Screening and Interventions for Alcohol and Other Drug Problems in Medical Settings: What Works? Thomas F.

Babor

What is Screening, Brief Intervention and Referral (SBIR)?

Screening to find: -- at-risk drinkers (and drug users) -- possible alcohol (and drug) dependence Brief Intervention -- Early detection --Time limited -- Low cost, easy to use Referral of more serious cases to further diagnostic assessment specialized care

Requirements for a public health approach to SBIR:

The target condition should have sufficient conceptual clarity to permit reliable measurement; The natural history of the disorder should be fairly well understood, along with risk factors and populations at risk; The test(s) used for screening should be reliable, valid, inexpensive, easy to administer, and acceptable to both treatment providers and the target population; Appropriate treatments (or brief interventions) should exist so that persons identified can be managed effectively.

Types of Alcohol Risk

Hazardous Use elevated risk without presence of physical or mental harm Harmful Use consumption causing physical, mental, or social harm Alcohol Dependence a cluster of behavioral, cognitive, and physiological phenomena that may develop after repeated alcohol use

The Drinkers Pyramid

Dependent Drinkers Risky Drinkers Low Risk Drinkers Abstainers

Where is the bulk of harm?

Persons with alcohol dependence experience the most harm But there are far more hazardous and harmful drinkers Most alcohol-related harm is caused by people who usually drink moderately People move from moderate to at-risk use and back

THE SUBSTANCE ABUSE PYRAMID

IV users Crack cocaine addicts MISAs/homeless substance abusers Treatment seeking drug addicts Chronic marihuana users (severe cannabis dependence) Regular cannabis users (moderate, mild cannabis dependence) Weekend/recreational drug users (marijuana, Ecstasy) Occasional substance abusers (marijuana users, risky drug users)

Screening Tests for Alcohol, Tobacco and Other Drugs

AUDIT (1993) ASSIST (2002) Alcohol Use Disorders Identification Test The Alcohol, Tobacco and Substance Involvement Screening Test

AUDIT: Alcohol Use Disorders Identification Test

Completed by patient in 2 to 3 minutes 10 questions; yields objective, numeric score Determines risk level; type of intervention needed, if any

Domains and Item Content of the AUDIT Domains Question Item Content Number ________________________________________________ Hazardous 1 Frequency of drinking Alcohol 2 Typical quantity Use 3 Frequency of heavy drinking Dependence Symptoms Harmful Alcohol Use 4 5 6 7 8 9 10 Impaired control over drinking Increased salience of drinking Morning drinking Guilt after drinking Blackouts Alcohol-related injuries Others concerned about drinking

Risk Level Intervention Zone I Zone II Zone III Alcohol Education Simple Advice Simple Advice plus Brief Counseling and Continued Monitoring Referral to Specialist for Diagnostic Evaluation and Treatment

AUDIT Score* 0-7 8-15 16-19

Zone IV

20-40

*The AUDIT cut-off score may vary slightly depending on the countrys drinking patterns, the alcohol content of standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where the patients score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence. It may also be instructive to review the patients responses to individual questions dealing with dependence symptoms (Questions 4, 5 and 6) and alcohol-related problems (Questions 9 and 10). Provide the next highest level of intervention to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10.

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

Content Domain 1) Life-time use Question Which of the following substances have you ever used? (tobacco products, alcoholic beverages, cannabis, cocaine, stimulants, inhalants, sedatives/hypnotics, hallucinogens, opioids, and other drugs; non-medical use only)?

2) Current use 3) Dependence 4) Problems 5) Problems 6) Problems 7) Dependence 8) HIV Risk

In the past three months, how often have you used the substances you mentioned? How often have you had strong desire or urge to use (first drug, etc.)? How often has your use of (first drug, etc.) led to health, social, legal or financial problems? How often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc.)? Has a friend or relative or anyone else ever expressed concern about your use of (first drug, etc.)? Have you ever tried to control, cut down or stop using (first drug, etc.)? Have you ever used any drug by injection (non-medical use only)?

Patient Comfort with Screening

100 90 80 70 60 50 40 30 20 10 0%
Very Comfortable
%

Diet/Exercise Smoking Drinking

(n = 35,257) Uncomfortable

Very

Patients Sense of Screenings Importance to Providers

100 90 80 70 60 50 40 30 20 10 0
%

Diet/Exercise Smoking Drinking

Very Important

Very

(n = 35,033)Unimportant

SELF-REPORT SCREENING TESTS: A CAVEAT

The accuracy self-report screening tests depends on: The context (especially perceived threat) The type of substance (e.g., alcohol vs. heroin) The degree of confidentiality Perceived purpose of the questions The procedure (questionnaire, interview, computer)

SCREENING TESTS: A SUMMARY

A variety of questionnaires and lab tests have been developed for alcohol and, to a lesser extent, for other psychoactive substances Performance varies with the test, the population, and the gold standard Most questionnaire tests are accurate enough for routine alcohol screening Lab tests are more useful for drugs than alcohol, but sensitivity tends to be marginal

The Brief Intervention

3 to 5 minutes of brief advice 5 elements

Feedback patients screen results Graphic display of patient risk level Illustrate risks; review drinking limits Solicit commitmentcut back or stop Give patient brochure, encouragement

AMETHYST PROJECT
Alcohol Misuse Early Treatment Intervention Study

Sequence of Study and Procedures Associated with Each Condition

Screening Recruitment WHO Composite Interview Schedule Stratified Random Assignment

GROUP I Control group

GROUP II Simple Advice Review interview results Explain Sensible Drinking Leaflet (5 min)

GROUP III Brief counselling Review interview results Explain Sensible Drinking leaflet (5 min) Introduce Problem Solving Manual (15 min) Mention Diary cards and identify a helper

Mention six-month follow-up interview Ask patient to fill out Health and Daily Living Questionnaires Six month follow-up

MarijuanaTreatment Project Baseline, 4, 9, & 15-months % of Days Smoked Marijuana (N=207)

1
% of Days Smoked per Week

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 BL 4-mo 9-mo

Delayed Treatment Brief Treatment Extended Treatment

15-mo

BRIEF INTERVENTIONS: SUMMARY

Brief interventions are effective in reducing alcohol consumption for at least 12 months in patients who are not alcohol dependent Pooled results from clinical trials show a 24% reduction in alcohol consumption Those who receive an intervention are twice as likely to change their behavior compared with control groups Effects on injury, medical care, and mortality also demonstrated Brief interventions have fairly low costs and have been shown to be cost-effective in 3 economic studies

BRIEF INTERVENTIONS: Population Groups

Brief interventions have been found to be effective in a wide variety of population groups: men, women; young, old; college students and settings: primary care, hospital, emergency, trauma using a variety of different providers: physicians, nurses, health educators

Remember the Titanic!

Time for A Public Health Approach

Brief interventions are effective with smokers and risky drinkers,
and there is some evidence that they work well with marihuana users -- two decades clinical research, program development -- effective screening tests available -- training programs developed

SBIR poised for next step in dissemination

SBIR risk reduction information, journals, materials exist in

diverse formats There is general agreement on the need to broaden the base of treatment, i.e., expand treatment and early intervention services to less severe cases and populations at risk

The Diffusion of Innovations to Prevent Disease, Disability and Death: Barriers

Training Role incompatibility Time Priorities Resources

Institutional barriers