' clinical experience.
The algorithm follows a patient with substance use problems who presents in a primary care setting. The chart will serve as a guide or road map through screening, brief assessment, brief intervention, assessment, referral, specialized treatment, and followup care as they are detailed in the TIP.
Since substance use disorders are often chronic conditions that progress slowly over time, primary care clinicians, through their regular, long-term contact with patients, are in an ideal position to screen for alcohol and drug problems and monitor each patient's status. Furthermore, studies have found that primary care clinicians can actually help many patients decrease alcohol consumption and its harmful consequences through office-based interventions that take only 10 or 15 minutes
(Kahan et al., 1995;Wallace et al., 1988). This potential, however, is largely untapped: Saitz and colleagues found that of a sample of patients seeking substance abuse treatment, 45 percent reported that their primary care physician was unaware of their substance abuse
*(Saitz et al., in press).
Yet even though screening and limited treatment of substance use disorders do not require a large time investment, the Consensus Panel that developed this TIP recognized that many primary care clinicians are already overwhelmed by the demands imposed by expanded gatekeeper functions. The Panel realized that a practical approach to addressing patients' substance abuse problems was needed: one that recognized the time and resource limitations inherent in primary care practice and offered a series of graduated approaches that could be incorporated into a normal clinic or office routine.
Biological, medical, and genetic factors as well as psychological, social, familial, cultural, and other environmental features all bear on substance abuse. Addressing the condition effectively requires a team effort, especially when it has progressed beyond the early stage. For this reason, in addition to screening and intervention treatment options, these guidelines include information about viable referral for assessment and treatment, as well as followup.
Readers will notice that the TIP contains more information on alcohol use and abuse than on use of illicit drugs. This reflects both the scope of the problems and the research literature available about them. It is estimated that about 18 million people with alcohol use problems and 5 million users of illicit drugs need treatment.
Although the Panel recognizes that tobacco is an addictive substance with a major public health impact, it is not included in this TIP because the topic falls outside CSAT's purview. Readers are referred to Smoking Cessation: A Guide for Primary Care Clinicians, published by the Agency for Health Care Policy and Research
(Agency for Health Care Policy and Research, 1996).
The Consensus Panel's recommendations are based on a combination of clinical experience and research-based evidence. In the list below, the summary guidelines supported by the research literature are followed by (1); clinically based recommendations are marked (2). Citations supporting the former are referenced in the body of the document. Screening and assessment instruments mentioned below are reproduced and discussed in Chapters
2 and 4 and
Appendix C.
The guidelines are presented in more detail in
Chapter 6.
The Consensus Panel that developed this TIP recommends that primary care clinicians -- a term that includes physicians, physician assistants, and advanced practice nurses -- follow the guidelines below.
Periodically and routinely screen all patients for substance use disorders. (2)
Ask questions about substance abuse in the context of other lifestyle questions. (2)
Use the Alcohol Use Disorders Identification Test
(AUDIT) to screen for alcohol problems among English-speaking, literate patients, or use the first three quantity/frequency questions from the AUDIT, supplemented by the CAGE questionnaire. (1)
Use the
CAGE-AID (Cage Adapted to Include Drugs) to screen for drug use among patients. (1)
Ask "Have you used street drugs more than five times in your life?" A positive answer suggests further screening and possibly assessment. (2)
Ask high-risk patients about alcohol and other drug use in combination. (2)
Use the
TWEAK to screen pregnant women for alcohol use. (1)
Ask pregnant women "Do you use street drugs?" If the answer is yes, advise abstinence. (2)
Use the
CAGE, the AUDIT, or the Michigan Alcoholism Screening Test -- Geriatric Version (MAST-G) to screen patients over 60. (1)
Screen adolescents for substance abuse every time they seek medical services. (2)
When recording screening results, indicate that a positive screen is not a diagnosis. (2)
Present results of a positive screen (and conduct all discussions about substance use) in a nonjudgmental manner. (1)
Perform a brief intervention with patients whose substance abuse problems are less severe. (1)
Include in the brief intervention feedback about screening results and risks of use, information about safe consumption limits and advice about change, assessment of patient's readiness to change, negotiated goals and strategies for change, and arrangements for followup visits. (1)
Refer high-risk patients to a specialist, if possible, for in-depth assessment. (2)
Ensure that a specialized assessor has familiarity with psychiatric disorders. (2)
Ascertain that assessment is sequential and multidimensional. (1)
Check the gamma-glutamyl transferase (GGT) as part of the assessment process. (2)
Use the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, in combination with the American Society of Addiction Medicine's Patient Placement Criteria, Second Edition, to make a diagnosis and devise an assessment-based treatment plan. (1)
Become familiar with available assessment and treatment resources. (2)
Keep encouraging reluctant patients with substance use disorders to accept treatment of some kind. (2)
Visits to primary care clinicians provide unparalleled opportunities to intervene with substance abuse problems at a relatively early stage in disease progression. Office or clinic visits also give clinicians an opening to discuss substance abuse prevention with patients and in many cases, forestall problems from ever developing. As one primary care physician observed, "With respect to substance abuse, our charge is straightforward: first we must ask something, then we must do something." This TIP is intended to assist primary care clinicians with both tasks.
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