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Resource Guide: Screening for Drug Use in General Medical Settings

Screen, then Intervene: Conducting a Brief Intervention

Step 4: Advise, Assess, Assist and Arrange

This brief intervention gives patients a chance to learn about their drug use—especially as it pertains to their health—from an objective third party with medical training. It relies on the premise that advice from an expert has been shown to promote change.11,12

Step 4: Brief Intervention

Review results with patient, then:

  • Advise patient about drug use
  • Assess readiness to quit
  • Assist patient in making changes
  • Arrange treatment or follow-up care

Begin by reviewing screening results with the patient.

  • Ask permission to have a short discussion about the screening results.
  • Report back the types and amounts of use reported (giving patients the NIDA-Modified ASSIST tally sheet may be helpful).
    • Allow the patient to correct omissions so you get the full picture of use.
    • Prompt the patient: "Tell me more about your use of drug X and Y" (for each drug the patient reported).
  • If the patient has used within the past 3 months, review other ASSIST responses.

Reminders to improve patient rapport:

  • Avoid tone that the patient might think is judgmental or confrontational.
  • Show an interest in what the patient's life is like.
  • Acknowledge the patient's current view of his/her drug use.
  • Signal to the patient that having mixed feelings about a drug use problem is normal.
  • Highlight patient confidentiality (and its limitations).

ADVISE—Provide medical advice about the patient's drug use.

  • Explain that it is your role as his/her medical provider to convey health recommendations
  • Recommend quitting before problems (or more problems) develop. Give specific medical reasons.
    • Medically supervised detoxification may be necessary for discontinuing use of some drugs (e.g., benzodiazepines).
  • Reminder:

    The screen is only one indicator of a patient's potential drug use problem. It is not a substitute for clinical judgement, which you should use to determine when an intervention is warranted.

    When appropriate, educate patients on the following:
    • Use of even small amounts of drugs or tobacco may negatively impact health and performance (e.g., driving or operating machinery).
    • Because drug intoxication can lead to impaired judgment and risky behaviors, refer all sexually active patients for confidential testing for HIV and other sexually transmitted diseases or provide an onsite testing opportunity, if they do not know their status or have not been tested recently. Encourage all patients to practice safe sex.
    • Refer all patients with past or current injection drug use (Question 7) for HIV and Hepatitis B/C testing if they have not been tested twice over a 6-month span following their last injection.
  • Make referrals to evaluate suspected co-occurring conditions (e.g., psychiatric consultation for depressed, inattentive, or anxious patients or pain specialist consultation for patients seeking narcotic prescriptions for chronic nonmalignant pain).
  • Provide recommendations based on risk level:

High Risk

A strong recommendation to change substance use is essential. Consider making a statement such as: "Based on the screening results, you are at high risk of having or developing a substance use disorder. It is medically in your best interest to stop your use of [insert specific drugs here]. I am concerned that if you do not make a change quickly, the consequences to your health and well-being may be serious." Include a referral for additional assessment (the NIDA-Modified ASSIST provides a risk level, but not a diagnosis of abuse or dependence). Let the patient know that the assessment will determine whether they have a diagnosis of substance abuse or dependence and if substance abuse treatment is indicated. Whether to attend treatment will be the patient's decision.

  • Specific examples of harm for different problem drug categories may be helpful.
  • Emphasize that there are many ways to change substance use behavior (e.g., community treatment programs, self-help groups, medications, etc.).
  • Emphasize that treatment is often on an outpatient basis and programs are often accommodating of concerns like maintaining employment, insurance reimbursement, child care, etc., depending on the patient's concerns.

Moderate Risk

Consider beginning the discussion by saying, "Based on the screening results, you are at moderate risk of having or developing a substance use disorder. It is medically in your best interest to change your use of [insert specific drugs here]."

  • Add information that is specific to the drugs the patient uses.
  • Express your concern about specific ways drugs might negatively impact your patient's life (e.g., health, relationships, work, etc.).
  • Emphasize that there are many ways to change substance use behavior (e.g., community treatment programs, self-help groups, medications, etc.).

Lower Risk

Consider having a discussion about acceptable levels of use and the potential for future problems. You may begin the discussion by saying, "Your screening results show you are unlikely to have a substance use disorder. However, people with any history of substance use can be at some risk of adverse consequences and developing a disorder especially in times of stress or if they have just started to use recently. It is impossible to know in advance whether or not a person will become addicted. As your physician I encourage you to only use alcohol moderately and responsibly and to avoid using other substances."

