Hi. I'm Derek Blevins. I'm going to be going through the module for Screening, Assessment and Treatment Initiation for SUD. I don't have any financial relationships to disclose that but I received salary support from NIDA research fellowship grant. I would like to acknowledge the contributions of Dr. Williams, Dr. Smith, Dr. Bisaga and Dr. Levin for this presentation and for mentorship. The overarching goal of PCSS-MATT is to make available the most effective medication-assisted treatment to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. The educational for this objectives, so by the end of this activity, participants should be able to screen and assess for substance use disorders and co-morbid disorders. This will be done using brief and extended screening tools, evaluating for both physical health and mental health as related to substance use disorders. We'll be able to utilize screening, brief intervention and referral to treatment, commonly referred to as SBIRT, strategies and principles. Utilize motivational interviewing strategies, describe continuum of care models of SUD treatment, apply ASAM criteria when referring to treatment and integrate screening assessment and ASAM criteria for SUD treatment referrals. This is an overall outline of the presentation. So we'll start with screening and assessment, brief intervention, referral to treatment, continuum of care models, ASAM criteria and then some referral resources that might be helpful. I just thought I would start with a couple of cases. These are two very different cases. Hopefully by the end of the presentation, you'll feel comfortable doing the screening assessment, brief intervention or referral. So the first case is a scenario that may be encountered frequently with healthy individuals coming in for a pre-employment or school physical exam. So this is a 22 year old male, a new patient, presents for employment physical for his first job out of college. He says everything is "great." He denies any complaints. He has no past medical or psychiatric history, doesn't take any medications. He reports drinking "socially" and denies any drugs or tobacco. On further questioning, he admits that he drinks on Friday and Saturday nights, typically six "mixed drinks" at the bar. He's never had any alcohol related problems, including blackouts, except for that one time in college. He also smoke that cannabis vaporizer pen one to two nights per week with friends. No, he doesn't really consider marijuana a "drug", which is why he told you that he denied any drug or alcohol or tobacco use. So these are some questions I'd like to think about as we go through this presentation and we can address at the end, which is how would you approach discussing alcohol and cannabis use with this patient? Which screening tool or tools would you use? Does he need a brief intervention or referral to treatment? What is his current "stage of change?" If he returned with increased alcohol use and a DUI, what should come next? The second patient is someone who may have made at a typical sick person or a sick patient that is, someone who may or may not be well known to your clinic and staff and may have seen other treatment providers who maybe have not assessed for problematic substance use. So this sheet described this person on your schedule as, "I'm depressed and my belly hurts." This is a 54 year old female who presents her follow-up for hypertension treatment. She previously saw provider for 10 years in your clinic and now her cares transferred to you after her doctor's retirement. Her record, hypertension has been difficult to manage despite numerous medication trials. Previous doctor's notes have said that she's a regular drinker, needs AA but no other details were provided. She presents now for regular follow-up for hypertension, but it's a new complaint of feeling depressed and having abdominal pain. It becomes clear to you that her abdominal pain is likely gastritis from alcohol. She admits that drinking has "gotten out of hand" and she says she "needs to go to AA." Her first episode of depression lasted about three months, started before she had any problems with alcohol. Then during the second episode, she began drinking more, which allowed her to "numb her emotions." She tried to come back a few times but her spouse is a "moderate" drinker who also keeps alcohol in the house. So again, we'll consider these questions as we go through the module. How would you screen or assess this patient for substance use disorder? Does she need a brief intervention or a referral to treatment? What is her stage of change? What strategy would you use? According to the ASAM criteria, what would be the best place for her treatment? What could you do to initiate treatment in the interim? Again, these are two very different patients that are commonly encountered in primary care or primary psychiatric clinic. So the first part of the module, we'll talk about screening and assessment. This is an overview of the module, of the section rather. First we'll talk about some various screening tools and how to use SBIRT and motivational interviewing, some brief versus extended screening tools with some examples here, the CAGE, AUDIT, the drug abuse screening tests or DAST, CRAFT and NIDA Screen and Modified-ASSIST. I'll show you the NIAAA rethinking drinking websites. We'll talk about some extended substance abuse assessment questions and diagnosis, including DSM-5 criteria, and then additional physical and mental health assessment