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The type and sequence of activities undertaken in response to screening results will depend on several factors: the severity of any positive findings, the specialized assessment and treatment resources available, and the primary care clinician's expertise in the substance abuse field. All patients who undergo screening for alcohol and drug use should be told the results. Those who screen negative because they are abstinent should be commended for their health-conscious lifestyle with reinforcing comments about the benefits of drug- and alcohol-free living. The clinician may wish to ascertain, however, whether current abstinence reflects a lifelong commitment, a recent decision, or recovery from some previous episode of substance abuse or dependence that may indicate a potential for relapse. This can be resolved by saying, "Not drinking is a healthy decision. What made you decide not to drink?" Patients with positive findings from the screening will need some type of followup. The next step may not be immediately apparent from the initial screening and depends on how much time and effort the clinician is willing to commit and how much training and experience she has in addiction medicine. The Consensus Panel recommends that clinicians at this point conduct a brief assessment to obtain more information. The questions should cover the severity of the suspected alcohol or drug involvement, the types and frequency of problems connected with the patient's use, and other special medical and psychiatric considerations. If the patient's responses suggest a diagnosis of a substance abuse or dependence disorder according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a), the clinician should initiate a referral for an in-depth assessment. However, if only mild to moderate substance abuse problems are apparent, if the patient appears to be at risk for experiencing negative consequences as a result of current consumption patterns, if coexisting illnesses or conditions may be exacerbated by continued drinking or other medications, or if the patient refuses referral for further assessment or treatment, the clinician can initiate a brief, office-based, therapeutic intervention. Guidelines for Clinician Involvement in the Care Of Substance-Abusing PatientsIn 1979, the American Medical Association issued guidelines recommending that all physicians with clinical responsibility become involved in the prevention and treatment of alcohol- and drug-related problems among their patients at one of the following three levels:
Although these AMA guidelines were promulgated before the development and widespread use of brief interventions in office-based practices, this type of early care seems to fit naturally between the minimal responsibility for early identification of alcohol or drug problems and the more involved, but still limited, responsibilities of primary care clinicians for managing withdrawal and making treatment referrals. Brief InterventionBrief intervention is a pretreatment tool or secondary prevention technique that primary care clinicians can easily incorporate into their medical practice settings. Within one or several office visits, a clinician explains screening results, provides information about safe consumption limits and advice about changing, assesses the patient's readiness to change, negotiates goals and strategies for change, and arranges for compliance monitoring. These five steps are discussed in detail below. Brief intervention is quite inexpensive for the yield, involving clinician-patient contacts of 10 to 15 minutes -- the typical duration of an office visit -- and a limited number of sessions. At least one followup visit is usually recommended, but the number and frequency of sessions depends on the severity of the problem and the individual patient's response. The broad goal of brief intervention is to get patients to reduce or eliminate alcohol or other drug consumption and thereby avoid or minimize associated problems, whether through the technique itself or through subsequent referral. The specific goal varies depending on the patient's current status and previous treatment attempts. For a patient who does not realize there is a problem, the goal may be to get the individual to start thinking about the issue and come back for another visit. A brief intervention could also be an appropriate primary prevention tool for the alcohol or drug user who is at risk for problem development because of a hazardous consumption pattern but has not yet experienced harmful consequences (e.g., the college student who is drinking heavily in a fraternity setting). For patients who recognize that some of their health or other problems are alcohol- or drug-related, and who are ready for and capable of change, the goal will be to reduce or eliminate substance use through specified steps. If the problem is more serious, and if initial attempts to change do not succeed, the goal of brief intervention is to convince a patient to accept a referral for more specialized assessment and treatment services. Brief intervention is an appropriate response to the types of patients mentioned above for several reasons. A specialized alcohol and drug treatment network has been developed for persons with relatively severe and chronic substance abuse disorders, but the majority of patients seen in most general practice medical settings are likely to have only mild to moderate