Step 3: 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 move to Step 4.

Step 4: ASSIST patient in making a change.

• Jointly complete a progress note form (Sample Progress Notes) with the patient to document the screening results and create a followup plan.
• Help set concrete (and reasonable) goals for making a change (see 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.

Step 5: ARRANGE specialty assessment, drug treatment, followup visit.

A. 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 inject ion drug users), use clinical judgment to determine whether additional assessment is necessary. Use SAMHSA's treatment locator (see additional resources, http://dasis3.samhsa.gov/) or NIDA's National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs (see additional resources, http://ww2.drugabuse.gov/CTN/ctps.php) to locate assessment resources.
• If nearby treatment resources are not available, consider providing support group contact information and self-change materials (see additional resources), 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.

B. Schedule a followup appointment within 1 - 2 weeks for moderate and high-risk patients and low -risk patients in certain groups.

C. 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: