The Scope of the Problem and the Case for Screening, Brief Intervention, and Referral to Treatment

e-mail: [email protected] May 2008 The Scope of the Problem and the Case for Screening, Brief Intervention, Objectives and Referral to Treatment After reading this issue, the Lee Kim Erickson, MD clinician should be able to: azardous alcohol use and alcohol astounding numbers that we need to • Identify the scope of the problem to implement abuse and dependence are more address. prevalent in the United States screening, brief intervention, H This is undeniably a massive public health and referral for treatment than most conditions routinely screened • Review the history of and for and treated by physicians, yet doctors problem, yet doctors rarely screen for it or integrate the Screening, usually fail to identify and treat problem give advice to their patients about alcohol Brief Intervention, Referral use. In 1997, 10 states collected data and Treatment Program into alcohol use. The impact of this failure on society is enormous. Alcohol consump- on health interventions for smoking and their practice drinking. Only 23 percent of binge drinkers • Develop a protocol to tion is the third most common actual effectively screen patients 1 received advice about alcohol; two million cause of death in the United States. 9 for alcohol use and to Alcohol is a factor in 60 to70 percent of opportunities to intervene were lost. Inad- perform a comprehensive equate training and pessimism about the risk assessment homicides, 40 to 50 percent of fatal motor vehicle accidents, 60 percent of fatal burn effectiveness of intervention make many • Formulate strategies to physicians reluctant to screen for alcohol effectively communicate injuries and drownings, and 40 percent of concern about alcohol use 2 problems; physicians also feel constrained fatal falls. The National Institute on Alco- 10 or abuse without judging hol Abuse and Alcoholism conservatively by time and reimbursement pressures. patient behavior • Identify links with estimates economic costs in excess of Most physicians are familiar with the 3 appropriate treatment $184 billion a year. late-stage sequelae of alcoholism. Acute resources Hazardous alcohol use and abuse cuts hepatitis, pancreatitis, gastritis and • Examine the rationale bleeding ulcers, cirrhosis and liver failure, and evidence to support a wide swath through all age groups. pharmacotherapy’s to treat On any average day in the past year, cardiomyopathy and heart failure, acute alcohol problems in the 8,000 children ages 12 to 17 had their withdrawal and delirium tremens are primary care setting first drink.4 Approximately 47 percent of sadly common place on inpatient medical people who begin drinking before the age wards. Health care providers are used Faculty information can be to seeing only these sickest of patients, found on page 2. All faculty of 14 become dependent later in life, com- have stated they have no pared with 9 percent who begin drinking and therefore understandably do not conflict of interest to disclose. after the legal age of 21.5 Nearly 18 per believe that intervention and treatment cent of eighth graders and 41.2 percent work because they have little experience Activity Development Team of tenth graders have been drunk at least with the patients who get better. Yet data – Barbara A. Layne, RN, has on treatment for alcohol dependence returned her disclosure form once.6 In 2001 alone, 2.8 million 18-24 stating that she has no relevant year old college students reported driving shows success rates well above popular financial relationships to under the influence; 696,000 reported perception: decreases in alcohol use of disclose. being assaulted by a fellow student under 60 percent, decreases in criminal activity the influence, and 97,000 were victims of of 50 percent, and increased employment alcohol-related sexual assault.7 And while rates of 40 percent. It is estimated that every dollar spent on treatment saves us the prevalence of problem alcohol use 11 in the elderly is debated, it is clear that $12 in crime and health care costs. In there are serious concerns about alcohol comparison, consider our success rates use in older patients who are already at at managing hypertension—less than one increased risk for falls and hip fractures, third of patients with high blood pressure automobile accidents, and multiple are adequately treated and controlled. Copyright © 2008 medication interactions.8 These are all Pennsylvania Medical Society continued on page 2 2

The Scope of the Problem and ized controlled trial of 774 problem change. And for patients identified as drinkers, those who received brief having more severe alcohol problems, the Case for Screening, Brief interventions had significant reductions Referral to treatment is most appropriate. Intervention, and Referral to in seven-day alcohol use and episodes As of August 2007, the SBIRT program Treatment of binge drinking, as well as significantly fewer hospital admissions and emer- had screened 536,000 individuals and continued from page 1 gency room visits. The positive effect of had been implemented in multiple trauma the brief intervention was sustained at 48 centers/emergency rooms, community Alcohol abuse and dependence is more months and provided an estimated sav- clinics, federally qualified health centers, prevalent than hypertension and re- ings of $43 in future health care costs for and school clinics and primary care prac- sponds to treatment at higher rates. 16 every dollar spent.15 tices. More about the SBIRT program can be found at http://sbirt.samhsa.gov In the last decade, research has been In response to this overwhelming and many useful screening and inter- focusing on earlier intervention and evidence, the Substance Abuse and vention tools are available through the prevention of alcohol problems. Many Mental Health Services Administration Pennsylvania SBIRT project site at http:// studies on brief interventions for haz- (SAMHSA) launched the Screening, Brief www.ireta.org/sbirt/clinical_tools.htm. ardous alcohol use have repeatedly Intervention, and Referral to Treatment The SBIRT approach to problem drinking demonstrated immediate decreases in (SBIRT) initiative, an implementation grant is a simple, concrete way to incorporate alcohol consumption and alcohol related program to translate the research into screening for and intervention of one morbidity and mortality.12,13 In one practice. SBIRT represents a paradigm of our biggest public health issues into trauma center, brief interventions for shift in health care’s approach to alcohol routine medical care. It is long overdue. hazardous alcohol use decreased use and abuse and targets the hazard- What can you do to help? alcohol consumption at 12 months ous and problem drinker in an effort by 21.6 drinks per week, compared to intervene earlier and prevent further Screen patients universally for alcohol, to an increase of 2.3 drinks per week morbidity, mortality, and progression even if they present with other addictive in the control group receiving no to end-stage alcoholism. Screening disorders, i.e., opiate dependence, etc. advice. There was also a 47 percent quickly assesses the level of alcohol use reduction in injuries requiring a visit to and identifies the appropriate level of an emergency room or trauma center.14 References are available at intervention. Brief intervention focuses on And it appears that the decreases in www.pamedsoc.org/counterdetails increasing awareness regarding alcohol morbidity and mortality may hold longer or by calling (800) 228-7823, use and motivation toward behavioral than six to 12 months. In one random- extension 7806.