substance use problems and may not require treatment in this formal system. Since rapid progression to a full-scale substance abuse or dependence disorder is not inevitable, specialized treatment is not always advisable. Spontaneous remission occurs in substance disorders as in many other medical conditions, so brief intervention may be all that is needed (Sobell et al., 1993; Vaillant et al., 1983). Furthermore, brief intervention in a primary care setting does not wield the stigma associated with longer-term specialized treatment. In fact, specialized substance abuse treatment could actually cause harm if, for example, a patient is coerced into participating in a treatment program that is antithetical to her values or if her coexisting psychiatric illness is ignored during formal substance abuse treatment. Nor are light to moderate consumers of alcohol and other drugs likely to seek help directly from the specialized substance abuse treatment system, particularly if problems related to substance use are transient or only mildly inconvenient. Many persons do not recognize -- or they deny -- that their difficulties are directly caused by or complicated by alcohol or drugs. The physical condition or health concern that brings the patient to a primary care clinician's office offers a "teachable moment" -- through a traumatic crisis or a welcomed event such as pregnancy -- in which the risk factors associated with alcohol and other drug consumption can be pointed out and behavior potentially changed. Since all treatment must be considered in the context of risk/benefit analysis, a conservative and palliative approach within a primary care setting may be preferable to specialized treatment absent a well-substantiated diagnosis of a substance use disorder (Institute of Medicine, 1990). Brief interventions as secondary prevention tools have the potential to help an estimated 15 to 20 million heavy drinkers in the U.S. alone by minimizing serious adverse consequences such as costly emergency room visits, domestic violence, or road accidents (National Institute on Alcohol Abuse and Alcoholism, 1993). The occasional alcohol- or other drug-related problems of a very substantial number of moderate users account for a large share of the public health burden (Samet et al., 1996). Effectiveness in General Medical Practice SettingsClinical trials and research studies in this country and abroad over the past 15 years have demonstrated the feasibility and effectiveness of brief intervention (Kristenson et al., 1983; Persson and Magnusson, 1989; Romelsjo et al., 1989). The technique is commended as practical and cost-effective by the Institute of Medicine, and several variations have been evaluated as successful on a number of dimensions (Institute of Medicine, 1990). Convincing evidence compiled over the past 20 years demonstrates that this approach, when used with carefully selected patients, can reduce or eliminate alcohol consumption and ameliorate or markedly limit associated problems (Orford et al., 1976; Edwards et al., 1977; Bien et al., 1993). Though few studies have included illicit drug users, the Panel believes that brief intervention has the potential to stop or curb some patients' drug use also. Most research on brief intervention has focused on patients who are moderate to heavy drinkers rather than alcohol dependent, with encouraging results. Brief interventions of even a single session can decrease alcohol consumption and its harmful consequences by 20 to 50 percent (Kahan et al., 1995). Even modest effects for 10 to 20 percent of participants are potentially important because of the prevalence of alcohol-related problems and the large public health implications (Bien et al., 1993). Researchers in one large-scale English study estimated that 15 percent of patients with alcohol-related problems in general practice settings would reduce consumption to moderate levels following a 10-minute brief intervention (Wallace et al., 1988). In a large-scale preventive health effort in Malmo, Sweden (Kristenson et al., 1983), heavy drinkers identified by elevated liver enzyme levels of gamma-glutamyl transferase (GGT) were encouraged to lower their alcohol consumption and received monthly checkups with a nurse and quarterly followups by a physician. Compared to a control group receiving no treatment, these heavy drinkers more successfully reduced their absenteeism and hospitalization rates as well as mortality over a 6-year period. Another important study found no difference between the effectiveness of advice and counseling about drinking practices delivered by alcohol treatment specialists in a traditional outpatient setting and that provided by general practitioners with the support of specialist staff in a medical setting (Drummond et al., 1990). At 6-month followup, both groups exhibited similar improvements on a variety of drinking-specific and other related outcomes. The research literature on brief interventions demonstrates that this approach works for women as well as men (Sanchez-Craig et al., 1989). Recent studies (WHO Brief Intervention Study Group, 1996) supported by the World Health Organization in 10 countries confirm that brief interventions can work in a variety of cultural settings and with diverse populations and health care systems. However, no studies pertain to the specific applicability of this technique for older adults or adolescents. Although research studies have established the important