questions. So first part of that, again, is focused on screening. Alcohol and drug screening. So these are general principles, some basic information about screening more broadly as well as specific recommendations from the US Preventative Services Task Force regarding alcohol screening. Before I go through these, I would say it's important to keep in mind that an individual should not be diagnosed with a substance use disorder merely as a result of a positive screening. Doing so could also carry some unintended consequences if it's documented incorrectly in their clinical chart. Just keep in mind that someone with risk for hypertension or with one elevated blood pressure reading are not diagnosed with hypertension despite there being some risk involved with an elevated blood pressure reading. Similarly, a substance use disorder diagnosis should only be given if diagnostic criteria are met. But we'll go into this more later. So again, some basics of screening here. The idea that they're used for illnesses with high prevalence, used for early detection for better outcomes. The tests should have high sensitivity and specifically for alcohol misuse, the USPSTF recommends clinician screen adults age 18 or older and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Again, a positive screen does not result in SUD diagnosis but indicates importance for further evaluation. The screening tests should be universal, quick, and non-judgmental and the point of them being that they detect a risky or problematic use. So the first screen that I've included here is the NIDA Quick Screen which evaluates for both problematic alcohol and drug use with one screening question that's then followed by more detailed questions in the NIDA-ASSIST. The quick screen is included here for the purposes of showing a tool that can assess for both alcohol, drugs then as well as tobacco use. Note that the quick screen question asked about past year alcohol use with a limit of four drinks per day for women and five drinks per day for men. We'll talk more about the NIDA tests when we talk more specifically about screening for drug use. Alcohol screening. This screening question addresses that past 30 days with a lower threshold for a number of drinks or any alcohol you use in these populations listed here. So patients under 21, patients who are pregnant, who may have medication interactions. This is the list of medication that do interact with alcohol, not an exhaustive list. Medical conditions that may also be problematic if someone is drinking. Then dangerous situation like driving when drinking or operating machinery. Again, just to point out that this is the past 30 days screen, women drinking more than one drink per day or men more than two drinks per day. Again, the point being that you would need to ask more questions that that was a positive screen. Some other screening tools for alcohol, a few that's simple are commonly used and well-validated tools for assessing problematic alcohol use are the AUDIT and the CAGE. The full AUDIT is 10 items. However, it's been abbreviated to just the first three questions, which is called the AUDIT-C. The point of the audit is really to detect risky drinking or an active alcohol use disorder. The CAGE, on the other hand, is four items, it's an acronym, and it detects moderate or severe alcohol use disorder that may not actually detect risky drinking. So an important point here, despite both of these being commonly used screening tools that are pretty simple, short, easy to remember, the AUDIT-C is a much better screening tool to detect risky or problematic drinking as compared to the CAGE. So here are the questions on the AUDIT. Again, you can see it's ten questions, each question is scored from 0-4. You total the score and if it's equal to or greater than eight, it would be considered a positive screen. This is not differentiated for men and women on the full AUDIT. Now, the first three questions that I mentioned are actually the AUDIT-C. It is scored differently, which we'll talk about on the next slide. I just wanted to point out that just just the first three questions and that these three questions are actually sufficient for screening for risky alcohol use. But it's an important point too to say that questions 4 through to 10 can give you some more detailed information that could guide either your brief intervention or the type of referral that you're going to consider. So here are again, just the first three questions of the AUDIT, which is called the AUDIT-C, scored in the same way from 0-4. However, there is a difference in the way that it's scored between men and women. So men having a score greater than or equal to 4 have a positive screen and for women that's 3. This is related to differences in pharmacology between the sexes regarding alcohol. An important point, also in terms of thinking about standard drinks, is that people consider a standard drink to be very differently. So one drink can range from anything from a very small glass of wine in the evening to a large Long Island iced tea, and patients will often say that they have a one drink regardless. So the most common standard drinks are 12 ounces of five percent alcohol beer, five ounces of 12 percent alcohol wine, and one and a half ounces of 80 proof or 40 percent alcohol liquor. If you can keep those in mind when patients are talking about the number of drinks that they have, for the most part, you're in good shape. As you'll see here though, there are some