  • Intervention duration may be minimal
  • Use your clinical judgment based on the medical status of the patient and drug being used. For example, pregnant women,* youth, people with histories of substance use disorders, and others for whom any drug use could potentially pose a serious risk may benefit from a complete intervention regardless of apparent risk level.

* 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.

ASSESS the patient's readiness to quit.

  • Have a conversation about whether the patient is ready to quit. For example, you might say something like, "Given what we've talked about, do you want to change your drug use?"
  • If the patient is unwilling to quit, raise awareness about drugs as a health problem. Let patients who are not ready know that you will revisit the issue at future visits and have resources available when he/she decides to pursue making a change.
  • If the patient is ready to quit, reinforce current efforts and then assist patient in their efforts to make changes that will help them reduce and/or quit their drug use.

ASSIST patient in making a change.

  • Jointly complete a progress note form (Appendix 2) with the patient to document the screening results and create a followup plan.
  • Help set concrete (and reasonable) goals for making a change (see Appendix 3: Change Plan Worksheet, for more information).
    • Ask interested patients to complete a change plan before they go home.
    • Make a copy without their name or the name of your office on it, give it to them to take home, and tell them you will check in on their progress at the next visit.
    • For patients who do not complete a change plan, schedule a second appointment to continue the discussion and to complete the change plan. You may provide a blank copy for them to take home and ask them to return with it, but some patients may need to start again with a fresh copy during their second appointment.
    • For patients not interested in completing a change plan, encourage them to set a few brief change goals (e.g., cutting back, trying a self-help group); record the goals to check progress at the next visit.
  • Prescribe medications for office-based treatment of tobacco, alcohol, or opiate addiction, as appropriate.

ARRANGE specialty assessment, drug treatment, followup visit.

Offer continuing support at follow-up visits.

  • Refer patients as appropriate.
  • Schedule follow-up.
  • Offer continuing support at follow-up.
  • Refer patients as appropriate.
    • Because the screening does not provide a diagnosis of abuse or dependence, refer high-risk patients for a full assessment. For moderate-risk patients and low-risk patients with special concerns (e.g., pregnant women, past injection drug users), use clinical judgment to determine whether additional assessment is necessary. Use SAMHSA's treatment locator (see additional resources, http://findtreatment.samhsa.gov/) or NIDA's National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs (see additional resources, www.drugabuse.gov/about-nida/organization/cctn/ctn) to locate assessment resources.
    • If nearby treatment resources are not available, consider providing support group contact information and self-change materials, as well as counseling resources—clergy or mental health referrals.
    • Obtain a written information release to send the screening results to all providers who will receive referrals.
  • Schedule a followup appointment within 1–2 weeks for moderate and high-risk patients and low-risk patients in certain groups.
  • Offer continuing support at followup visits.
    • Annual rescreening is indicated for patients who report any drug use at baseline (even with scores of 0–3) and for any other patients about whom you remain concerned. For moderate- and high-risk patients, rescreen at next appointment.
    • At followup, make targeted recommendations to moderate-, high- and select lower-risk patients accordingly:

High Risk—Targeted Recommendations:

  • Determine whether the patient followed through with the referral.
  • Offer additional brief intervention for patients who did not attend the referral.
  • Make additional referrals for patients who missed referral.
  • Obtain records of assessment and/or treatment for patients who attended referral and/or treatment.
  • Discuss ways to help support recommendations of referral source.

Moderate Risk—Targeted Recommendations:

  • Determine whether the patient reduced or abstained from use.
  • For patients who did not make progress with change efforts, acknowledge change is hard, repeat brief intervention, and discuss additional ways to support the patients' efforts.
  • For patients who have made changes, reinforce efforts and encourage additional goal-setting.
  • Follow up at subsequent visits.

Lower Risk—Targeted Recommendations:

  • If the patient indicated that he/she wanted to make a change, ask what, if anything, the patient decided to do about substance use.
  • Encourage abstinence from tobacco and illicit drugs and advise low-risk alcohol users to remain within acceptable drinking levels.
  • On evidence of escalation of use, conduct brief intervention.

 

This page was last updated March 2012