Faculty and all others who have the ability to control the content of continuing medical education activities sponsored by the Pennsylvania Medical Society are expected to disclose to the audience whether they do or do not have any real or apparent conflict(s) of interest or other relationships related to the content of their presentation(s). Lee Kim Erickson, MD is Medical Director for Quality at President of Allegheny County Medical Society and West Penn Hospital, Forbes Regional Campus, Monroeville, President-Elect of the Pennsylvania Society of Addiction Pa. She is a resident faculty member of West Penn Family Medicine. Medicine Residency Program in Pittsburgh, Pa. and director of the SBIRT Program. She is board certified in Bradley J. Miller, DO, FAAFP is Director of the Family Medicine. Dr. Erickson is a member of the American Osteopathic Medical Education and Director of the Academy of Family Physicians, Pennsylvania Academy of Williamsport Hospital and Medical Center Osteopathic Family Physicians, and the Society of Teachers of Family Family Medicine Residency Program. He is a member of the Medicine. Screening Brief Intervention Referral and Treatment (SBIRT) Rural Subcommittee for the Pa Department of Health, Adam J. Gordon, MD, MPH, FACP, FASM is Assistant Bureau of Drug and Alcohol Programs. Professor of Medicine, Division of General Internal Medicine, and Core Faculty of the Center for Health Equity Research Dr. Miller is board certified in Family Medicine by both the and Promotion, among other appointments. He is a staff American Board of Family Medicine and the American physician with the Veterans Administration (VA) Pittsburgh Osteopathic Board of Family Physicians. He is a member of Health System, and Director, Substance Abuse Detection many professional organizations including the Pennsylvania and Early Intervention Program of the Veterans Affairs, Medical Society, Lycoming County Medical Society, Pennsylvania Academy of Family Physicians, Pennsylvania

FACULTY Pittsburgh, Healthcare System. FACULTY Osteopathic Medical Association, and the Society of Dr. Gordon is board certified in internal and addiction Teachers of Family Medicine. medicine. He is a member of many professional organizations, including the American Medical Association, Sanjay Paidsetty is a medical student at the University of Pennsylvania Medical Society, Allegheny County Medical Pittsburgh School of Medicine and is a research assistant Society, American Society of Addiction Medicine, and the with the United States Department of Veterans Affairs American Society of Internal Medicine. He is presently Pittsburgh Healthcare System. 3 Communicating with Patients About Alcohol Use Bradley J. Miller, DO

The Screening, Brief Intervention, consumers, and approximately five 1) Initial screen. Consists of a very Referral and Treatment Program percent of adults are alcohol-dependent simple set of questions that can be n an effort to expand and enhance (see Figure 1: Drinker’s Pyramid). performed in a variety of formats state substance abuse treatment Therefore, the role of the practitioner is to and settings. The questions focus service systems, the Substance on alcohol use patterns and allow I 1) support a patient’s low-risk Abuse and Mental Health Services the medical provider to easily Administration (SAMHSA) awarded consumption or categorize the patient’s alcohol seven states, including Pennsylvania, 2) provide education and guidance use as low-risk or high-risk. Those with a Screening, Brief Intervention, regarding a patient’s high-risk patients that exhibit a high-risk Referral and Treatment (SBIRT) consumption or use of alcohol would be subject to cooperative agreement. The overall goals secondary screening. for SBIRT in primary care settings are to: 3) provide referral services for alcohol dependence. Effective initial screening of alcohol 1) improve the identification of use begins with knowledge of low substance misuse with the target STEP I: Screening and Assessment and high-risk drinking levels in population being non-dependent, In order for substance use screening to different subsets of the population, at-risk users, be effective and routinely performed by as well as an understanding of what medical providers, there needs to be a constitutes a standard drink (See 2) decrease the overall alcohol and Table 1: Low-Risk Drinking Limits). drug use in patients, and simple, concise, systematic approach to screening every patient. The screening Please note how important it is to 3) create an informed, medically- process has three components: the initial clarify what the patient considers sound, prevention-based continuum screen, the secondary screen, and the to be one drink. For example, of care between general medical assessment. continued on page 4 practice and specialized drug and alcohol treatment centers. The role of the practitioner is to identify Table 1: Low-Risk Drinking Limits and assess (Screen), provide intervention (Brief Intervention), and referral for Amount of Alcohol Low-Risk: (Referral) substance use. This article will Per Serving (Drink) focus on the SBIR process with regard to alcohol use in adult patients. Women (excluding pregnancy): A standard drink is: • No more than one drink per day if • A 12 ounce can/ Overall in the United States, a daily consumer bottle of beer approximately 70 to 75 percent of • No more than three drinks per • A 5 ounce glass of wine adults are low-risk alcohol consumers. session if irregular consumer • A 1.5 ounce shot of liquor Approximately 20 to 25 percent of • No more than seven drinks per the population is high-risk alcohol week Men: Figure 1: Drinker's Pyramid • No more than two drinks per day if a daily consumer • No more than four drinks per ses- Alcohol Dependent sion if irregular consumer • No more than 14 drinks per week High-Risk Level All persons over 65: • No more than one drink per day • No more than seven drinks Low-Risk Level per week

All persons younger than 21 and Abstainers pregnant women: • There is NO ACCEPTABLE DAILY OR WEEKLY LIMIT 4