other types of wine that patients drink that have different percentages of alcohol and are often consumed in different quantities. I mentioned the CAGE. These are the CAGE questions. As it says, it's a mnemonic. Have you ever felt you needed to cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt guilty about drinking? Or have you ever felt you needed a drink first thing in the morning to steady your nerves or to get rid of a hangover, which is the eye-opener question? A positive screen would be two or more "Yes" answers to these questions. The CAGE has been around since the late 1960s. That's pretty easy to remember because it's a mnemonic. However, it doesn't actually detect lab Advanced problematic drinking compared to the audit. You can imagine that cut down, annoyed, and guilty requires some level of insight. Rather, the audit few questions focus more on the frequency and amount, which are much more objective. NIAAA have launched their rethinking drinking campaign on their website, which allows anyone to go on and input their drinking pattern and receive personalized feedback. You'll see that the first question is the same as the NIDA Quick Screen, but it also asked about weekly consumption. So you can see here that I have put "Yes, this person consumes more than four standard drinks any day in the past year." That on average, how many days per week do you drink alcohol? Five. On a typical drinking day, how many drinks do you have? Five. Then you can see that it gives personalized feedback based on that information. So more than four per day for women or five per day for men is defined as binge drinking by NIAAA and exceeds the recommended single-day limit. For weekly consumption, NIAAA recommends a limit of seven drinks for women and 14 drinks for men. So you can see here that anyone exceeding either of these is considered at increased risk, and anyone exceeding both parameters is highest risk. Now, moving on to drug screening more specifically, the simple screen for substance use other than alcohol simply ask about any non-medical uses of medication, any illicit drug or tobacco use or any use of substances for intoxication, others substances. A "Yes" on any of these questions warrants further questions, and it leads to brief intervention, if not, a referral to treatment. Another commonly used self-report measure is the DAST or Drug Abuse Screening Tests. That can be administered with other clinic paperwork when a patient comes in for an initial or follow-up appointment. The scoring is done by indicating a zone of use. This includes healthy, risky, harmful, or severe, and then an indicated action, which could be; nothing, giving advice, doing a brief intervention, or referring a patient to a specialized treatment. There is the longer version, 28-item, as well as the shorter, 10-item version of the DAST. The CRAFFT, which again in mnemonic, and actually stands for car, relaxed, alone, forget, friend, and trouble is specifically for patients under age 21. They're for adolescents and gives a probability ranging from 30 percent to 100 percent and can either be self-administered or clinician administered. But again, it is specifically for adolescents. The questions are geared to better assess adolescents. Here we are back looking again at the NIDA Quick Screen. So we looked at the first time primarily for alcohol, and now we're seeing the tobacco, prescription drugs, and illegal drug questions. Again, just remembering that this is past year use. If the answer the ended questions is "Yes," then you would move on to the NIDA-ASSIST. After "Yes" on the quick screen, answering these additional questions can provide a score that indicate the level of risk. It is a comprehensive screening assessment. The scoring is a big complex. I've included the link here so you can look at more detail in terms of how it scored, but it does give you a level of risk per substance. So they may answer "Yes" to two or three, and you would ask few questions for each of those substances. It puts them in a category of lower risk, moderate risk, or higher risk. So thinking now about some additional assessment. So we've talked about primarily screening for alcohol, drugs, or tobacco. Now, thinking about an extended substance use assessment, physical assessment, and mental health assessments. These move beyond the basic screening questions. Again, it's important, I think, to reiterate that a screening assessment does not equate to a DSM-5 diagnosis of an SUD. It's important to note that the DSM-5 diagnosis is often not required for substance use to be considered risky or problematic. There may be significant overlap between the screening questions and the DSM-5 diagnostic criteria, but without asking those 11 DSM-5 criteria, the severity cannot really be determined. It's easiest to remember the criteria by these four major categories; impaired control, social issues related to substance use, physical or psychological consequences, and physiologic symptoms including withdrawal and tolerance. You'll notice that there are no criteria regarding frequency or amount of use or consumption, which is different than the screening tools and screening questions. So a person could use a drug, let's say, marijuana daily and not meet DSM-5 criteria, although this is the exception and not the rule for a frequent illicit substance user, as further questioning or collateral information is likely to suggest impaired control and related social issues. But even this person's use is