short-term effects of brief interventions, the relative effectiveness of different components is not yet clear. Specifically, the optimal number and duration of brief advice visits is not known. While studies of smoking cessation programs indicate that four or five interventions work better than one (Kahan et al., 1995), and some researchers have found correlates between additional followup contacts and alcohol consumption reduction (Wallace et al., 1988; Persson and Magnusson, 1989), other studies have found no advantage beyond single sessions (Chick et al., 1988; Babor and Grant, 1992) and no difference in outcomes between 5-minute sessions and 30- to 60-minute visits (Chick et al., 1988). Other research focusing on the educational component of brief interventions have found that having patients read self-help booklets and manuals can be an effective intervention with heavy but nondependent drinkers (Heather et al., 1986, **1990). (See Appendix D.) Selecting Appropriate Patients for Brief InterventionIn response to screening questionnaires or other suggestive symptoms or laboratory findings from an office visit, patients can be categorized into one of three groups:
This separation into groups requires some clinical judgment but can usually be accomplished quickly and easily with a brief assessment that follows up on positive responses to the screening instruments and clarifies the information provided. For example, further questions about why a patient acknowledges "feeling guilty" about drinking (on the CAGE questionnaire) may reveal alcohol-related difficulties with the family or at work (Brown, 1992). Additional questions to elucidate a patient's current (within the last 12 months) drinking or drug-using pattern are also appropriate, especially if tolerance and a likelihood of withdrawal effects are suspected. A review of the patient's chart may be indicated if medications are prescribed that will be affected by alcohol or other drug use, if the patient may be pregnant or planning to conceive, or if other medical or psychiatric conditions are present that could be exacerbated by otherwise acceptable alcohol use patterns. A patient's earlier substance abuse and psychiatric treatment history can also help the clinician decide whether to perform a brief intervention or refer for specialized assessment. Samet and colleagues (Samet et al., 1996) recommend that clinicians
In general, patients with recurrent and significant alcohol- or other drug-related problems within the past 12 months that interfere with role performance; cause legal, social, or interpersonal problems; or pose dangers to the individual and others are less likely to respond to a brief intervention. Not all patients, however, who experience a serious alcohol- or other drug-related incident need referral for specialized substance abuse treatment: The college student injured in an auto accident may have been driving while intoxicated but not be a regular consumer of alcohol or other drugs. Patients with several additional diagnostic criteria for substance dependence (e.g., physical tolerance, withdrawal symptoms, uncontrollable use, unsuccessful attempts to reduce consumption, or an intensive and excessive focus on obtaining the substance with accompanying impact on other occupational, personal, or social activities) are even more likely to require specialized and intensive treatment beyond the capabilities and time limits of the primary care clinician who is not an addiction specialist. Patients with a previous history of substance abuse treatment are not likely to achieve abstinence from an office-based intervention alone (Sanchez-Craig, 1990; Bien et al., 1993 ; Kahan et al., 1995). Nonetheless, patients who are suspected to have diagnosable substance use disorders may initially resist referral for further assessment, even though they express a willingness to participate in a brief intervention. Even though they are unlikely to be very successful in cutting down their use or maintaining recovery for any length of time through informal self-help mechanisms, a brief intervention may help motivate them to accept the needed referral or come to terms with the diagnosis (Chafetz, 1961, 1968; Chafetz et al., 1962, 1964; Brown, 1992). Brief intervention is not necessarily a one-time activity conducted only in response to an initial positive screen. Some patients may successfully reduce their consumption or abstain for some period of time, only to relapse or resume heavy and risky use at a later point in response to stress. Ongoing monitoring by the clinician, even if quite informal, is a logical part of the health care provider's responsibility for continuity of care and patient supervision (Institute of Medicine, 1990). Critical Components of Brief InterventionsThe Consensus Panel recommends that brief interventions include five components, although the individual needs of the patient should ultimately shape the clinician's response beyond this basic framework, and each case will follow its own course. For example, a patient who makes an office visit specifically to discuss a substance use problem (a rare occurrence) would be approached differently than a patient with a suspected substance use problem that is uncovered during a visit. The sequence and specific emphasis placed on these five key elements can be quite different for individual patients, and other brief intervention models exist. However, the following are the most common components.
