<v ->Hi, my name is Derek Blevins.</v> I'm an Assistant Professor of Psychiatry at Columbia University, and part of the Division on Substance Use Disorders at the New York State Psychiatric Institute, and I'm also a practicing addiction psychiatrist. The title of today's talk is: Screening, Assessment, and Treatment Initiation for Substance Use Disorders. I have no financial relationships to disclose. I would like to acknowledge Robin Williams, Jennifer Smith, Adam Bisaga, and Frances Levin for their mentorship and their contribution to some of the content of this presentation. And these faculty also did not have any financial relationships to disclose. So the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. At the conclusion of today's activity, participants should be able to screen and assess for SUD and comorbid disorders. Use brief and extended screening tools. Evaluate both physical and mental health as related to substance use disorders. Utilize screening, brief intervention, and referral to treatment, or SBIRT strategies and principles. Utilize motivational interviewing strategies. Describe continuum of care and models of SUD treatment. Apply good clinical judgment, and/or the ASAM criteria when referring to treatment. And then integrate screening, assessment, and ASAM criteria for SUD treatment referrals. This is an outline for the talk, so first we'll talk about screening and assessment, then brief intervention, referral to treatment, continuum of care models, the ASAM criteria, and then some useful referral resources. So this is a scenario that you may encounter frequently with healthy individuals coming in for a pre-employment or school physical exam. This is a 22 year old male who is a new patient, presents for their employment physical for their first job out of college. He says everything is great, he has no complaints, has no past medical or psychiatric history. He doesn't take any medications. He does tell you that he drinks socially, and denies using any drugs or tobacco. On further questioning, he reveals that he drinks on Friday and Saturday nights, typically six mixed drinks at the bar. He has never had any alcohol related problems, including blackouts. Well, except for that one time in college. He also smokes a cannabis vaporizer pen one to two times per week with friends, but he doesn't consider cannabis to be a drug. So these are some questions to think about as we go through the module. So how would you approach discussing alcohol and cannabis use with this person? 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? And if he returns to your office with increased alcohol use and a DUI, what should come next? The second patient may be a more typical sick patient visit, someone who may or may not be well known to you or clinic staff, and may have seen other treatment providers who may not have assessed for unhealthy substance use. So this is a 54 year old female who presents for follow up for hypertension. She previously saw a different provider for 10 years in your clinic. And according to records, hypertension has been difficult to manage despite numerous medication trials, and the previous doctor's notes simply say, "Regular drinker, needs AA", but doesn't really provide any other details. She presents now for regular follow up for hypertension, but with a new concern of feeling depressed and having abdominal pain. It becomes clear that the abdominal pain is likely gastritis from alcohol. She does report that drinking has gotten out of hand, and says she needs to go to AA. In terms of her depression, her first episode lasted three months, started before she had any problems with alcohol use. Then during her second episode of depression, she started drinking more, which allowed her to numb her emotions, as she describes it. She's tried to cut back a few times, but her spouse is a moderate drinker who keeps alcohol in the house. So same or similar questions to think about as we go through the module. Two very different patients, and hopefully the module will prepare you for both. But for this person, how would you screen or assess for a substance use disorder? Does she need a brief intervention or a referral to treatment? What is her current stage of change? What type of strategies would you use to engage her? What would be the best setting for her treatment? And what could you do to initiate treatment in the interim? So this is an outline of screening and assessment, which may be the most valuable tools, as intervention or referral are contingent upon good screening and assessment. So we'll go through some of the screening tools, we'll talk about SBIRT, using motivational interviewing techniques. The brief tools that we'll talk about are the CAGE, the AUDIT-C, and the DAST. The extended tools include the AUDIT, CRAFFT questionnaire, and the NIDA Modified-ASSIST. And then we'll talk about an online tool called the TAPS. We'll then talk about some extended substance assessment and diagnosis, including the DSM-5 criteria, and then physical and mental health assessment as related to substance use disorders. So first starting with screening. So this is some basic information about screening more broadly, as well as specific recommendations from the US Preventative Services Task Force regarding alcohol screening. It is important to keep in mind that an individual should not be diagnosed with a substance use disorder merely as a result of a positive screen, and doing so could carry unintended consequences if it's documented incorrectly in their clinical chart. So screening tools are used for illnesses with high prevalence. They're used for early detection