Communicating with patients Figure 2: Initial Screening Questions about alcohol use continued from page 3 On average, how many days Risky Behavior a week do you drink alcohol? the patient may have one martini On a typical day when you drink, Men Women per night or “one drink,” however, If amount how many drinks do you have? martinis may contain up to two exceeds risk to four shots of distilled spirits, Weekly Average = >14 >7 levels, perform and hence the patient is actually AUDIT consuming two to four standard What is the maximum number >4 >3 drinks, an amount well beyond the of drinks you had on any low-risk drinking limits. given day in the past month? } Once the low-risk drinking limits are understood, screening a patient for excessive use would include questions that establish his or her Figure 3: The Alcohol Use Disorders Identification Test drinking pattern. The initial screening The Alcohol Use Disorders Identification Test: Interview Version can be done easily and in a variety Read questions as written. Record answers carefully. Begin the AUDIT by saying "Now I am going to ask of ways. For instance, the patient you some questions about your use of alcoholic beverages during this past year." Explain what is meant by could fill out a self-disclosure form, "alcoholic beverages" by using local examples of beer, wine, vodka, etc. Code answers in terms of "standard the nurse could ask the screening drinks." Place the correct answer number in the box at the right. questions when taking vitals, or the 1. How often do you have a drink containing alcohol? 6. How often during the last year have you needed (0) never [Skip to Qs 9-10] a first drink in the morning to get yourself going physician could ask the questions (1) Monthly or less after a heavy drinking session? as he or she is examining the patient (2) 2-4 times a month (0) Never (See Figure 2: Initial Screening (3) 2-3 times a week (1) Less than monthly (4) 4 or more times a week (2) Monthly Questions). (3) Weekly (4) Daily or almost daily Ideally, each patient should be 2. How many standard drinks containing alcohol do 7. How often during the last year have you had a screened whenever possible, you have on a typical day when you are drinking? feeling of guilt or remorse after drinking? especially if he or she is a high-risk (0) 1 or 2 (0) Never alcohol consumer. Otherwise, yearly (1) 3 or 4 (1) Less than monthly (2) 5 or 6 (2) Monthly screening on those patients who (3) 7, 8, or 9 (3) Weekly are low-risk consumers is sufficient. (4) 10 or more (4) Daily or almost daily Patient populations who may 3. How often do you have six or more drinks on 8. How often during the last year have you been not routinely come into the office one occasion? unable to remember what happened the night (adolescent and young adult patients (0) Never before because you had been drinking? (1) Less than monthly (0) Never in particular) should be screened (2) Monthly (1) Less than monthly whenever possible. (3) Weekly (2) Monthly (4) Daily or almost daily (3) Weekly Once the patient’s consumption Skip to Questions 9 and 10 if Total (4) Daily or almost daily of alcohol is established, the Score for Questions 2 and 3 = 0 physician can then decide whether 4. How often during the last year have you found 9. Have you or someone else been injured as a more information about their that you were not able to stop drinking once you result of your drinking? had started? (0) No alcohol consumption is warranted, (0) Never (2) Yes, but not in the last year otherwise, the screening process (1) Less than monthly (4) Yes, during the last year can end at that point. (2) Monthly (3) Weekly 2) Secondary Screen. If the patient (4) Daily or almost daily exhibits at-risk alcohol consumption 5. How often during the last year have you failed 10. Has a relative, friend, doctor, or a doctor or an- to do what was normally expected from you other health worker been concerned about your based on the initial screen, a more because of drinking? drinking or suggested you cut down? formalized screening measure (0) Never (0) No is then performed. Typically (1) Less than monthly (2) Yes, but not in the last year (2) Monthly (4) Yes, during the last year a structured questionnaire is (3) Weekly employed. Choosing an alcohol (4) Daily or almost daily screening method can be difficult considering the number of Record total of specific items here structured questionnaires that exist If total is greater than recommended cut-off, consult User's Manual continued on page 5 5

Communicating with patients comprehensive information to both patient’s level of risk with regard to physicians and patients. his/her drinking pattern. The four about alcohol use levels of risk and corresponding continued from page 4 The AUDIT consists of ten questions AUDIT scores shown below are (see Figure 3: AUDIT). The first presented as general guidelines for (i.e., AUDIT, brief MAST, CAGE, three items measure the quantity assigning risk levels and intervention CRAFFT, TWEAK, etc.) Essentially, and frequency of alcohol use. The modalities (see Table 2: Risk Levels all of these measures screen next three questions ask about the and Figure 4: Drinker’s Pyramid with patients based on amount and occurrence of possible dependence Risk Levels). frequency of use. Some measures symptoms, and the last four are more effective screens for abuse questions inquire about recent and The medical provider may need to or dependence (CAGE), while others lifetime problems associated with adjust the intervention according target risky behavior (AUDIT). No alcohol use. to his or her best judgment of the patient’s individual circumstances. screening instrument is perfect. The AUDIT is easy to score. Each of However, despite their limitations, the questions has a set of responses Finally, in addition to the initial screen research supports the use of formal to choose from, and each response and AUDIT score, an essential screening instruments to increase has a score ranging from 0 to 4. component to the assessment the recognition of alcohol problems. The interviewer enters the score of the patient’s alcohol use is an Since one of the overall goals of corresponding to the patient’s understanding of the patient’s SBIRT is to improve the identification response into the box beside each medical and behavioral status. For of substance misuse with the question. All the response scores instance, elevated liver enzymes, target population being the non- should then be added and recorded memory lapses, hypertension, dependent, at-risk user, the Alcohol in the box labeled “Total.” gastritis, depression, and so forth Use Disorders Identification Test can be early indicators of alcohol 3) Assessment. The information related systemic illness and/or (AUDIT), a screening questionnaire obtained during the initial and that focuses on risky behavior, is dependence and can help establish secondary screening helps to the severity of the patient’s overall an effective instrument to use as a assess the severity of the patient’s secondary screening instrument. health as it is related to his/her alcohol use and to guide the alcohol misuse. If the relationship Developed by the World Health physician’s approach during the brief Organization, this test is a exists, establishing a link to the intervention that will follow. At this patient’s medical problems and standardized, systematic, validated point, the physician has quantitative instrument that identifies low-risk, alcohol consumption can be a information to present to the patient powerful component of the brief high-risk, and dependent alcohol during the brief intervention (the consumption. Although other intervention and can motivate the patient’s drinking pattern and patient to modify his or her behavior. self-report instruments have been AUDIT score). found to be useful, the AUDIT has Therefore, consider additional testing the advantages of providing more An essential component of the assessment is to understand the continued on page 6

Figure 4: Drinker's Pyramid with Table 2. AUDIT Risk Levels Corresponding AUDIT Zones AUDIT Risk Level Description Intervention AUDIT Scores Types of Drinkers Score 20+ Probable Alcohol Dependence Alcohol education to support Zone I Low-risk 0-7 low-risk use 8-19 High-Risk Drinkers Brief Intervention focused on Zone II At-risk 8-15 reduction of at-risk use 1-7 Low-Risk Drinkers Brief Intervention focused on Zone III High-risk reduction of high-risk, hazardous 16-19 0 Abstainers use; possible referral

Probable Referral to specialist for diagnostic Zone IV 20-40 Dependence evaluation and treatment 6