Each of these steps is discussed in more detail in the following paragraphs, along with what could be considered a sixth step -- referral for more in-depth assessment or to specialized treatment. 1. Give feedback about screening results, impairment, and risks while clarifying the findingsThe clinician should report and interpret the findings (e.g., questionnaire answers, laboratory results, or observations from the examination) that have led to concern about the patient's substance use. Prompt feedback is one of the key elements commonly found in successful clinical trials of brief interventions (Bien et al., 1993). All results should be presented in a straightforward, nonjudgmental manner and framed in medical terms the patient can readily understand. Concerns about potential or actual health effects should be stressed (Fleming, 1995). Following are some sample scripts.
In presenting positive screening results to a patient, the primary care clinician must avoid being adversarial and should pay careful attention to semantics. For example, the phrase "people for whom substance use is creating problems" is less off-putting than the pejorative labels of "alcoholic" or "addict." Neutral, nonstigmatizing language allows both clinician and patient to discuss substance use as potentially problematic with negative effects that can be confronted and addressed in much the same way that diabetes is. Clinicians also must recognize that positive findings from the screening or initial assessment may trigger resistance or provoke feelings of guilt, shame, or anger. These negative reactions can usually be counteracted if clinicians continue to focus on the relationship between the health complaint that originally prompted the patient's visit and substance use or on the negative consequences of the patient's alcohol- or drug-using behavior as revealed in the screening. To ease this discussion and gain as much information as possible, clinicians should
2. Inform the patient about safe consumption limits and offer advice about changeOnce screening results and health risks or concerns are conveyed, the primary care clinician needs to explain to the patient what acceptable and safe use levels are for the relevant substance. Most high-risk or heavy drinkers do not realize that their alcohol consumption patterns are not "normal" (Fleming, 1995). Acceptable levels for alcohol use can be stated as quantity/frequency indicators considered nonhazardous for most adults or given as population norms. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines low-risk drinking as "no more than two drinks per day" for men and "no more than one drink per day" for women, with never more than four drinks per occasion for men, three for women (National Institute on Alcohol Abuse and Alcoholism, 1995b, p. 1). It is crucial to note, however, that safe consumption limits are only relevant for low-risk or at-risk drinkers -- and not always for them. There are no safe levels for patients meeting the DSM-IV criteria for substance abuse or dependence or for others with specified medical conditions such as pregnancy, breast cancer, or peptic ulcer. Drinking or drug use is never acceptable for adolescents. Hence, abstinence may be the goal for many patients. The concept of low-risk use does not apply to illegal drugs. While reducing consumption (e.g., smoking a decreasing number of marijuana cigarettes per week) may be a realistic intermediate step, abstinence from illegal drugs is always the ultimate goal. Even with alcohol, the personal characteristics and behaviors of the patient must be taken into consideration in defining low-risk use. Body weight, age, and gender influence reactions to alcohol as do interactions with other prescription drugs and health conditions. Patients also should understand concepts of tolerance and metabolism rates. Even one or two drinks can be dangerous if consumed rapidly and on an empty stomach, especially by persons who do not drink regularly. Although States have established blood alcohol concentration levels beyond which driving is illegal, these are usually much higher than levels at which reaction times are slowed. Hence, low-risk use varies across substances and individuals. Persuasive advice from the clinician has been described as the essence of the brief intervention (Edwards et al., 1977) and is the component found most often across 32 research studies of brief intervention (Samet et al., 1996; Bien et al., 1993). The health care provider should clearly state her own recommendations about consumption goals at this point, keeping these in the context of lifestyle issues and living habits (Kristenson et al., 1983; Chick et al., 1984). The more the advice can be integrated with health concerns and consequences of continued use, the better the chance of success. Clinician authority in offering advice can be strongly motivating, even though the patient's responsibility and capability for complying needs to be encouraged too. Some sample comments follow.