for better outcomes, they should have high sensitivity. The recommendation from the USPSTF is that any adult 18 years or older be screened for unhealthy alcohol use, and then those people should be provided with a brief behavioral counseling intervention if they do screen positive for risky or hazardous drinking. Again, a positive screening does not result in a substance use disorder diagnosis, but does indicate the importance of further evaluation. These tools are universal, quick, and non-judgemental. And again, the goal is to detect risky or problematic use. The NIDAS Quick Screen 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 purpose of showing a tool that can assess for all substance use, including alcohol, tobacco, and drugs. Note that the Quick Screen question asks about past year alcohol use, and it has a limit of five and four drinks per day for men and women respectively. And just to note, a recent study reported that using the five or more drinks cut-off performed well for gender minority individuals, also including transgender and gender expansive individuals. Regarding alcohol more specifically, this screening question addresses the past 30 days, with a lower threshold for a number of drinks, or any alcohol use in these populations. People under age 21, pregnant women on certain medications that may have interactions, or medical conditions, or using in dangerous situations like driving or operating heavy machinery. A few simple commonly used and well-validated tools for assessing for problematic alcohol use are the AUDIT and the CAGE. The AUDIT, the full version is 10 items. The AUDIT-C is the abbreviated version, which is three questions, the first three questions of the AUDIT. And the goal of the AUDIT or AUDIT-C is to detect for risky drinking, or an active alcohol use disorder. The CAGE is a four item screening tool, which detects moderate or severe alcohol use disorder, but may not detect risky drinking. So the AUDIT-C is a better screening tool to detect risk or problematic drinking. So this is the AUDIT, which is the 10 question screening tool, with items rated from zero to four, with a positive screen for either men or women if the score is greater than eight. The abbreviated version of the AUDIT is the first three questions, which is a well-validated and sensitive screening tool. The additional AUDIT questions I will say may provide you with more detailed information that could guide your brief intervention or motivational interviewing techniques, or the referral. So this is the abbreviated AUDIT-C with the scoring guides. The scoring does differ between men and women for the AUDIT-C, which is also congruent with other screening tools that have a lower limit for the amount of alcohol that women should drink due to differences in alcohol pharmacology, and differential impacts between the sexes. When asking about number of drinks, it is important to quantify by grams of alcohol. A self-report of one drink can sometimes range from a small glass of wine to a large long island iced tea. So the most common standard drinks are 12 ounces of 5% alcohol beer, five ounces of 12% alcohol wine, and one and a half ounces of 80-proof or 40% alcohol liquor. So this is the CAGE questionnaire. CAGE stands for cutdown, annoyed, guilty, and eyeopener. It's been around since the late 1960s. It's easy to remember because of the acronym, however, it does not actually detect less advanced problematic drinking compared to the AUDIT. As you can imagine, the questions about cut down, annoyed, and guilty do require some level of insight, whereas the AUDIT-C questions focus more on the frequency and amount, which are more objective. But a CAGE screening with two or more yeses would be a positive screen. A simple screening tool for substance use other than alcohol simply ask about any non-medical use of medication, or any illicit drug or tobacco use, or any use of other substances for intoxication in the past 30 days. A yes on any of these questions would warrant further evaluation, and at least a brief intervention if not a referral to treatment. The DAST or drug abuse screening test is a self-report measure that can be administered with other clinic paperwork. It has a score that equates to a zone of use, and those zones include healthy, risky, harmful, or severe. And then it also has an indicated action, and those actions can be do nothing, give advice, give a brief intervention, or refer to specialized treatment. The CRAFFT, which is another acronym that stands for car, relax, alone, forget, friends, and trouble, is specifically for patients under age 21. And it gives a probability ranging from 30% to a hundred percent of having a substance use disorder diagnosis. And this can also be either self-administered, or administered by a clinician. So back to the NIDA Quick Screen, we talked about this as a quick screening for alcohol. It does also include the questions about tobacco, prescription drugs, and illegal drugs. And again, if someone were to answer yes to any of these questions, then it would be followed by the NIDA-ASSIT. And this is what the NIDA-ASSIST looks like. So after a yes on the Quick Screen, answering these additional questions can provide a score that indicates a level of risk. So a scoring between zero and three is low risk. Between four and 26 is moderate risk. And 27 or more is high risk. It is seven pages long, it's more comprehensive, is more time investment. The scoring is complex, but it does give you a level of risk per substance that a person screens positive for. You can find the complete assessment and scoring available on the NIDA website. The