Communicating with patients Physician: On a typical day when you and in the “High-Risk Drinkers” zone on drink, how many drinks the Drinker’s Pyramid (Utilize the AUDIT about alcohol use do you have? score to help establish risk level as continued from page 5 well as appropriate brief intervention Mr. B.: Usually just one, but approach) (i.e., blood work, EKG, depression sometimes when I am screen) and follow up if warranted. stressed, I might make In addition to the initial and secondary another. (On occasion, the screenings, Mr. B’s ROS and physical The following case illustrates how the patient is consuming six exam reveals that he suffers from physician uses the initial screen, sec- to eight drinks per night untreated hypertension and gastritis. ondary screen, and medical history to based on the amount of He also states that he has been more assess the patient’s level of risk. alcohol per drink.) agitated in recent months. These medical/behavioral issues may be related Mr. B. is a 47 year old white male who Physician: During the past month, to his alcohol consumption. presents to the office for his yearly physi- what would you say is the cal. He has no new concerns today. Past maximum number of drinks Overall Assessment: Mr. B exhibits medical history is positive for being over- you had on any given day? a high-risk drinking pattern and has weight. He has a family history of CAD in medical/behavioral issues that may be his father. Vitals are BP 160/98, HR 80, Mr. B.: Oh, never more than two. related to his alcohol consumption. and weight 210. During your review of I have trouble waking up systems the following occurs: in the morning if I do. Conclusion: Mr. B is appropriate for brief intervention. Physician: So Mr. B, as part of your Discussion: routine health screening, Initial screening: Revealed that on four Step II: The Brief Intervention I would like to ask some or five nights per week he consumes one Brief Interventions (BIs) are short questions regarding use or two martinis, each containing three or dialogues between the medical of any substances such as four shots of gin. provider (non-addiction specialists) smoking, alcohol, etc… and the patient that provide feedback, would that be okay? Assessment: When he drinks alcohol, education, and guidance regarding the (Establish “normalcy” to Mr. B consumes three to eight shots drug and/or alcohol use of the patient. the process of screening) of distilled spirits per drinking session Brief interventions are successful at which exceeds the at-risk limits of Mr. B.: Sure? encouraging and motivating behavioral daily consumption for males (two or changes in the patient’s drinking pattern Physician: Do you drink alcohol? less drinks per day if a daily consumer, that can ultimately lead to reduction of and no greater than four per session if the patient’s consumption to a safer Mr. B.: Yes. less regular consumer). In addition, he level, or abstinence. has four to five drinking sessions per Physician: On average, how many week, placing his weekly consumption Brief interventions are meant to be just days a week do you between 12 to 40 drinks per week. that brief (5 to 10 minutes) and are consume alcohol? (Low-risk is up to 14 for males). (Use easy to conduct in any medical setting Mr. B.: I have a drink four or five low-risk and high-risk drinking levels (inpatient, outpatient, emergency/ days a week, you know, to assess whether further questioning trauma centers). With practice, BIs, after work to help me wind is warranted.) like alcohol screening, can become a down. routine component to the medical care Given the information discovered in of the patient. There are three essential Physician: Do you drink beer, mixed the initial screening, further evaluation components to the BI: provide feedback, drinks, wine? of the patient’s alcohol consumption engage patient feedback, and negotiate/ is warranted. The AUDIT is performed. Mr. B.: I like gin martinis, I’ve learned advise a plan for behavioral change. to make them just right. Secondary Screening: Mr. B’s AUDIT 1) Providing feedback—This initial score was 9 (see Figure 5: Mr. B’s Audit, Physician: How many shots of alcohol component of the BI helps to page 7). He scored highest on the first legitimize and substantiate the do you use to make a three questions regarding consumption martini? physician’s concerns with regard and frequency. He had some positive to the patient’s use of alcohol. Mr. B.: You know, the standard responses on the last four questions This is accomplished by providing three, sometimes four. regarding recent and lifetime problems the patient-specific data gathered (Pt is consuming three to associated with alcohol. during the initial and secondary four drinks per night Assessment: The AUDIT score places screens and comparing that data based on the amount of him in “Zone II” of the AUDIT score risk alcohol per drink) assessment and intervention analysis continued on page 7 7

Communicating with patients powerful component to this stage in This method, known as motivational the BI. When applicable, linking the interviewing, creates a safe haven about alcohol use patient’s presenting complaint and for the patient to discuss his or continued from page 6 how it relates to substance use may her alcohol use and can affect be helpful in establishing a patient’s their willingness to talk freely about and risk level to that of the general sense of understanding, ownership, why and how they might change. population. At the same time, and responsibility for his or her A key component of motivational educating the patient with regard alcohol misuse. interviewing is to acknowledge how to low-risk drinking limits as well the patient reacts (both verbally as the risks and harms associated 2) Engage patient feedback and non-verbally) to the physician’s with higher-risk drinking patterns Throughout the BI, it is important questions or statements by is essential. Establishing a link to to engage the patient in a repeating, reaffirming, or redirecting the patient’s medical problems conversational tone that is both non- the patient’s response. and alcohol consumption can be a judgmental and non-confrontational. Asking open-ended, thought- provoking questions is an important exercise when performing a BI. Figure 5: Mr. B's AUDIT Test Doing so reinforces the patient’s “definition” of their alcohol use, The Alcohol Use Disorders Identification Test: Interview Version Read questions as written. Record answers carefully. Begin the AUDIT by saying "Now I am going to ask establishes credibility to the patient’s you some questions about your use of alcoholic beverages during this past year." Explain what is meant by response, and enhances the sense "alcoholic beverages" by using local examples of beer, wine, vodka, etc. Code answers in terms of "standard of control and responsibility the drinks." Place the correct answer number in the box at the right. patient has with regard to their 1. How often do you have a drink containing alcohol? 6. How often during the last year have you needed alcohol use. Use this time to allow (0) never [Skip to Qs 9-10] a first drink in the morning to get yourself going (1) Monthly or less after a heavy drinking session? the patient to digest the information (2) 2-4 times a month (0) Never that has been shared and to guide (3) 2-3 times a week (1) Less than monthly the patient through the planning (4) 4 or more times a week (2) Monthly (3) Weekly process. Attempt to illicit the patient’s 4 (4) Daily or almost daily 0 understanding of their alcohol use 2. How many standard drinks containing alcohol do 7. How often during the last year have you had a and at what level he or she may be you have on a typical day when you are drinking? feeling of guilt or remorse after drinking? willing to change his or her behavior. (0) 1 or 2 (0) Never Pay attention to and acknowledge (1) 3 or 4 Gin martinis (1) Less than monthly statements that suggest a change in (2) 5 or 6 3-4 shots/drink (2) Monthly (3) 7, 8, or 9 (3) Weekly the way the patient thinks about his (4) 10 or more 1 (4) Daily or almost daily 1 or her drinking. 3. How often do you have six or more drinks on 8. How often during the last year have you been one occasion? unable to remember what happened the night Here are some examples of brief (0) Never before because you had been drinking? intervention questions that help illicit (1) Less than monthly (0) Never (2) Monthly (1) Less than monthly and propel the discussion: (3) Weekly (2) Monthly Same day as #4 (4) Daily or almost daily (3) Weekly ­ • Help me to understand what Skip to Questions 9 and 10 if Total (4) Daily or almost daily you enjoy about drinking? Score for Questions 2 and 3 = 0 1 1 4. How often during the last year have you found 9. Have you or someone else been injured as a ­ • Now tell me what you enjoy less that you were not able to stop drinking once you result of your drinking? about drinking. had started? (0) No (0) Never Called in sick for work (2) Yes, but not in the last year ­ • On a scale from one to 10, (1) Less than monthly (4) Yes, during the last year how ready are you to change any (2) Monthly once in past year (3) Weekly aspect of your drinking? Why did (4) Daily or almost daily 1 0 you choose that number and not 5. How often during the last year have you failed 10. Has a relative, friend, doctor, or a doctor or an- a lower one? to do what was normally expected from you other health worker been concerned about your because of drinking? drinking or suggested you cut down? ­ • Do you think your medical (0) Never (0) No condition/behavior may be (1) Less than monthly (2) Yes, but not in the last year (2) Monthly (4) Yes, during the last year directly related to your drinking? (3) Weekly (4) Daily or almost daily ­ • Have you ever thought about 0 0 your drinking and how it might Record total of specific items here affect your life? If total is greater than recommended cut-off, consult User's Manual 9