slightly risky, regardless of the presence or absence of an SUD diagnosis. Here are some additional questions that may be helpful after a positive screening to better understand your patient's substance use. Answers to these questions will guide aspects with a physical and mental health assessment and help with your brief intervention or consideration referral options. For instance, in a poly-substance users, the drug of choice may indicate that AA or NA may be a better option for referral. The amount and route of administration may encourage you to further investigate particular body systems on exam or at lab work. Past withdrawal symptoms may indicate that the person needs more medical attention with discontinuation of the substance. If they've had a past overdose, particularly on opioids, you could recommend or prescribe [inaudible] to the patient or involve family members. If a patient overdose after detoxification and not start on medication-assisted treatment, they should be referred to a program that offers medication-assisted treatment. So you can see that asking these questions about drug of choice, when they last used, how frequently they use, the amount they're using regularly, the route of administration, when they started using, if they've had periods of abstinence, if they use other drugs, and if they use them together or separately, what sort of past withdrawal symptom that they've had, if they've had past treatment, any past overdoses and if that was related to detox or treatment, and then past drug related complications or prior treatment. So again, these can all help guide your next step in the conversation. Thinking about the physical assessment, this is just included for completeness. So one physical exam item that should be thorough is inspection of injection site, not all of which may be exposed if the patient is closed. Patients could be skin or muscle popping. So that's an important thing to keep in mind. Regarding labs, pregnancy tests, drug screening, and infectious disease may not be routinely included but should be included for patients who are using substances. For some medication-assisted treatments, they are metabolized by the livers, so getting baseline liver function testing can also be helpful. I've included a list of common physical complications related to more common substances abuse. So thinking about alcohol, systems that are majorly impacted can be the cardiovascular system, gastrointestinal system, and hematologic system. With opioids, thinking about and the respiratory system, infectious diseases, gastrointestinal and reproductive. With marijuana, which is less common concerned with physical assessments, but cardiovascular issues like tachycardia, gastrointestinal, there's a described hyperemesis syndrome, and in genital urinary, there have been some associations with testicular cancer and cannabis use. So things to keep in mind that don't commonly come up. Thinking about stimulants, of course, the cardiovascular system, gastrointestinal, musculoskeletal, and neurological systems can be impacted, and of course, tobacco, cardiovascular, respiratory, and gastrointestinal systems. So just things to be keeping in mind when you are doing your physical exam and thinking about which kind of labs that you want to draw. Moving on to the mental health assessment. A more detailed mental health assessment can also contribute to a more comprehensive understanding of the patient and their needs, particularly for the purpose of referrals. Components of the mental health assessment would include a mental status examination, appearance; attitude, if the patient's cooperative or not; the types of behavior they're exhibiting; their speech; the way they describe their mood, but also their affect; thought processes; thought content, particularly obsession or suicidal or homicidal ideation; any perceptual disturbances like hallucinations, and also thinking about tactile hallucinations as well [inaudible] visual; their orientation, and their insight and judgments. Another thing that can be helpful in the cognitive exam. Many mental status exam or a MoCA are commonly used and easy to administer in the clinic. Thinking also about current physical or sexual abuse and then evaluating for risk of harm to self, others or an ability to care for self. So if they've had current or recent ideation, plan or intent for harm to self or others, any history of harm to self or others, any access to firearms or other lethal means, and then inability to perform activities of daily living or ADLs. Thinking, again, about mental health assessment, it's important to keep in mind the high rates of other psychiatric illnesses or psychiatric syndromes that may result from substance withdrawal or prolonged substance use. The very commonly comorbid psychiatric disorders include major depressive disorder, bipolar disorder, anxiety, and psychotic disorders, ADD or ADHD, and PTSD. Borderline personality disorder and antisocial personality disorder are also commonly comorbid. Then, thinking about substance-induced disorders and symptoms of substance withdrawal. So thinking about the temporal relationship with substance use, periods of abstinence may help clarify symptoms, if their symptoms go away or continue during periods of abstinence. Then, the expected withdrawal signs and symptoms based on the substance they're using. An increasingly important point, as we learn more about how to better treat both psychiatric and substance use disorders, is that