TAPS is a four item screening tool for, it stands for tobacco, alcohol, prescription medication misuse, and elicit substance use in the past year, and also includes a brief assessment of the past three months. It was intended for primary care settings. The positive screening is followed by additional questions for further assessment as someone advances through the questions. It's a modified version of the NIDA Quick Screen and ASSIST Lite. It also provides a risk level ranging from minimal to high, and for specific substances or substance use disorders. And this is also available online on NIDA's website, and it is easy to access. This is just a screenshot of the first question of the TAPS, asking about nicotine. The subsequent questions depend on the response to the first question. So moving on from the basic screening questions, to thinking about more extended substance use assessment, and physical and mental health assessment, which will provide additional information to guide the discussion and inform treatment recommendations. So first, while there may be significant overlap between the screening questions and the DSM-5 criteria for a substance use disorder, it is important to reiterate that a screening assessment does not equate to a DSM-5 diagnosis of a substance use disorder. It's also important to note that a DSM-5 diagnosis is not required for substance use to be considered risky or problematic. In terms of the the diagnostic criteria, it's easiest to remember the criteria by the four major categories here. So impaired control, physical or psychological consequences of use, social issues related to use, and then what are called the physiologic criteria, or withdrawal or tolerance. You'll notice that there are no criteria regarding frequency, or amount of use, or consumption. So a person could use a drug, say marijuana, daily, and not meet DSM-5 criteria. Although this is the exception, not the rule, for a person frequently using a potentially addictive substance. As further questioning or collateral is likely to suggest some level of impaired control, or possibly related psychosocial issues. But even if the person's use does not meet SUD criteria, the use could still be classified as a risky, and necessitate a brief intervention or referral to treatment. So here are additional questions that may be helpful after a positive screen to better understand your patient's substance use. Answers to these questions will guide aspects of the physical and mental health assessment, and help with your brief intervention and consideration of referral options. For instance, in a person using multiple substances, the drug of choice may indicate that AA or NA may be a better choice. The amount and route of administration may encourage you to further investigate particular body systems on exam or with laboratory work. Pass withdrawal symptoms may indicate that the person needs more medical monitoring with discontinuation. If they use any opioids, or any other powder substance like cocaine, methamphetamine, or ketamine, or have had a prior overdose, you would likely want to prescribe a naloxone kit to the patient, or involve family members. If a patient overdosed after opioid detoxification, and was not started on medication treatment, then they should be referred to a program that offers medication for opioid use disorder, like buprenorphine, methadone, or extended release naltrexone. The physical assessment is included here for completeness. One physical exam item that should be thorough is inspection of injection sites, not all of which may be exposed if the patient is clothed during the interview. And a patient could be skin or muscle popping as well. Regarding labs, pregnancy testing, drug screening, and infectious disease, including sexually transmitted infection screening, should be pretty standard. For some medication treatments that are metabolized by the liver. baseline liver function tests can also be helpful. I've included a list of common physical complications related to the more commonly used substances. So alcohol, of course, known effects on the cardiovascular system, the GI system, and the hematologic system. Opioids, respiratory depression or apnea, infectious disease related to IV use in particular, gastrointestinal issues like constipation, and reproductive issues related to modifications or changes in the endocrine system, such as amenorrhea or testicular atrophy. And then cannabis is known to cause tachycardia. There is an associated hyperemesis syndrome with regular and higher amounts of cannabis use. And there are also some associations with testicular cancer in regular cannabis use. For stimulants, of course, the cardiovascular system can be highly affected, and can include myocardial infarctions. Infectious disease, again, related to particularly in injection drug use. So people that are injecting cocaine and methamphetamine are at the same risk of infection as people who are injecting heroin or other opioids. Gastrointestinal issues, actually more related to the cardiovascular system, so mesenteric ischemia, rhabdomyolysis, and potential kidney failure as a result. And then neurologic issues like seizures or stroke. And then of course, the health issues related to tobacco use, which affects the cardiovascular, respiratory, and GI systems. 