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SUBSTANCE ABUSE
Screening, diagnosis, management

WHO SHOULD READ THIS?

All PAs who can screen patients for substance abuse, follow up with those who have a history of substance abuse, and refer any patients with active substance abuse to appropriate treatment facilities.

WHY IS THIS IMPORTANT?

The estimated annual cost of substance abuse in the United States is more than $400 billion, with one in four deaths attributed to the use of alcohol, tobacco, or prescription and illegal drugs.¹ Ten percent of people in the United States have a history of substance abuse.² In the primary care setting, between 10% and 16% of patients have medical and/or psychosocial issues related to addiction,³ and fewer than 25% of patients who require treatment for substance abuse receive it.¹ In patients who are admitted to treatment facilities, the most commonly abused substance is alcohol, followed by alcohol in combination with another drug. Marijuana and heroin are the two most common illicit drugs seen in admitted patients.⁴

Addiction is a chronic, relapsing disease that may require multiple interventions. Patients with addiction are of all ages, both genders, and come from all socioeconomic and ethnic groups.³ Despite the widespread nature of the problem, the stigma associated with addiction may hinder management.² The use of brief screening tools has been successful in helping patients to reduce alcohol consumption.^3,5 Even with emerging positive outcome data, however, the majority of patients are not screened for substance abuse.⁵

WHAT ARE THE CURRENT RECOMMENDATIONS?

The US Preventive Services Task Force recommends screening for alcohol abuse but says that the evidence is insufficient to recommend screening all adults for illicit drug use.⁶ Intervention for addiction has been shown to improve the health of patients and, for alcohol abuse, has proven cost-effective over the long term.¹ The Substance Abuse and Mental Health Services Administration and the Center for Substance Abuse Treatment support the SBIRT approach (screening, brief intervention, referral, and treatment), which has been shown to reduce the frequency and severity of substance use and to increase the number of patients who enter treatment.^7,8

Screen Multiple screening tools are available (see Table. “Screening tools for substance abuse” in the online version of this article). The CAGE and AUDIT questionnaires are specific for alcohol. The CAGE questionnaire is brief and may be more familiar to clinicians, but the AUDIT is more sensitive.⁹

PAs may also simply ask the patient two questions: “Have you ever had a drinking problem?” and “Have you had any alcohol in the previous 24 hours?” If the patient responds positively to both, the sensitivity for alcohol problems is 92%.⁹ Regardless of the screening technique used, PAs should combine results with objective data (ie, the results of urine drug screening) to enhance validity.⁷

Brief intervention If the screening tool suggests a substance abuse disorder, employ a patient-centered, empathetic, and motivational technique. One option is the FRAMES interview strategy.^3,8

Offer Feedback regarding the current and potential adverse events of addictive behavior.
Encourage the patient to assume personal Responsibility for the addiction and its consequences.
Provide Advice based on the stage of the patient’s addiction, readiness to seek help, and severity of health concerns.
Provide a Menu of reasonable treatment options to encourage patient responsibility.
Employ an Empathetic approach and promote Self-efficacy as the patient establishes and meets goals.

Brief screening and intervention have been shown to reduce consumption, motivate patients to seek treatment, and help them to remain abstinent.^3,7

Referral Identify the community resources available (see Table 1). Determine if detoxification is required by coordinating care with an addiction medicine specialist.

Treatment The most significant barrier for patients is access to treatment.³ For patients with substance use disorders, treatment options may include inpatient residential care, intensive outpatient counseling, self-help groups such as Alcoholics Anonymous, and/or a combination of cognitive, behavioral and medical therapies.

Detoxification is often the first step in management.
Inpatient treatment may consist of admission to a treatment facility for medical and cognitive therapies.
Residential treatment facilities provide patients with a safe place to reside as they adjust to a drug-free life.
Intensive outpatient rehabilitation/ programs consist of regular, intensive group counseling sessions.
Pharmacologic treatment may include naltrexone (Relistor, ReVia, Vivitrol), methadone (Dolophine, Methadose), or buprenorphine (Buprenex, Suboxone, Subutex) for the management of opioid addiction. These medications reduce withdrawal symptoms and, in the case of naltrexone, reduce cravings and the associated euphoria.³ Disulfiram (Antabuse) or acamprosate (Campral) may be useful for the patient with alcohol addiction.³

Managing the patient with addiction requires a comprehensive, multidisciplinary approach. An addiction medicine specialist is a valuable resource.¹⁰ A combination of treatment options can be successful in helping patients achieve and maintain abstinence.^1,3

WHAT’S NEW?

