Unhealthy drug use: How to screen, when to intervene
Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and implementing a brief intervention a routine part of care.
Conducting a brief intervention
Depending on the patient’s risk level for developing a substance use disorder, he or she should receive either brief advice (for those at low risk) or a BI (for those at moderate or high risk) and, if needed, a referral to treatment. Two popular approaches are FRAMES (Feedback, Responsibility, Advice, Menu of Strategies, Empathy, Self-efficacy) and the NIDA-recommended 5 As intervention. The latter approach entails Asking the patient about his drug use (via the Quick Screen); Advising the patient about his drug use by providing specific medical advice on why he should stop or cut down, and how; Assessing the patient’s readiness to quit or reduce use; Assisting the patient in making a change by creating a plan with specific goals; and Arranging a follow-up visit or specialty assessment and treatment by making referrals as appropriate.19
What about children and adolescents? Implementing a drug SBI in young patients often entails overcoming unique challenges and ethical dilemmas. Although the American Academy of Pediatrics recommends SBI for unhealthy drug and alcohol use among children and adolescents,33,34 the USPSTF did not find sufficient evidence to recommend the practice.1,8,35 Screening for drug use in minors often is complicated by questions about the age at which to start routine screening and issues related to confidentiality and parental involvement. The Center for Adolescent Health and the Law and the National Institute on Alcohol Abuse and Alcoholism provide useful resources related to youth SBI, including guidance on when to consider breeching a child’s confidentiality by engaging parents or guardians (TABLE 3).
TABLE 3
Resources
NIDA Resource Guide NIDA-Modified ASSIST Coding for SBI reimbursement SAMHSA’s Treatment Services Locator NIDA’s List of Community Treatment Programs SAMHSA Opioid Overdose Toolkit Buprenorphine training program Center for Adolescent Health and the Law NIAAA Alcohol Screening and Brief Intervention for Youth |
Help is available for securing treatment, reimbursement
In addition to NIDA, many other organizations offer resources to assist clinicians in using drug SBI and helping patients obtain treatment (TABLE 3). For reimbursement, the Centers for Medicare and Medicaid Services has adopted billing codes for SBI services.36,37 The Substance Abuse and Mental Health Services Administration (SAMHSA)’s Behavioral Health Treatment Services Locator and NIDA’s National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs can assist clinicians and patients in finding specialty treatment programs. Self-help groups such as Narcotics Anonymous, Alcoholic Anonymous, or Self-Managment and Recovery Training may help alleviate problems related to insurance coverage, location, and/or timing of services.
SAMHSA’s Opioid Overdose Toolkit provides guidance to clinicians and patients on ways to reduce the risk of overdose. Physicians also can complete a short training program in office-based buprenorphine maintenance therapy to provide evidence-based care to patients with opioid dependence; more details about this program are available from https://www.buppractice.com.
CASE › You decide to use the 5 as intervention with Mr. M. You explain to him that he is at high risk of developing a substance use disorder. You also discuss his elevated BP and the possible negative effects of drug use, especially cocaine, on BP. You advise him that medically it is in his best interest to stop using cocaine and stop or reduce using cannabis. When you ask Mr. M about his readiness to change his drug use, he expresses moderate interest in stopping cocaine but is not willing to reduce his cannabis use. At this time, he is not willing to discuss these issues further (“I’ll think about that”) or create a specific plan. You assure him of your ongoing support, provide him with resources on specialty treatment programs should he wish to consider those, and schedule a follow-up visit in 2 weeks to address BP and, if the patient agrees, drug use.
CORRESPONDENCE
Aleksandra Zgierska, MD, Phd, Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI 53715-1896; aleksandra.zgierska@fammed.wisc.edu
