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Resource Guide: Screening for Drug Use in General Medical Settings

Step 2 - Conducting a Brief Intervention

ADVISE patient according to screening results.

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.^10,11

Step 2: Discuss screening results.

Review screening results.
Provide medical advice.

Review 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 of 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)

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.

This page was last updated April 2009.