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. So a full mental status examination, cognitive exam, like a mini mental state exam, or a MoCA. Focusing on or getting a history related to abuse or trauma. And then evaluating for risk of harm to self, others, or inability to care for self. So things like recent suicidal ideation, plan, or intent, any sort of history of harm to self or others. Access to lethal means like firearms, or inability to perform activities of daily living. For the mental health assessment, it's important to keep in mind the high rates of comorbidity with other psychiatric illnesses, including depressive disorders, bipolar disorder, anxiety and psychotic disorders, ADHD and PTSD, also high comorbidity between personality disorders, especially borderline and antisocial personality disorder. And then you want to also be thinking about substance induced symptoms or disorders, and substance withdrawal. And it can be helpful to think about the temporal relationship with substance use. If there were differences during periods of abstinence, that can help clarify a primary psychiatric disorder, or a substance induced disorder. And then thinking about the expected withdrawal signs or symptoms depending on the substance, or substances that a person is using. This is just a really important point that treatment of substance use disorder should be concurrent with, and not subsequent to the treatment of psychiatric disorders, with evidence that this results in more improvement in both domains. This is really increasingly important as we learn more about how to better treat both primary psychiatric and substance use disorders. This doesn't necessarily mean that someone will require psychiatric medication for a substance induced diagnosis, but psychosocial interventions should address psychiatric symptomatology. So after screening, we're going to move on now, and talk about brief intervention. So as I already mentioned, there is a difference between unhealthy use and addiction. So unhealthy use is defined as use that threatens health and safety, and by definition is not addiction. Addiction on the other hand, we think about as a chronic disease, and this would equate to a DSM-5 diagnosis of moderate or severe substance use disorder. So with unhealthy use, a brief intervention is warranted. With addiction, we really expect someone to be referred to treatment if they have met criteria for addiction to any substance. So broadly speaking, the major elements of a brief intervention are engagement, motivation, and planning. There are three similar methods of providing a brief intervention. So MI, which the strategies are engage, focus, evoke, and plan. A brief negotiated interview, which is raising the subject, providing feedback, enhancing motivation, negotiating a plan. And then the five A's, which was developed by NIAAA, which is ask, advise, assess, assist, and arrange. And you can hear some similarities across this engage, motivate, and plan spectrum for these similar methods. The brief interventions are brief, so five to 10 minutes. The goal is to educate patients in a nonjudgmental way. You really want to appeal to the patient's goals and values. Allow for the patient to contribute to the discussion. Also allow for the patient to disagree with you. Encourage the patient to problem solve, and reflect to them their commitment to change. So these are the stages of change which people may be familiar with. Pre-contemplation, contemplation, preparation, action, and maintenance. Relapse sometimes is a component of the stages of change, but it doesn't have to be, of course, we want people to stay in the maintenance phase. So relapse doesn't always occur. Patients can present at initial visits or follow ups in various stages of change. Regardless of the stage of change, a patient can and should be engaged. Those successful discussions about substance use treatment planning will be informed by understanding the stage of change that a person is currently in, and we'll discuss some of these strategies in the next slides. If a person is in pre-contemplation, it doesn't permit an action on the part of the treatment provider, but rather informs the patient centered conversation. So all patients should be engaged within the continuum of care, which also includes harm reduction. So this is the engagement phase of motivational interviewing, and some of the things that we aim to do are develop a comfortable way to introduce the topic. You want to establish rapport with the patient, and ask permission to discuss particularly difficult topics like substance use in a non-judgmental and empathic way. You want to frame the discussion within the context of medicine. Emphasize any potential medical consequences, and really think about the language that you're using in this time period of the discussion. So saying recreational drug use as opposed to illegal drug use. Saying substance or alcohol use as opposed to using the term abuse. Want to normalize the questions you're asking, so simply saying that they're routine questions. And integrate these strategies into preventative care. So some examples of things that you may say during this engagement phase, "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 substances?" Or, "You can improve and prevent a lot of health problems by reducing drug and alcohol use." OARS is an easy acronym to remember for this engagement phase, and can be very helpful. What this stands for is open-ended, affirm, reflect, and summarize. So open-ended questions don't lead the patient, or ask any yes or no questions. So an example would just be, "Can you tell me a little bit more about your alcohol use?" Affirm is showing appreciation and understanding of their experience. It should be genuine, and it can be really as simple as saying, "Wow", or, "That's really difficult." Reflect is demonstrating understanding of what they're saying, and clarifying any misunderstandings. For