Primary care clinicians will not have time and are not expected to educate each patient about all possible hazards of alcohol and other drugs. Substance-specific pamphlets are useful at this stage of the brief intervention to reinforce and expand on what the clinician has said. (See Appendix D.) Some clinicians may train other office staff (e.g., nurses or health educators) to assist with providing relevant information or helping patients to develop specific strategies for change and to recognize risky situations and "triggers" that frequently lead to substance abuse. 3. Assess the patient's readiness to changeThe clinician must keep in mind the incremental nature of behavioral change and understand that many patients find such change difficult. A useful analogy is heart disease risk. A clinician may advise a patient to stop smoking, begin a regular exercise program, modify his diet, and lose 40 pounds to reduce the risk of heart disease, knowing, however, that incremental progress toward these goals is all that can be realistically expected. In making recommendations, the patient's readiness and willingness to change should also be taken into account. People with substance use disorders generally fall into one of five stages along a continuum that provides a useful framework for monitoring progress (Prochaska et al., 1992). The stages are
Most patients in primary care settings are in one of the first three stages and can be expected to express ambivalence or resistance to change, at least initially. A few patients may be taking concrete actions already or even experiencing a relapse (Marlatt et al., 1988; Miller and Rollnick, 1991; Prochaska, 1994). There is not necessarily a correlation between severity of substance use and a patient's readiness to change. Life events such as marriage, divorce, death in the family, job change, or moving may put individuals at a greater risk for substance-associated problems and may also affect their readiness to change. For example, a study of trauma patients found that some associated their injury with their alcohol use (Longabaugh et al., 1995). Such an acknowledged association can be seen as an indication of readiness to change, and the clinician can help the patient move further along that continuum. Patients' reactions to initial feedback about screening results or a recommended referral for further assessment or specialized treatment also offer strong clues regarding their readiness to change. Since only a few can be expected to offer immediate agreement, the primary care provider must be prepared for resistance and setbacks. If clinicians encounter resistance to the brief intervention from their patients, they should avoid the temptation to regard this as a challenge to their authority or to react in an authoritarian way. Studies show that the more confrontational or directive the clinician, the more resistant the patient is likely to be (Miller and Sovereign, 1989). Conversely, an empathic and supportive attitude creates a safe environment that the patient will feel comfortable coming back to, even if goals are not successfully achieved. A clinician should not think of resistance as failure, because one of the goals of treatment is to move patients along the readiness-to-change continuum. Each discussion of the substance abuse problem will help the clinician understand a patient's readiness to change and may move a patient from contemplation toward action. Developing a realistic sensitivity to the patient's location on this continuum can be key to a successful intervention. Samet and colleagues have developed a useful set of interview guidelines, summarized in Figure 3-1 below, to help the primary care clinician respond appropriately to patients in each of the six readiness-to-change stages (Samet et al., 1996). 4. Negotiate goals and strategies for changeIf the patient indicates a readiness and willingness to change, it is time for the clinician and patient to explore the possibilities and work together to develop a realistic plan with goals the patient considers achievable. With alcohol, the clinician can first suggest that the patient reduce consumption to below unsafe or potentially hazardous levels. If the patient feels this is impossible, the clinician should ask, "What do you think you can do?" If a patient who is using illegal drugs or abusing prescription drugs does not feel ready yet to discontinue use, the clinician can suggest a tapering schedule. Ultimately, the patient must choose the goal: The clinician can only remind the patient that reducing or stopping alcohol use or abstaining from other drug use will help eliminate the health or social problems substance use is causing. Following are some sample scripts:
Patients will be more motivated to change if they are helping to set goals and develop strategies for change. Some studies have found self-help manuals to be a helpful adjunct for planning change (Chick et al., 1984; Heather et al., 1990). One study of brief interventions for problem drinkers concluded that women may prefer to use self-help instruction manuals because of their fear of social stigma (Sanchez-Craig et al., 1989). The clinician also can suggest readings or specific strategies (e.g., what to do instead of drinking or what reminders might be useful when consumption seems appealing). A patient can gather information and put his own problem in a context by attending an open 12-Step meeting. The clinician can also suggest that the patient keep track of consumption in a daily diary. Many substance users are unaware of the quantity they consume or deny actual patterns to themselves and others. Daily diaries to record actual consumption have been found to be more accurate than general recollections (Antti-Poika et al., 1988). Even patients who are not ready to change their behavior may be willing to keep a diary. A written contract is often a good idea too; sometimes patients forget what they agreed to do. Clinicians can fold the written contract into an information book for the patient and keep a copy for themselves. Figure 3-1: Interview Approaches that Account for the Patient's Readiness for Behavioral ChangePermission could not be obtained for electronic reproduction. Please consult the source or a hard copy of this TIP (24) to obtain a copy of Figure 3-1. Source: Samet et al., 1996. Reproduced with permission from Archives of Internal Medicine 156:2287-2293, 1996. Copyright 1996, American Medical Association. The goals of the intervention must reflect a patient's current situation and responsibilities in life. For example, abstinence should be a goal for a pregnant woman or one who is trying to conceive since alcohol or drug use in the first trimester -- especially in the weeks immediately following conception -- is especially dangerous to the fetus. On-the-job abstinence should be the goal for airline pilots, physicians and nurses, or school bus drivers; and nobody, of course, should drink and drive. Patients taking a variety of medications that interact harmfully with alcohol or other illicit drugs, including many over-the-counter preparations, should at least temporarily suspend drinking or other drug use. The effects of alcohol are particularly enhanced by sedatives, sleeping pills, anticonvulsants, antianxiety drugs, antidepressants, and some painkillers. Finally, patients with mental disorders such as schizophrenia or bipolar disorder should not consume alcohol or other drugs since use can prompt reemergence of symptoms and associated problems of medication compliance or reactions (see Appendix A for more on drug-drug and drug-alcohol interactions). It is difficult to negotiate ways to address patients' substance use without understanding the larger context of their lives. Women are more likely than men to abuse prescribed sedative-hypnotics, and prescription drug abuse is a problem among elderly patients (Seale and Muramoto, 1993). The course of the brief intervention is also influenced by the patients' language and culture. Direct confrontation is anathema in some Native American and Asian cultures, and the clinician must adjust his or her approach accordingly. Health care providers have found an emphasis on health status the most persuasive tack with Appalachian substance users. Problem users in that culture can best explain -- to themselves and their peers -- their need to abstain on that basis. In short, each patient must be treated individually, and the clinician's relationship with the patient is the best source of information about the patient. 5. Arrange for followup treatmentOnce the patient and clinician have negotiated a plan of action to address the patient's substance abuse, they need to monitor progress. Any medical problem other than substance use (e.g., high blood pressure) should also be monitored, as should abnormal physical markers (e.g., elevated GGT levels). Patients need help in making progress, and whatever tools work should be used. It is encouraging for patients to see measurable changes, for example, in mean corpuscular volume and GGT levels. Monitoring compliance is a trust issue. The clinician should express trust in the patient; then, if the patient is not honest about reporting substance use, the clinician must confront the patient and renegotiate the parameters of the relationship. Making honesty one of the ground rules works surprisingly well. The wish to preserve the trust of the clinician can be a part of what motivates patients to continue returning for followup monitoring. If a patient tries to deceive the clinician, the clinician should persist: "Your continued use of [alcohol or other relevant drug] is a problem. What do you think will help you stop using?" Use of a collateral informant is another way to monitor compliance, but that can be problematic. Enlisting