treatment of substance use disorders should be concurrent with and not subsequent to treatment of psychiatric disorders, with evidence that this results in more improvement in both domains. A former strategy was that substance use disorders should be treated first and see what's leftover, and then treat the psychiatric symptoms that remain, but it's much more commonly accepted now to treat both at the same time. This does not necessarily mean that they require psychiatric medications for substance-induced diagnosis, but psychosocial interventions should address psychiatric symptomatology like depression or anxiety. So moving on from screening now to talk more about brief intervention. So first, I think the most important is to understand who needs a brief intervention as opposed to a direct referral to treatment. So when we think about substance use, we categorize it more broadly into two categories of problematic use and addiction. When we're talking about problematic use, we're thinking about substance use that threatens health and safety, and we wouldn't consider that to be addiction, whereas addiction is a chronic disease and would equate to a DSM-5 diagnosis of moderate or severe substance use disorder. So thinking about in these two categories, if you think about problematic use, a brief intervention is always warranted or needed, whereas as opposed to addiction, when you think about their chronic disease, having a moderate to severe substance use disorder, a referral to treatment is really required at that point. But it's important to note that twice as many patients will require only a brief intervention as compared to referral to treatment. So thinking about brief intervention, broadly speaking, the major elements of brief intervention are engagement, motivation, and planning. There are three similar methods of providing a brief intervention. So motivational interviewing or MI includes engaging a patient; focusing, evoking, and planning, they sound similar to engagement, motivation, and planning; BNI or a brief negotiated interview raises the subject provides feedback, enhances motivation, negotiates the plan. Again, sounds pretty similar. Then, the five A's of NIAAA, which is ask, advise, assess, assist, and arrange. Some important considerations for each of these, they should be about 5-10 minutes. You would educate the patient and be non-judgmental on your education. You want to appeal to the patient's goals and values and allow for their contribution, and also allow for their disagreement. Allowing for their disagreement means that you don't have to be the all-knowing expert giving some sort of ultimatum. Taking this attitude and allowing them to disagree can reduce their resistance to the intervention. Encourage the patient to problem-solve, to think of ways that they may be able to reduce or stop and reflect to the patient their commitment to change. We'll go into this in more detail. This is just a reminder of the stages of change and keeping in mind that patients can present at initial visits or follow-ups in various stages. Most often we would say people start in precontemplation and move forward, but someone may come to you already in the contemplation or preparation or even the action phase. So going back to our engagement, motivation, and planning. So looking at engagement, you want to develop a comfortable way to introduce the topic, establish rapport, and ask permission to discuss, being nonjudgmental and empathic. Frame this discussion within the context of medicine. Emphasize medical consequences and consider the language that you're using. Thinking about recreational drug use as compared to illegal drug use, which sounds more scary, and concerning, and carries some additional consequences in the patient's mind, or just saying drug or alcohol use as opposed to using the word abuse. You want to normalize your assessment in saying that your questions are routine and integrate it into preventative care. So some ways that you might engage a patient would be to say, I'd like to ask you some routine questions I ask all patients, or would you mind taking a few minutes to discuss your use of tobacco, alcohol, and other drugs? Or saying you can improve and prevent a lot of health problems by reducing drug and alcohol use. So in terms of motivational interviewing, an easy mnemonic to keep in mind is ORAS, open-ended, affirm, reflect, and summarize. So open-ended questions, don't leave the patient or ask yes or no questions. For example, you could say, "Can you tell me a little more about your alcohol use?" Affirmation; show appreciation and understanding of their experience, and they should be genuine and can be as simple as wow or that's really difficult. Reflection to demonstrate understanding of what they're saying and clarify any misunderstandings. So for example, so while you don't really like drinking, it provides you with some relief. Then, summarizing would take to periodically review the discussion up to that point and offer to discuss anything missed or needing clarification. So inquiring about current patterns of substance use during the engagement process, determine patient perception of substance use, identifying their personal values and goals, discussing the impact of substance use on their goals, and developing discrepancy between substance use and achieving goals. Elicit the need and perceived ability to change. So these are all additional engagement strategies. Moving onto motivation, you want to provide