Recent studies have strongly suggested the presence of specific genetic coding in patients with substance use disorders.^11,12 Eliciting a positive family history of alcohol or drug addiction may further help identify patients at risk for substance abuse disorders.¹³

WHAT’S IMPORTANT?

Long-term abstinence is enhanced when the patient accepts responsibility and wants to get better, when there is strong family support, and when there is ongoing therapy and/or monitoring. Regularly inquiring about the patient’s progress in recovery will support and motivate patients to maintain sobriety.³

Patients may have multiple, concurrent addictions. Patients with a history of addiction to one substance are at high-risk to abuse substances in other categories.¹³ Therefore, potentially addictive substances should be administered with caution in patients with a history of substance abuse.

WHAT ELSE IS IMPORTANT TO KNOW?

Medical detoxification is only the first step in management and is typically insufficient to maintain long-term abstinence. An acceptable duration of inpatient and/or structured outpatient treatment is determined according to individual needs.^1,3 Patients with comorbid conditions, such as depression or generalized anxiety disorder,² and those with a history of multiple drugs of abuse may struggle to achieve abstinence.²

Patients who have a history of substance abuse require frequent follow-up in order to promote abstinence. Primary care providers play a pivotal role in assisting this patient population with obtaining and maintaining long-term abstinence.^3,10 Involvement of the patient’s family and/or support system is a vital component of treatment success, and identifying motivating factors for the patient to stay in treatment can assist in long-term abstinence. JAAPA

REFERENCES

	1.	Lanier D, Ko S. Screening in Primary Care Settings for Illicit Drug Use: Assessment of Screening Instruments — A Supplemental Evidence Update for the US Preventive Services Task Force. Evidence Synthesis No. 58, Part 2. AHRQ Publication No. 08-05108-EF-2. Rockville, MD: Agency for Healthcare Research and Quality: January 2008. http://www. ahrq.gov/clinic/uspstf08/druguse/drugevup.pdf. Accessed June 11, 2008.
	2.	Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States results from the national epidemiology survey on alcohol and related conditions. Arch Gen Psychiatry. 2007;64(5):566-576.
	3.	Weaver MF, Jarvis MAE, Schnoll SH. Role of the primary care physician in problems of substance abuse. Arch Intern Med. 1999;159(9):913-924.
	4.	National Institute on Drug Abuse (NIDA) InfoFacts. Treatment trends. Revised March 2005. http://www.nida.nih.gov/Infofacts/treatmenttrends.html. Accessed June 11, 2008.
	5.	Fleming MF. Screening and brief intervention in primary care settings. Alcohol Research and Health. 2004-5;28(2): 57-62. http://pubs.niaaa.nih.gov/publications/arh28-2/ 57-62.htm. Accessed June 11, 2008.
	6.	United States Preventive Services Task Force. Screening for illicit drug use. Released January 2008. http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm. Accessed June 11, 2008.
	7.	Screening, brief intervention and referral to treatment. http://sbirt.samhsa.gov/. Accessed June 11, 2008.
	8.	SAMHSA/CSAT treatment improvement protocols. The executive summary. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.59349. Accessed June 11, 2008.
	9.	Blondell RD. Trauma case finding. In: Graham AW, Schultz TK, Mayo-Smith MF, et al. Principles of Addiction Medicine. 3rd ed. Chevy Chase, MD: American Society of Addiction Medicine; 2003:349-360.
	10.	Mersy DJ. Recognition of alcohol and substance abuse. Am Fam Physician. 2003;67(7):1529-1532,1535-1536.
	11.	Kendler KS, Myers J, Prescott CA. Specificity of genetic and environmental risk factors for symptoms of cannabis, cocaine, alcohol, caffeine, and nicotine dependence. Arch Gen Psychiatry. 2007;64(11):1313-1320.
	12.	Lachman HM, Fann CSJ, Bartzis M, et al. Genomewide suggestive linkage of opioid dependence to chromosome 14q. Hum Mol Genet. 2007;16(11):1327-1334.
	13.	Goldman D, Bergen A. General and specific inheritance of substance abuse and alcoholism [commentary]. Arch Gen Psychiatry. 1998;55(11):964-965.

This article was written by Alison C. Essary, MHPE, PA-C. Contributors included the other members and staff of 2007-2008 CSAC: Lawrence M. Herman, MPA, PA-C, Chair; Anthony E. Brenneman, MPAS, PA-C; Edward C. Hendrikson, PhD, PA-C; Marie-Michèle Léger, MPH, PA-C; Robert McNellis, MPH, PA; Daniel L. O'Donoghue, PhD, PA-C; and Eileen M. Van Dyke, MPS, PA-C. The manuscript was edited by Sarah Zarbock, PA-C.

SUBSTANCE ABUSEScreening, diagnosis, management