Health Professionals

About 70 percent of Americans-approximately 191 million people-visit health care professionals, such as primary care physicians, at least once every two years. Health practitioners are in a unique position not only to prescribe needed medications appropriately, but also to identify prescription drug abuse when it exists and help patients recognize the problem, set goals for recovery, and seek appropriate treatment, when necessary.

Specifically, screening and brief intervention strategies stress the importance of the patient-doctor relationship in identifying unhealthy behaviors before they evolve into life threatening conditions.

The following questions are discussed in this section:

• Why should health practitioners screen for prescription drug abuse and misuse?
• What is meant by the term screening?
• What is meant by the term brief intervention?
• What does the screening and brief intervention process look like?
• How can you use screening tools to identify prescription drug abuse and misuse?
• How can you conduct brief interventions and make proper assessment referrals for prescription drug abuse and misuse?

Why should health practitioners screen for prescription drug abuse and misuse?

Health care professions play an important role in their patients' lives. A short conversation can present an opportunity to let patients know if and how non-medical prescription drug use may risk their health and well-being. Screening provides an opportunity for health care professions to identify substance abuse behaviors and to intervene early and potentially enhance medical care by increasing awareness of the likely impact of substance use on a patient's overall health.

The National Institute on Drug Abuse (NIDA) suggests these reasons for drug screening in general medical settings:^xvi

• Identify drug users early and briefly educate them about the adverse consequences of continued drug use and available resources for quitting
• Enhance medical care by increasing awareness of the potential impact of substance use on physical health-more specifically, the interaction of substance use with a patient's medical care, including potentially fatal drug interactions
• Improve linkages between primary and secondary health care services and specialty drug and alcohol treatment services

These suggestions apply equally to prescription drugs that are abused or misused as they do for illicit drugs or alcohol.

What is meant by the term screening?

Charles Curie, administrator for the Substance Abuse and Mental Health Services Administration (SAMHSA), describes screening in this way:

The purpose of screening is not diagnosis. A screening instrument does not enable a clinical diagnosis to be made, but rather indicates whether there is probability that key features of the target problem are present in an individual. Used intelligently and sensitively, with respect for privacy and confidentiality, screening can provide vital information and can enable people to lead longer, healthier, and ultimately more rewarding lives.^xvii

A screening instrument, or tool, is used as an indicator, not as a diagnosis. What might screening indicate? It might show that an individual demonstrates behaviors or possesses attributes shared by a group of people who are at-risk for substance abuse or dependence. This information serves as an essential jumping off point for health professionals. Armed with some knowledge that the individual may be at risk, further resources can be directed to determine if a referral for treatment assessment is necessary.

What is meant by the term brief intervention?

Brief intervention…

• Is a low-intensity, short-duration technique.
• Focuses on increasing insight and awareness regarding substance abuse.
• Can motivate those at risk to change their behavior.

Brief intervention usually begins with feedback about the screening results and advice for the patient. A brief intervention in a primary care setting can range from five minutes of brief advice to thirty minutes of brief counseling.

Brief intervention is a valuable tool for treatment for problematic or risky substance use. It can also encourage those with more serious dependence to accept more intensive treatment within the primary care setting, or referral to a specialized treatment agency. The aim of the intervention is to help the patient understand that their substance use is putting them at risk and to encourage them to reduce or give up their substance use. In cases where an individual is unready for a referral, or does not admit that prescription drug abuse or misuse is an issue, brief intervention can be a helpful intermediary strategy.

What does the screening and brief intervention process look like?

Health care practitioners, in general, and primary care physicians in particular, can play an important role in patients' lives. A short conversation, combined with a screening tool, can let patients know if and how prescription drug abuse and misuse may endanger their health.

NIDA's "Five A's of Intervention" is a useful framework for helping health care professionals and their patients and clients understand screening and brief intervention.^xviii

• ASK – Screening is the first "A" because it asks one or more questions related to drug use. Usually a formal screening instrument is employed at this step.
• ADVISE – The second "A" involves strong direct personal advice by the provider to the patient to make a change, if it is indicated by the screening results.
• ASSESS – The third "A" refers to determining how willing a patient is to change his or her behavior after hearing the health care professional's advice.
• ASSIST – The fourth "A" refers to helping the patient make a change if he/she appears ready.
• ARRANGE – The final "A" is to refer the patient for further assessment and treatment, if appropriate, and to set up follow-up appointments.

How can you use screening tools to identify prescription drug abuse and misuse?

Screening for prescription drug abuse can be incorporated into routine medical visits by asking about substance abuse history, current prescription and over-the-counter drug use, and reasons for use. Screening also can be performed if patients present with specific symptoms associated with problem use of a medication.

There are a number of screening tools available for health care professionals. Some of these are specific to alcohol, illicit drug, or tobacco use. Recently, versions of these common screening tools have been adapted to detect risk for non-medical prescription drug use.

A version of the CAGE questionnaire has been adapted for use by physicians as one screening tool to determine prescription drug abuse:^xix

1. Have you ever felt the need to Cut down on your use of prescription drugs?
2. Have you ever felt Annoyed by remarks your friends or loved ones made about your use of prescription drugs?
3. Have you ever felt Guilty or remorseful about your use of prescription drugs?
4. Have you Ever used prescription drugs as a way to "get going" or to "calm down?"

The National Institute for Drug Abuse's Clinician's Screening Tool was adapted from the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), developed, validated, and published by the World Health Organization (WHO). One of the modifications made to the ASSIST is the addition of items pertaining to prescription drug abuse and misuse. NIDA-modified ASSIST tools are specifically designed to fit into today's busy clinical practices. A quick reference guide has been developed to serve as a prompt to medical professionals to initiate screening. This abbreviated guide provides a snapshot of the NIDA-modified ASSIST, briefly summarizing the questions, scoring and next steps. (Note: the NIDA-modified ASSIST has not been proven valid and reliable for persons under 18 years of age.)

How can you conduct brief interventions and make proper assessment referrals for prescription drug abuse and misuse?

The National Institute for Drug Abuse's Clinician's Abuse's Clinician's Screening Tool suggests these steps conducting brief intervention:^xx

• Review screening results with the patient.
  • Ask permission to have a short discussion about the screening results.
  • Report back the types and amounts of use reported. Allow the patient to correct omissions so you get the full picture of use. Prompt the patient: "Tell me more about your use of drug X and Y" (for each drug the patient reported).
• Provide medical advice about the patient's drug use based on risk level.
  • Explain that it is your role as his/her medical provider to convey health recommendations.
  • Recommend quitting before problems (or more problems) develop. Give specific medical reasons.
  • Make referrals to evaluate suspected co-occurring conditions (e.g., psychiatric consultation for depressed, inattentive, or anxious patients or pain specialist consultation for patients seeking narcotic prescriptions for chronic nonmalignant pain).
• Assess patient's readiness to quit and assist the patient to make a change.
• Arrange specialty assessment, drug treatment, and a follow-up visit.
  • As appropriate, refer patients to further assessment and treatment.
  • Schedule a follow-up for moderate- and high-risk patients and offer continuing support.