clear, specific, personalized feedback. Include risk and consequences of use, particularly if they've already had any risk or consequences. Express concern and recommend explicit changes. Support patient self determination autonomy. Tailor it to the patient's level of health literacy. Emphasize your confidence in their ability to change. Assure continued support throughout the process. Emphasize their strength and past successes, but also validate any frustration, and while remaining optimistic. Again, this is an important time to reflect and summarize as they're engaging with you more in the conversation. I'd love preparing them for the next stage. A few things you might say in this portion of the conversation and motivation would be, "You think that your smoking of tobacco and marijuana has been making your asthma worse? As your doctor I agree that smoking less will reduce your asthma symptoms. Or the support your family gave was very helpful when you cut back on your smoking last year, maybe your family support can help again now as you try to quit completely. Or remember when you quit smoking cigarettes, I can't imagine how tough that was, but you actually did it. I'm confident you can use those same skills to cut down on your drinking." Now thinking about planning, you want to make goals that are aligned with the patient's readiness to change. Going back to thinking about stages of change. A goal should be attainable, measurable, and timely. You should help anticipate any potential challenges to achieving those goals, and change strategies as needed. You want to avoid being argumentative or being defensive. You can recommend the ideal, but accept less if the patient resists the ideal situation. You want to follow up at least within a month, reinforce the ideas, reassess, and update the plan, acknowledge their efforts and experiences, offer continued to support despite their progress, and give help and guidance for a social support. So some things you may say in terms of planning would be, "What changes do you think you can make with your drinking and use of painkillers? Well, it sounds like limiting the alcohol and pain killers you keep at home, and that might be a great first step. How do you feel about making that change? When do you think you'd be able to start? What do you think might get in the way? Or I can understand that it's not an option to get that drinking socially, but I agree with you that not drinking alone is a big first step." Now moving from brief intervention, to referral, to treatment. So again, we're certainly thinking about those people that fit the addiction as opposed to problematic drinking, or we're talking about referral to treatment. So we'll talk about some evidence based treatments and peer supports, continuum of care model, the ASAM placement criteria, and then some referral resources that can be helpful. So we considering referral resources that can be helpful to keep treatment options in mind. This will be discussed later, but there are FDA approved medications for alcohol, opioids, and tobacco use disorders. Most psychological treatments have then shown beneficial for substance use disorders, that pharmacologic treatment should be strongly considered and encouraged for opioid use disorder given the risk of relapse, overdose, and infectious disease. So here I've just listed the FDA approved medications for alcohol, opioids, and tobacco, and I listed the psychosocial interventions. Then keeping in mind also that there are various types of 12-Step facilitation. So there's not only AA and NA, particularly in larger cities, they may have marijuana anonymous, cocaine anonymous, or crystal meth anonymous, that may fit better with the patient's goals and comfort level. So this is the continuum of care model as provided by SAMHSA. I think the important thing to point out here is that the indicated section of prevention is really where brief interventions sets in, beyond the indicated which we would be targeting individuals with a high risk to have minimal but detectable signs and symptoms of substance use. Anything beyond that, you're thinking about referral to other treatment. Then I want to talk something about the American Society of Addiction Medicine. They provided widely accepted criteria to help determine the location of treatment. They give guidelines for patient placement, transfer, or discharge for patients with substance use disorders who may have co-morbid medical or psychiatric conditions. They do this in the six dimensions of assessments. One is acute intoxication or withdrawal potential. Two is the biomedical or physical conditions or complications. Three is the psychiatric, emotional or behavioral cognitive complications. Four is readiness to change. Again, thinking about the stages of change again. Five, relapse, continued use or continued problem potential. Then six is what their environment is like, their recovery or living environment. To the level of care that are recommended based on this six dimension are here on this pyramid. As you go up the pyramid, the level of intensity of treatment increases, and fewer people should require such a higher intensity. So most people are going to require early intervention or outpatient as compared to inpatient treatment. But going up the pyramid, you have early intervention, outpatient, intensive outpatient, a partial hospitalization program, residential treatment, and then inpatient admission in a hospital setting that would be. So thinking about who might