continued on page 8 8

Communicating with patients four shots of gin, is actually considered three or four about alcohol use drinks given the above continued from page 7 definitions of what is a standard drink. (Review 3) Negotiating and advising a plan— results of screening and As the BI unfolds, the physician and educate patient on what is patient begin to negotiate a plan of considered a standard action to help the patient decrease drink) or abstain from alcohol consumption. The patient’s overall risk and level Mr. B: Wow, I had no idea. But of readiness for change help to who wants a martini with guide the conversation and overall only one or two shots of gin? negotiated plan for change. It is Physician: It may be the case that you important to encourage the patient feel that a smaller amount to feel comfortable with the plan and of alcohol would not be that the plan represents a goal that is subject matter. With practice, the a large enough drink for actually attainable. At the same time, physician’s confidence in screening you, but I do think it is the physician needs to be able to feel patients and performing brief important to be aware comfortable with the patient’s plan interventions will improve. of how much alcohol you for change. Although it is the ultimate actually consume. What goal of intervention, oftentimes the The following case illustrates how the this means is that you negotiated plan does not include the physician uses the results from the initial consume more than what is patient completely abstaining from screen, secondary screen, and medical considered low-risk for alcohol or decreasing to a level that is history to perform a brief intervention, adult males that is, on considered low-risk. As stated earlier, plan for change, and follow up. average you consume more it is important to ask open-ended than two drinks per day questions that encourage the patient Physician: Mr. B, I wanted to review with you the information and sometimes more than to formulate a plan of action. Here are four drinks in one drinking some examples of such questions: you provided us with regard to your use of alcohol, session. (Define low risk ­ • What do you think are the next would that be okay? drinking pattern for the steps in making some changes? (Ask for permission to patient and how his discuss this topic) pattern compares) ­ • What changes do you think you can do to stay within the Mr. B: Sure. Mr. B: If that’s what you say my safe drinking guidelines? limit is, I understand, but Physician: The amount of alcohol that is this really a problem? ­ • This is what I heard you say… you reported consuming I mean I have never been in is above the recommended trouble or anything ­ • What do you see as your amount for adult males options? your age and places you in Physician: Yes, well you may not have been in trouble with the law Once a mutually agreed upon plan is a higher risk level drinking as a result of your alcohol, formulated, it is important to define pattern. Are you aware of but given the amount what steps are needed in order what is considered a of alcohol you are to accomplish it. Verbally repeat low-risk drinking pattern? consuming and considering the plan to the patient to confirm Mr. B: I thought one or two drinks the answers to some of the that they agree to the terms and per day would be okay for questions that I asked, timelines for follow up. Recording me. It has never caused any you are at risk for the plan on a piece of paper or problems; I mean I’m not an developing problems with in the patient’s chart and having alcoholic or anything. alcohol related illness or them sign it can help reinforce their behavior in the future. dedication to following the plan as Physician: Yes, well interestingly, a (Reference AUDIT score well. It is important to offer quick standard drink is one shot and educate patient about follow up with regard to the plan or 1.5 ounces of spirits, a the medical/behavioral and to assure that the patient can 12 ounce can of beer, or a problems with higher call or come back sooner if needed. five ounce glass of wine. consumption) Finally, acknowledge the patient’s This means that one of your participation in the discussion given martinis which has three or the somewhat personal and difficult continued on page 9 9

Communicating with patients to try to cut back on your case management of drug and alcohol drinking? abuse and dependence. This program is about alcohol use implemented through grant agreements continued from page 8 Mr. B: I think I can give that a try. with the 49 Single County Authorities I’m not going to cut it out (SCAs) who, in turn, contract with private Mr. B: I feel good…is there completely, doc. drug and alcohol service providers. something you found out Physician: What do you think is a more Familiarity with the local SCA can be very that is concerning? appropriate amount of helpful. The SCA will be able to provide Physician: In fact, the elevated blood alcohol to be drinking? a comprehensive list of treatment pressure that you have services including local drug and alcohol Mr. B: Well given what you said, I today and the gastritis you treatment facilities (both inpatient and think I can limit to just one have been experiencing outpatient), Alcoholics and Narcotics martini maybe three nights may be related to this Anonymous programs, and other per week. I’ll even try to use alcohol consumption. resources. The Pennsylvania Department just three shots of gin. Also, the agitation that you of Health BDAP website is a reliable described certainly can be Physician: That certainly will be an source of Drug and Alcohol treatment the result of or could be improvement from what programs within the Commonwealth. worsened by alcohol intake. you are currently drinking. Contact information for the SCA in your (Directly link patient’s Let’s meet again in say, two county is provided on pages 17 and 18. medical/behavioral to three weeks to see how Some helpful ways to create a treatment problems or the risk these you are making out with this and referral network for patients afflicted problems may have as a change. Does that seem with alcohol abuse may include the result of continued use) reasonable? (Physician following: negotiates a plan. The What are your thoughts amount of alcohol • Contact the local SCA to understand about the information that consumed may at times what treatment services, financial I just shared with you? not be ideal. Quick follow resources, and referral networks Mr. B: Well, I guess I really never up is essential.) may be available in your area. thought that I was drinking Like other medical skills, the physician’s • Meet with a representative of the too much before now. Now ability to screen and perform brief local treatment program(s) to un- that you say it, my stomach interventions improves and becomes derstand the specific services that does burn more when I automatic with practice. they provide as well as the preferred have had more than one method for referral. martini. I never put the two together. (Pay attention Creating Links with • Request patient handout or contact to and acknowledge Treatment Resources information from local treatment statements that suggest In certain situations, it is important for the programs for your office. a change in the way the patient to receive a higher level of care These steps will benefit not only your patient thinks about their for their alcohol use. This certainly would patients, but also all service providers, as drinking.) be appropriate for alcohol dependent individuals; however, enhanced treatment knowing one another will increase and Physician: So it seems that you see a may also be appropriate for any individual facilitate referrals and continuity of care. connection with how your whose use of alcohol interferes with or stomach feels and how endangers their or another individual’s much you have had to well being. In such cases, referral to an drink? How might you avoid alcohol treatment specialist would be this from happening in the an essential component of the patient’s future? recovery. Counter Details welcomes physician input. Mr. B: Well obviously, if I didn’t In order to refer a patient to an alcohol To offer suggestions, counter drink more than one martini treatment specialist, it is important to points and comments, please call I would most likely decrease know what treatment resources exist in (800) 228-7823, ext. 7806 or email the times that my stomach your community. In Pennsylvania, the [email protected] hurts. Department of Health’s, Bureau of Drug and Alcohol Programs (BDAP) is charged Physician: Given the information that I Editor with developing and implementing shared with you regarding Barbara A. Layne, RN, Director a comprehensive health, education, your drinking pattern, do Chronic Disease and Wellness and rehabilitation program for the you think it is reasonable prevention, intervention, treatment, and 10 Emerging Medications to Treat Alcohol Use Disorders Sanjay Paidisetty, BS and Adam J. Gordon, MD, MPH, FACP