example, "So while you don't really like drinking, it provides you with some relief." And then finally summarizing is taking time to periodically review the discussion up to that point, and to discuss anything that you missed, or anything that needs clarification. Some other things to consider during this initial part of the discussion is inquiring about current patterns of substance use. Determine patient perceptions of substance use. Identify their values and goals. Discuss the impacts that substance use has on those goals. Develop any discrepancy between substance use and achieving those goals. And then elicit the need and perceived ability to change. So the second part of motivational interviewing after engagement is motivate or motivation. During this time period you're going to be providing clear, specific, personalized feedback. You want to include risk and consequences of use. Express concern, and recommend explicit changes. Support patient's self-determination and autonomy. Tailor this part of the conversation to the patient's level of health literacy. Emphasize your confidence in their ability to change. Assure continued support throughout the process. Emphasize their strengths and past successes. You can validate their frustrations, but remain optimistic. You want to reflect and summarize regularly during this phase of the discussion, and you want to start preparing the patient for the next steps. So a few examples of things that may be said during this portion of the discussion. "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 from your family was very helpful when you cut back on your your smoking last year. Maybe they 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 now to cut down on your drinking." And then the last kind of stage or phase of motivational interviewing is planning. This is making goals aligned with readiness to change and patient's goals for treatment. Really meeting patients where they are. Goals should be attainable, measurable, and timely. You want to help anticipate any potential challenges that they may encounter. You're going to change strategies as needed, and be flexible. Avoid any argumentation or defensiveness. You may recommend the ideal, but certainly accept less if the patient is resistant to the ideal. You want to plan for follow up at least within a month. You're going to continue to reinforce, reassess, and update the plan. Acknowledge their efforts and experiences with the process, offer continued support despite whatever progress they've made, even if that is not making much progress. And then give help and guidance for social support. So a few things that may be said during this planning phase, "What changes do you think you can make with your drinking and use of pain medications?" Or, "It sounds like limiting the alcohol and pain meds you keep at home 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 kind of things might get in the way?" Or, "I can understand that it's not an option to give up drinking socially, but I agree with you that not drinking alone is a big step." So now we'll move on to referral to treatment. And before we talk about the continuum of care, I do want to just mention and emphasize harm reduction. So the definition of harm reduction is a set of practical strategies and ideas that are aimed at reducing negative consequences associated with drug use. It's also a movement for social justice built on the belief in, and respect for the rights of people who use drugs. Harm reduction is both for people who are, and aren't ready to change their use. Some examples of harm reduction are naloxone kits, fentanyl test strips, syringe exchange, or safe injection sites, clean snort kits, drug testing, and condoms. So harm reduction can really be used across the continuum of care, and both inside and outside of the traditional kind of treatment settings. The examples included here are, the most basic and practical of harm reduction strategies, but it can be much broader, especially in the medical or psychiatric treatment setting, where there are additional resources to help reduce the physical or psychological harm related to substance use. Things like routine infectious disease testing, echocardiograms, education about injection site infection, prevention and care, and routine depression or other mental health screenings. Understanding and discussing this risk, set and setting can also help the individual and their treatment provider maximize harm reduction approaches. So the risk is the risk itself related to the activity, such as overdose with opioid use. The set is the mindset that the person is in. So thoughts, mood, or expectations at the time of use. And then setting is the physical or social environment. So now we'll think about some evidence based treatments, and peer support, talk about the continuum of care models, the as ASAM criteria, and then finally, some helpful referral resources. So when considering referral resources, it can be helpful to keep treatment options in mind. So there are FDA-approved medications for alcohol, opioid, and tobacco use disorders. And many can safely and effectively be prescribed in primary care settings. For alcohol, I do just want to note that the evidence base for Topiramate is strong, despite it being an off-label indication. In terms of the treatments for opioid use disorder, I wanted to point out that the subdermal buprenorphine implant was actually discontinued in 2020, but there are additional injectable products that are in the pipeline. Most of the psychosocial treatments have been shown beneficial for substance use disorders. However, pharmacologic