require an inpatient admission based on the AFM criteria, so this is someone who might be currently intoxicated or if they're not currently intoxicated, they're at high risk of withdrawal symptoms. They also may have co-morbid medical issues requiring attention, or co-morbid psychiatric issues. The other domains, they may have low readiness to change, a high likelihood of continued use, and their poor recovery environment. Those things are necessarily required. When you're thinking about inpatient treatment, you're really thinking about withdrawal and co-morbid medical or psychiatric issues that need more attention. Going down the pyramids, the next would be residential treatment. These are people who are not yet acutely intoxicated, or have a low likelihood of withdrawal requiring treatments, have little to no active medical issues, there are no safety issue like suicidality or homicidality. They need constant supervision to support change. They're unable to stop using or remain abstinent, and they have an unsupportive or dangerous recovery environment. So for residential treatment, again, you're less likely to need any kind of hospital based treatment, but they do need close supervision. They are not able to stop in their environment, and if they return to their environment, it's not as supportive, and may be dangerous. Then going down to the next step would be partial hospitalization. Again, these are people who don't need withdrawal treatment, are not acutely intoxicated. They might require some medical supervision, so they may need to be seen at some point over the course of the month by a medical provider or a psychiatric provider, but overall these conditions will be stable. But they do need daily supervision to support change. They have a high relapse risk, and their environment is less supportive. So they require a more intense structure. Then the next level would be intensive outpatient. So these again, low intoxication or withdrawal risk, and medical and psychiatric issues that can be managed as outpatient. They are cooperative with discussions around change, but they just may need a bit more structure. They're able to maintain abstinence, but they need closer monitoring. Again, they may have a less supportive environment, and the structure of the intensive outpatient program, it's helpful with that. I'm going down to the next level of the outpatient treatments. So again, no intoxication, no withdrawal risk. All of their medical and psychiatric issues are easily managed outpatient. They are cooperative with discussions around change. They're able to maintain abstinence for periods of time, and they have a supportive environment. So thinking about some referral resources. This not can often be the most difficult part after you've determined what level of care someone needs. SAMHSA actually has a national helpline that is 24-7, 365 days a year. It's provided in English and Spanish, and it provides referral to local treatment facilities, support groups, and community-based organizations. You can also order free publications and other information from SAMHSA. They also have an online treatment services locator that can be helpful. NIAAA has what they call their treatment navigator website, which the link is provided here. It provides education on diagnosis, treatment, how much treatment should cost and insurance. It also provides information on quality care, how to find it, and how to make that choice. They also provide links to the ABPN and ABAM provider locator websites so that it can be helpful to find a specific provider with addiction medicine certification. All right. Now that we've gone through screening, assessment, brief intervention, and referral to treatment, we want to think about those two patients again. So here we have our first patient who is here for his work physical. Just as a reminder, he's 22, new patient, just out of college getting his first job, mentioned that he drinks socially. But then when you ask more questions that he is drinking six mixed drinks at the bar and he smokes cannabis vaporizer pen one or two nights a week but doesn't consider marijuana to be a drug. So how would you approach discussing alcohol and cannabis use with this kind of patient? So using open-ended questions, being non-judgmental, and patient-centered. Very important strategies just to begin with, with this patient. Which screening tool or tools that you would use? So the AUDIT-C, three questions at that thing alcohol use. The NIAAA tool if you think about, you could open the website while you're sitting in your office and input their information for them and talk about the recommendations from NIAAA. The DAST, which is 28 or 10 item drug abuse screening tool or NIDA-ASSIST, which again has a bit more involved and more comprehensive assessment but does ask also about multiple substances and questions about all these substances. Does he need a brief intervention or referral to treatment? So at this point, a brief intervention for problematic substance use will be indicated for this patient. Going back to the screening tool. So if you think about the cage in this person, it's unlikely to be an effective tool for him in terms of determining problematic or risky drinking because he may answer no to all of the cage questions. What is his current stage of change? So he's in the pre-contemplation stage. He's not really thinking about making any changes and doesn't really see any changes that's being necessary. If he returns with increased