Alcohol abuse and alcohol dependence, concept of disulfiram as a psychological known collectively as alcohol use disor- deterrent must be established; the absti- ders (AUDs), are prevalent in the United nent patient needs to be well-informed of States affecting an estimated 18 million the toxic effects and associate them with adults and incurring a huge economic the consumption of alcohol. burden exceeding $100 billion.1, 2 In the primary care setting, as many as Although disulfiram is the oldest of the an estimated 20 percent of outpatients FDA-approved treatments, it tradition- drink alcohol at hazardous levels.3-5 The ally has not been the “go to” drug for National Institutes of Health defines haz- alcohol dependence in the primary care ardous drinking as consuming more than setting through the years. One reason is 14 standard drinks per week for men the significant lack of controlled trials of and more than seven drinks per week for disulfiram’s efficacy due to the inability women and persons older than 65 years to perform blind studies, since both the 6 physician and patient must be aware of of age. Persons that engage in hazard- 14 ous drinking or have an AUD experience disulfiram’s side effects. The largest significant medical, social, and societal and most methodologically controlled trial consequences.7, 8 to date is a 52 week, multi-center trial, involving 600 male alcoholic veterans To address the consequences of hazard- randomized into three treatments; 1 mg ous drinking, the National Institute on (Vivitrol) (Table I, see page 11). Use of disulfiram (inactive dosage-psychological Alcohol Abuse and Alcoholism (NIAAA) these medications is limited in primary effect), 250 mg disulfiram (active dos- has encouraged all primary care and care settings due to lack of awareness age), and placebo. The study found no among clinicians that effective pharma- mental health clinicians to incorporate 11, 12 significant differences in abstinence rates AUD screening, identification, brief inter- cotherapy exist. This review will and time to first relapse between the vention, and treatment referral into their provide an overview of the rationale and three groups, but the 250 mg cohort that practices.6 Other authorities such as the evidence of efficacy of the four FDA- relapsed had significantly fewer drink- Institute of Medicine, U.S. Preventive approved medications to treat problem ing days compared with the other two Services Task Force, and Centers of Dis- drinking in the primary care setting. Each groups. Furthermore, the study found ease Control and Prevention have made medication may have specific utility in that a greater percentage of patients similar recommendations for a greater treating certain patient populations and who remained compliant achieved higher physician role in screening and treating are discussed below in the order of ap- abstinence rates than those who were of problem drinkers.9, 10 The NIAAA proval by the FDA. not compliant.15 This finding underscores recently updated a brief monograph, another reason for disulfiram’s lack of use “Helping Patients Who Drink Too Much: Disulfiram in primary care settings-limited efficacy A Clinician’s Guide,” which provides Disulfiram (Antabuse) is the oldest due to poor compliance in unsupervised screening, assessment, and brief inter- among FDA-approved medications conditions. Disulfiram is likely best indi- vention support materials to help assist for alcohol dependence. Available to cated for those that are having difficulty clinicians to implement these recommen- physicians since the 1940s, disulfiram is attaining sobriety, highly motivated to dations (downloadable at http://pubs. an aversive agent indicated for chronic obtain complete abstinence and/or those niaaa.nih.gov/publications/practitioner/ alcohol-consuming patients that have who can be treated under supervised cliniciansguide2005/guide.pdf).6 established abstinence and concurrently settings including a spouse or partner treated with psychotherapeutic thera- involved in the treatment program.16-20 Non-pharmacologic treatments are py.13 The medication works by irrevers- the mainstay of treatment for hazard- ibly inhibiting the enzyme acetaldehyde Clinicians must be aware that disulfiram ous drinking. However, pharmaco- dehydrogenase. Ethanol is initially me- has been associated with cases of logic treatments have recently been tabolized by alcohol dehydrogenase to hepatitis, neuritis, and skin eruptions. In developed and serve as an adjunct to acetaldehyde, which is then metabolized addition, more severe ethanol-disulfiram non-pharmacotherapy to help patients into acetate by acetaldehyde dehydro- reactions have been known to include reduce alcohol consumption and/or genase. When a patient taking disulfiram myocardial infarction, congestive heart establish abstinence. The US Food and consumes ethanol, the patient experi- failure, respiratory depression, and Drug Administration (FDA) has approved ences the effects of the accumulation of death.13 Patients also must be well edu- four medications to help treat problem acetaldehyde in the blood such as in- cated to avoid any foods or medications drinking; disulfiram (Antabuse), acamp- tense nausea, vomiting, and flushing. In rosate (Campral), oral naltrexone (ReVia, order for the drug to be efficacious, the Depade), and naltrexone injection depot continued on page 12 11

Table I: Medications Approved for Alcohol Dependence

Medication Company Mechanism Adverse Events Recommended Approx. of Action Dose Cost

Acamprosate Forest May restore to Diarrhea, nausea, 333 mg enteric 333 mg Campral® Pharmaceuticals, Inc. normal the altered somnolence coated tablet for oral (180 ea): balance of neuronal administration. $121.3678 excitation and Adults: 666 inhibition induced mg three times by chronic alcohol daily; moderate exposure through renal impairment possible interaction (creatinine clearance with GABA 30-50 mL/min): 333 and glutamate mg three times daily neurotransmitter systems

Disulfiram Odyssey Acetaldehyde Optic neuritis, 250 mg tablets for 250 mg Antabuse® Pharmaceuticals, Inc. Dehydrogenase peripheral neuritis, oral administration. (30 ea): Inhibitor polyneuritis, peripheral Initial: 500 mg/day $87.9978 neuropathy, hepatitis, in a single dose for skin eruptions, 1-2 weeks; average headache, drowsiness, maintenance dose: psychoses; 250 mg daily (range Disulfiram-Alcohol 125 to 500 mg). Reaction - flushing, 500 mg is maximum throbbing headache, daily dose. Continue nausea, sweating, administration until palpitation, tachycardia patient establishes self-control.