a patient's significant other to help monitor the patient's progress should be framed as a supportive rather than a policing effort. Before suggesting or agreeing to monitoring by a significant other, the clinician needs to be aware of marital and family dynamics, especially the potential for violence. A clinician using urine samples, Breathalyzers', and other toxicology tests may seem intrusive and suspicious to some patients, while others welcome the discipline imposed. The use of any form of objective monitoring beyond self-reports of substance abuse consumption must be negotiated between the clinician and the patient. Biological monitoring, if implemented, should be viewed as an informative measure, not cause for punitive action. Repeated positive urine tests or elevated GGT levels simply mean that the informal strategy for reducing or eliminating substance use is not working and that alternative approaches should be considered. Clinicians must also remember that biological markers, by themselves, do not necessarily provide an accurate reflection of substance use. GGT levels may reflect liver damage caused by factors other than alcohol; positive urine screens may be triggered by other legal substances or reflect use before a patient agreed to stop using a particular drug. Laboratory tests work best in conjunction with open communication between the clinician and the patient. The number of followup visits that should be scheduled will depend on the severity of the problem, the patient's response, and the clinician's available time. At least one researcher (Wallace et al., 1988) found that reduction of alcohol consumption correlated directly with the number of practitioner intervention sessions that were delivered, although the improvement in outcomes may have been due to self-selection bias, with more motivated patients changing their drinking habits and returning for more followup visits. Finally, patients should be told exactly who will see their medical charts and what information about the screening and intervention will be recorded, particularly if the clinician is part of a health maintenance organization or sends bills to a third party insurance carrier. The complex issues involved in protecting the confidentiality of patients with substance abuse problems are discussed in more detail in Appendix B. Deciding to refer for further assessment or treatmentOne of the most important concepts of substance use treatment is that one treatment failure is no reason to give up. Clinicians should be prepared for the brief intervention to fail: The patient may not be able to achieve or maintain the mutually established goal of reducing or stopping use after one, or even several, tries. Also, even though abstinence may be the ultimate goal of an intervention, clinicians must be willing to accept limited, incremental goals. The concept of relative recovery can be useful. An individual may not regain perfect health but may improve. A brief intervention targeted at substance use is not the same as a single dose of medication that will resolve an infection. Rather, substance use disorders are chronic conditions that often need repeated interventions or treatments before progress is stabilized. Incremental steps toward improvement are necessary not only in patient behavior but also in the patient's attitude and readiness to change. Clinicians should not expect that patients with problems related to alcohol and other drug use will have any less difficulty than other patients in making significant lifestyle changes. Lack of success in following the advice given and the strategies undertaken in a brief intervention can be a learning and motivating experience, evidence to a patient that substance use may be a bigger problem than previously thought. The clinician can steer a patient toward such a revelation by saying something like, "You weren't able to cut down your alcohol use as you contracted to do. Does this make you think this is a bigger problem for you than you thought?" Failure to achieve the goals of an initial brief intervention may move the patient along the continuum of change.A clinician cannot force a patient to undergo further assessment or accept a referral for specialized treatment even if the substance use disorder is severe. If the patient is only willing to accept a brief intervention, the clinician initially should try to work within this limitation, although some instruction should also be provided about the possibility of experiencing withdrawal symptoms. Arrangements for more intensive and frequent followup will also be needed. As stated above, brief intervention has several goals. If problem use persists after a brief intervention, those discussions between clinician and patient should serve as a springboard to a more in-depth assessment or specialized treatment. |
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