treatment should be strongly encouraged for opioid use disorder, given the risk of relapse, overdose, and infectious disease. In terms of the continuum of care model, I just wanted to point out where we are in terms of thinking about brief intervention and treatment. So brief intervention is really that last stage of prevention right before treatment. This is targeting individuals who are at high risk, who have minimal, but detectable signs or symptoms of mental illness or substance abuse problems, and this is prior to the diagnosis of a disorder. The ASAM criteria were developed as guidelines for patient placement, transfer, or discharge for those with substance use disorder, and comorbid medical or psychiatric conditions. There are six dimensions of assessment, including acute intoxication or withdrawal potential, biomedical conditions or complications, psychiatric conditions which are described as emotional, behavioral, cognitive complications. A patient's readiness to change, so going back to thinking about stages of change. Relapse, continued use, or continued problem potential. And then their recovery or living environment. And these criteria are widely accepted to help determine the location of treatment. So there are several levels of care that are recommended based on the six dimensions described in the previous slide. As you go up this pyramid, the level of intensity of treatment increases, and fewer people should require such high intensity. So the majority of people are going to require an early intervention. Then the next level of care would be outpatient treatment, an intensive outpatient, partial hospitalization, residential, and then the highest level of care would be inpatient treatment. So going down from the top of that pyramid, and thinking about the highest level of care, which is inpatient. Three main things to keep in mind, these are people who are either currently intoxicated or have a high risk of withdrawal. They have comorbid medical issues that require some level of attention, and comorbid psychiatric issues that require attention. In terms of readiness to change and their environment, that is not as important when assessing for the need for an inpatient level of care. So the next level of care after inpatient is residential treatment. So these are actually people who are not at any sort of acute kind of risk. So whether it's related to intoxication or withdrawal, or having significant medical or psychiatric complications that need more urgent attention. But they do need constant supervision to support change. They haven't been able to stop using or remain abstinent in community settings, and they may have unsupportive or dangerous recovery environment. The next level is partial hospitalization. Again, not needing really any acute care needs, but they may need some daily supervision to help support change. They have a high relapse risk, and have a less supportive environment, so in need of a more intensive structure. After partial hospitalization, we have intensive outpatient. So again, no acute care needs, may need and benefit from some additional structure. They are able to maintain abstinence, but under closer monitoring. And their environment may not be as supportive, and the structure is helpful. And then lastly, the lowest level of treatment is outpatient treatment. Again, not requiring any sort of acute needs. Their psychiatric and medical issues can all be managed as outpatient. They're cooperative with discussions around change, able to maintain abstinence in the community setting, and have a fairly supportive environment. So these are some referral resources. So SAMHSA has a national helpline that is staffed 24/7, 365 days of the year in both English and Spanish. It provides referrals to local treatment facilities, support groups, and community based organizations. Can also order free publications and other information from SAMSHA. They also have this behavioral health treatment services locator online. NIAAA also has a, what they call their treatment navigator. This is available online. It provides education on diagnosis, treatment, cost and insurance. Gives information on quality care, how to find it, and how to make a choice. And has links to board certified addiction psychiatry and addiction medicine providers. So now let's get back to our two very different clinical cases. So our 22 year old male who's coming in for his work physical. No real medical history, no medications, mentions that he drinks socially. The social drinking is six mixed drinks. He did have that one blackout in college. He also smokes a cannabis vaporizer pen one or two nights a week. So how would you approach discussing alcohol and cannabis use with this patient? So using open-ended questions, being non-judgmental, and keeping the conversation very patient centered. Which screening tools might you use? So the AUDIT-C, which is the three question screening tool, the abbreviated version of the AUDIT. You could also use the DAST to assess more for substance use. The NIDA-ASSIST, which is the more extended tool. Or the TAPS, which is the the adaptive tool online. For here, I would say the CAGE is unlikely to be an effective tool to determine problematic or risky drinking behavior, just keep that in mind, especially for this individual. And does he need brief intervention or referral to treatment? So at this stage, I would say he needs a brief intervention for unhealthy or problematic substance use. And what is his current stage of change? So pre-contemplation, not really considering any negative consequences of any substance use, alcohol or cannabis. If he returns