Naltrexone Barr Opioid receptor Nausea, headache, 50 mg scored ReVia 50 mg Depade® Pharmaceuticals, Inc.; antagonist that may and nervousness naltrexone (30 ea): ReVia® Mallinckrodt, Inc.; block the effects of hydrochloride $222.4478 Duramed endogenous opioids tablets for oral Pharmaceuticals, Inc. administration. Generic: Initiation: 25 mg, if no 50 mg withdrawal signs after (20 ea): one hour administer $103.0478 second 25 mg dose; maintenance: 50 mg/day (flexible).

Naltrexone Alkermes, Inc. Opioid receptor Eosinophilic 380 mg (in 4 mL Wholesale Depot antagonist that may pneumonia, interstitial diluent vial) by acquisition Vivitrol® block the effects of pneumonia, pain at intramuscular cost: endogenous opioids injection site, nausea, injection. Administer $695.00 abdominal pain, and every four weeks per shot79 somnolence alternating buttocks

Table adapted from Paidisetty and Gordon66 12

Emerging medications to outpatients over a 12-week period.34 during alcohol withdrawal.44, 45 Thus, it is Although non-adherence is strongly believed that acamprosate leads to the treat alcohol use disorder supported, it could also be argued that reduction in the physiologic severity of continued from page 10 those who comply with the treatment withdrawal and reduces the desire after are more motivated toward abstinence achieving abstinence.20, 45, 46 that contain ethanol or acetaldehyde, or more strongly believe in the drug.31, such as vinegar and anti-tussives. 32, 35 Of additional note, the drug is Acamprosate’s FDA approval was largely metabolized in the liver and excreted in based on several early European trials demonstrating abstinence efficacy over Naltrexone the urine, which raises a red flag when placebo.20 However, analysis of all the Naltrexone (Depade, ReVia) is an opioid considering its use for chronic alcohol published controlled clinical trials prior receptor antagonist approved by the consumers that commonly have liver to 2006 demonstrated mixed overall FDA in 1994 for the treatment of alcohol injury.36 Patients with a family history clinical efficacy.28, 47-59 This uncertainty dependence.21 The mechanism of how of alcoholism, history of abuse of other of efficacy was based on the trials dif- naltrexone aids alcohol dependent substances, higher depression scores, fering in patient characteristics, such as patients is not well understood. It is sug- or were diagnosed as alcohol dependent pretreatment abstinence requirements; gested that its antagonism of the µ-type earlier in life had a better treatment re- treatment settings, such as inpatient and possibly -type opioid receptors sponse with naltrexone.37-42 δ versus outpatient, adjunct psychosocial prevents the release of dopamine in the therapies; and outcome variables. The nucleus accumbens and diminishes lack of methodological standardization reward during alcohol consumption.22 among the studies and questionable Two large meta-analyses analyzed nal- efficacy was addressed by two recent trexone’s efficacy compared to placebo large US studies. Mason et al random- and agreed that in short term studies ized 601 alcohol dependent patients into (less than two weeks), naltrexone is sig- 2 g acamprosate, 3 g acamprosate, and nificantly superior compared to placebo placebo groups, and in a priori analysis in decreasing relapse rates.23, 24 The of this study, there was no significant COMBINE (Combined Pharmacothera- difference in the treatment efficacy pies and Behavioral Interventions) study, between acamprosate and placebo.60 a recent 16 week nine-arm study involv- However, post-hoc analysis, controlling ing 1,383 alcohol dependent patients for variables believed to be important for demonstrated naltrexone with medical treatment efficacy, found acamprosate management to be significant only in to be significantly more effective in increasing time to first drink compared to increasing the number of abstinent days placebo.25 Greater efficacy was demon- compared to placebo among patients strated with the combination of naltrex- who had a baseline goal of abstinence.60 one, medical management, and cognitive The COMBINE study found no significant behavioral therapy (CBT) as it increased differences in treatment efficacy between the mean percent days abstinent, acamprosate and placebo.25 reduced drinks per drinking day, and It is unknown why the favorable results reduced heavy drinking days per month of the European trials were not repli- compared to placebo and naltrexone cated by US studies. In addition to the with medical management groups.25 Acamprosate aforementioned differences in patient Naltrexone studies demonstrated mixed Acamprosate (Campral) was approved characteristics and treatment setting, it is efficacy. Several studies suggested by the FDA in 2004 and indicated to proposed by Johnson that the difference that naltrexone’s effects would be more maintain alcohol abstinence among may also be due to higher levels of ad- favorable if not for the poor patient alcohol dependent patients that are junct psychosocial care in US trials com- compliance postulated to be primarily abstinent at treatment initiation.43 The pared to European trials and/or the small due to adverse effects, such as nausea, medication is known chemically as therapeutic effect of acamprosate that is headache, fatigue, and nervousness. calcium acetylhomotaurinate and is a favored in single-site studies versus large 20, 26-33 A published study conducted structural analogue of GABA. The exact multi-center studies.20 No particular by Mark et al in 2003 found that the mechanism of how acamprosate works patient characteristics have been found most common reason physicians do is currently unknown, but one theory to correlate with acamprosate success; not prescribe naltrexone is the lack of commonly supported suggests the drug however, strong evidence suggests patient compliance.33 Furthermore, non- helps normalize the dys-regulated NMDA acamprosate is effective in adjunct to a adherence was found to be linked to a receptor and glutamergic neurotrans- variety of psychotherapies, such as brief significant increase risk of relapse after mission, which was created by chronic intervention.61, 62 Thus, how effective comparing compliant to non-compliant alcohol consumption, and observed continued on page 13 13