alcohol use and a DUI, what should come next? So this would maybe be indicative of an SUD diagnosis. So you think about now that he's increased his use, so his control of them paired and it had some social consequences of use. He would at this point require referral to treatment, and he might be a good candidate for outpatient or an intensive outpatient program. There's no indication that he has any psychiatric or medical issues, so outpatient would be appropriate as long as he hasn't experienced any major withdrawal symptoms that would increase your concern about seizures or DTUs if he were to stop drinking. Okay. Now, thinking about that second patient that came to your clinic. So just as a reminder, the 54-year-old female who came for hypertension follow-up and a previous note had mentioned that she was a drinker and need to go to AA. She's also depressed, having some abdominal pain. You assessed that it's likely gastritis from alcohol and then she admits that drinking has gotten out of a hand and she needs to go to AA. She'd continue drinking to numb her emotions, and her spouse is also a moderate drinker and keeps the alcohol in the house. So how would you screen or asses this patient for substance use disorder? So some screening tools, you may use the audit. Using the 10 item may give you some additional information that will be helpful to guide the discussion. Although using the AUDIT-C would be enough to screen for an alcohol or risky alcohol use. You can also think about the DSM-5 criteria for substance use disorder diagnosis. Again, there are 11 criteria that fit into those four domains. Also, thinking about a more comprehensive medical and psychiatric evaluation for this patient. Does she need a brief intervention or a referral to treatment? So clearly, this is a patient who would require referral to treatment. She clearly has some alcohol problems and may even meet diagnostic criteria just based on what we already know. She's had some medical and psychological problems and impaired control. So she at least have two criteria to meet a substance use disorder diagnosis. So more extended screening could guide questions, but she clearly needs some treatment. What would be her current stage of change? She would say she's in contemplation. She's already mentioned that she needs to go to AA and that alcohol is her problem. What interview strategies would you use for this patient? So thinking back to the broad strategies of engagement, motivation, and planning. So remember to use open-ended questions affirming her experiences, reflecting information back to her so that she knows that you understand and you can clarify any misunderstandings, and then summarizing its points throughout the conversation. The motivation giving personalized feedback based on her health conditions that are related to alcohol. For example, focusing on her strength and validating her frustrations. Then, planning, making attainable goals, anticipating challenges. For example, her husband is also drinking, another drinker and keeps alcohol at home, and making sure that you've scheduled a follow-up pretty soon that at least within a month. So according to the ASAM criteria, what would be the best place for her treatment? So this patient likely needs medically-supervised detox, given her medical and psychiatric comorbidity. This may be followed by residential treatment, given that her home environment may increase her risk of relapse after inpatient admission detox. What could you do to initiate treatment in the interim? So something to think about are referring to 12 step, some other kind of peer support or self-help groups or an alcoholic drug counselor. Thinking of medications like naltrexone or acamprosate, which are FDA-approved medications for alcohol use disorder, and considering depression evaluation, maybe even treatment like starting an SSRI or SNRI. Just to summarize we've talked about in this module, those screening tools exist at varying length and are available to evaluate alcohol and drug use. Further assessment of substance use, physical health, and mental health can guide next steps, especially thinking about the brief intervention or the referral. Brief interventions which are generally 10-15 minutes are effective when delivered appropriately, particularly for alcohol and tobacco users. Appropriate treatment referral depend on multiple medical, psychological, and psychosocial domains and can be guided by the ASAM criteria. Here's some references that can be helpful for this module. Now, I would just like to make you aware of two resources offered through PCSS that may be of interest. First, PCSS has a mentor program that's designed to offer mentoring assistance to those in need of more one-on-one interaction with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our member directory or we're happy to pair you with one. To find out more information, please visit our website using the web link noted on this slide. Second, PCSS offers a discussion forum which is comprised of our PCSS mentors and other experts in the field, who will help provide prompt responses to clinical cases or questions. We also have a mentor on-call each month that is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the fly to access the registration page. Finally, this slide, simply notes the consortium of lead partner organizations that are part of the PCSS project as well as their contact, and so website and Twitter and Facebook handle to find out more about what we offer.