with increased alcohol use and a DUI, what should come next? So this would be indicative of a substance use disorder diagnosis. He would meet the criteria at least of impaired control and social consequences. Likely he doesn't have any psychiatric or medical issues, so would be an appropriate candidate for outpatient treatment, as long as he has not experienced major withdrawal symptoms that increase the concern about seizures or delirium tremens. So this individual would now require a referral to treatment, having met a substance use disorder diagnosis. And again, for outpatient, or an intensive outpatient program. And then our second case was our 54 year old female who has hypertension, is known to the clinic, but new to the current provider. She's presenting now, reporting depression and abdominal pain. The abdominal pain, it is determined as likely gastritis from alcohol use. She is expressing that alcohol use has gotten out of hand, and that she needs to go to AA. She describes alcohol as numbing her emotions in some sort of self treatment for her depression. And her spouse, remember is a moderate drinker, and there's alcohol in the house. So how would you screen or assess this patient for a substance use disorder? So the AUDIT may be more helpful here to give you some more information about her alcohol use. You could also go through the DSM-5 criteria to give a specific substance use disorder or alcohol use disorder diagnosis. A medical exam, like a more full physical exam, doing some lab works, an EKG may be helpful. You want to do a mental state exam, a mini mental, and risk assessment. Does the patient need a brief intervention or a referral to treatment? So at this point, this patient certainly needs a referral to treatment. She's already clearly had alcohol problems, and can meet diagnostic criteria just based on her presentation alone so far, so without even asking more questions. And we know that she's had medical or psychological problems, and has impaired control. So a more extended assessment could really be helpful, but she does clearly need some type of treatment. And how would you describe her stage of change? So I'd say she's in the contemplation phase. She has mentioned that her drinking has gotten out of hand, but she hasn't really made any steps, or engaged in any planning on how to cut down. What interview strategies would you use for this person? So these are the three basic approaches in motivational interviewing, engage, motivate, and plan. So engage, remember the OARS, open-ended questions, affirmations, reflections, and summaries. Motivate, you can give personalized feedback, in particular around her stomach issues, potentially the impact the alcohol use is having on depression, and possibly an explanation for why her hypertension has been difficult to treat. You want to focus on the strengths that she has, and validate any frustrations about limited success with being able to cut down. And then finally, plan. So making attainable goals, anticipating the challenges that she may face as she tries to cut down or stop drinking. And then schedule a follow up to see her within the month, if not sooner if possible. And according to the ASAM criteria, what would be the best place for her treatment? So she may be someone who needs to start with inpatient treatment, and then transition to a residential treatment program. Likely she'll need some medically supervised detox, given her medical and psychiatric comorbidity. And this again can be followed by residential treatment, particularly since her home environment may increase her risk of relapse, with her husband who is a moderate drinker and keeps alcohol in the house. And what could you do to initiate treatment in the interim? So there's a few options referring to 12 step, or other peer support or self-help groups, and or some other type of alcohol or drug counseling. You may want to consider medication. So naltrexone and acamprosate are two FDA-approved medications for treatment of alcohol use disorder. And then consider more comprehensive depression evaluation, and possibly treatment for depression with a medication like an SSRI or an SNRI, which may also contribute to more success with her being able to cut down on her alcohol use when treating both the alcohol use disorder and depression concurrently. So in summary, screening tools of varying links are available to evaluate both alcohol and drug use. Further assessment of substance use, physical health, and mental health can guide next steps. Brief interventions, which are 10 to 15 minutes, are effective when delivered appropriately, especially for individuals with alcohol and tobacco use. And appropriate treatment referrals depend on multiple medical, psychological, and psychosocial domains, and can be guided by clinical judgment and the ASAM criteria. Here's some references from today's talk. And the PCSS Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices, in prescribing medications for opioid use disorder. PCSS mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment, including medications for opioid use disorder or MOUD. It is a three-tiered approach that allows every mentor, mentee relationship to be unique, and cater to the specific needs of the mentee, and is provided at no cost. PCSS also has a discussion forum where you can ask a clinical question to a colleague. And then PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry with multiple partners listed here.

substance use disorders

screening

treatment initiation

evidence-based practices

opioid use disorders

motivational interviewing

harm reduction strategies

ASAM criteria