Emerging medications to To further determine the length of lead- potential nonpharmacologic therapies in abstinence necessary for treatment available in the primary care setting.70 treat alcohol use disorder effect, O’Malley et al conducted a 24- continued from page 12 week study that examined treatment Although beyond the scope of this efficacy among 82 alcohol dependent review, studies and reviews have been acamprosate will be in the primary care patients with a four-day lead-in ab- performed characterizing the effects of setting where brief intervention is highly stinence. Four days was chosen as it combining medications and compar- utilized is yet to be determined. better reflected the length of time of ing the medications head to head, in detoxification stays and would help with adjunct to different psychotherapies, One clear benefit of acamprosate is real world application of the drug. Com- and in patients with psychiatric comor- its excretion through the renal system, 25, 62, 71-77 pared to placebo, patients given the high bidities. Currently, there is no which makes it safer than other alcohol dose Vivitrol (380 mg) had a significantly overwhelming evidence to support a pharmacotherapies in patients with liver higher rate of abstinence at the end of medication for a particular type of patient dysfunction. Furthermore, the drug can the study and increased time to first and clinical setting. Thus, there is no be used with anxiolytics, antidepres- heavy drinking event.68 definitive treatment for problem drinking. sants, hypnotics, disulfiram, and nal- Disulfiram may be more appropriate in trexone without serious complications.63 In the primary care setting, compliance a supervised, abstinence-goal oriented Common side effects include nausea, is a significant issue physicians’ must environment whereas naltrexone and diarrhea, and somnolence.43 continually battle against. The depot acamprosate may be more appropriate formulation overcomes the adherence for patients who seek alcohol consump- Naltrexone Depot issues found with the oral formulation and tion reduction. Naltrexone depot may The issue of compliance and adverse is much more conducive to the primary be superior to the other medications in effects with oral naltrexone helped push care setting, yet the depot is not immune regards to patients known to be non- the development of depot injection of to the adverse effects of pain at injec- compliant and motivated towards absti- naltrexone. This formulation offers the tion site, nausea, abdominal pain, and nence.66 Furthermore, caution should be advantage of preventing the patient from somnolence, and in more severe cases, used in considering these medications in discontinuing treatment, maintaining eosinophilic and interstitial pneumonia.67 the context of the patient’s other comor- constant plasma levels, and avoiding Both the oral and depot formulation inter- bidities, such as those with liver disease hepatic first pass metabolism which act with opioids and are contraindicated (i.e., disulfiram, naltrexone), renal disease decreases metabolites associated for patients on opioid analgesics and (i.e., acamprosate), or those in need of with severity and frequency of adverse with physiological opioid dependence. It opioid analgesia (i.e., naltrexone). events.64-66 Although three different is recommended that patients have an AUDs are a chronic medical condition, naltrexone depot formulations have opioid abstinent period of 7-10 days prior akin to hypertension or depression, and been investigated to date, only Vivitrol, to naltrexone initiation.36 Furthermore, the can be difficult to manage. As with any formerly Vivitrex (Alkermes Inc. and Ce- clinician must contend with management chronic medical disease, waxing and phalon, Inc.), has attained FDA approval issues when patients on depot formula- waning of treatment response should be as of April 2006. Vivitrol is indicated for tion experience acute pain and require expected. Without a “home run” treat- alcohol dependent patients who are able opioid analgesics. Another drawback to ment of AUDs, the clinician should be to abstain from alcohol in an outpatient the depot formulation is the significantly prepared for non-response to intensify setting prior to treatment initiation.36 higher cost compared to oral formulation. or change treatment accordingly, and Although the number of published to be willing to consider switching to Summary and Recommendations Vivitrol trials is lacking, results from another agent or referral to an addiction This review provides a brief overview recent studies have been promising. specialist or a treatment program. As of pharmacotherapy for hazardous In a study conducted by Garbutt et al, non-pharmacotherapy and pharmaco- drinkers that can be used in the primary alcohol dependent patients randomized therapy is implemented, the clinician care setting. Research has shown that to the high dose Vivitrol (380 mg) had a should be aware of the medical, social, disulfiram, naltrexone (oral and depot significantly greater reduction in heavy and environmental consequences of injection forms), and acamprosate are drinking compared with placebo. Fur- alcohol consumption and attend to them effective for treating patients with alcohol thermore, a subset of patients in the high as necessary to increase the potential of problems. Best evidence suggests that dose group who had a seven day lead in therapy success. non-pharmacotherapies should be used abstinent period prior to first dose had a with any pharmacologic treatment of greater reduction in heavy drinking and AUDs. Nonpharmacologic therapies were more likely to maintain abstinence such as behavioral therapy, motivational through the study. Of note, a gender References are available at enhancement therapy, and 12-step effect was observed demonstrating in- www.pamedsoc.org/counterdetails programs have been shown to be effec- creased efficacy of the drug among men or by calling (800) 228-7823, tive in enhancing alcohol consumption compared to women.67 extension 7806. reduction.69 Whitlock et al has reviewed 14 Resources for SBIRT

1) http://www.jointogether.org/resources/pdf/Screening-and- this page, for health care professionals doing SBI. Brief-Intervention-Bibliography.pdf http://www.ireta.org/sbirt/clinical_tools.htm extensive bibliography on SBI (Publication 2006) • Project Mainstream Syllabus 2) http://www.jointogether.org/keyissues/sbi/ Includes modules on Screening and Assessment, Brief screening-and-brief.htm Intervention, and Motivational Interviewing; improving extensive listing of SBI curriculum including: substance abuse education for health professionals http://www.projectmainstream.net/ • Boston University—Alcohol Screening and projectmainstream.asp?cid=23 Brief Intervention Curriculum This web-based tool can be used to teach skills • Treatment Research Institute—Multimedia for addressing alcohol problems (e.g. screening, Workshop on Brief Intervention for Substance assessment, brief intervention, and referral) in primary Abusing Adolescents care settings, with an emphasis on cross-cultural This program is a computer-delivered adaptation of efficacy. It includes a power point slide presentation, the Brief Intervention (“BI”) workshop that TRI Senior trainer notes, and three case-based videos Scientist Ken C. Winters, PhD, developed based on demonstrating skills for addressing alcohol problems in research with mild drug-abusing adolescents and primary care settings. their parents. (The entire CD, including the workshop, http://www.bu.edu/act/mdalcoholtraining/index.html manual, suggested scripts, worksheets, and a brief summary of drugs commonly abused by teenagers, is • Boston University—Emergency Department available for $100 from TRI.) Alcohol Education Project: Screening, Brief http://www.tresearch.org/resources/resources.htm Intervention, Referral and Treatment This web site has been funded in part by the NIH, • Western CAPT—Brief Alcohol Screening and National Institute for Alcohol Abuse and Alcoholism Intervention of College Students: and supported by ENA, ACEP and SAEM. The goal of A Harm Reduction Approach (BASICS) this web site is to promote the adoption of screening, This preventive intervention for college students brief intervention and referral to treatment (SBIRT) 18 to 24 years old aims at those who drink alcohol among emergency department (ED) providers. heavily and whose behaviors put them at risk for http://www.ed.bmc.org/sbirt/index.htm further problems. (A BASICS Therapist Manual can be ordered for $28 from Guilford Press. Other costs • Clinical Tools, Inc—Alcohol CME Curriculum include training, therapist manual, and the staff time to Includes courses on SBI for adolescents, and adults, identify and recruit appropriate students and to deliver motivational interviewing, case study. Some are the intervention.) http://casat.unr.edu/bestpractices/ from live presentations Carolinas Conference on view.php?program=132 Addiction and Recovery in Chapel Hill, North Carolina. Credits are offered for AACME, NBCC, NYS OASAS, • World Health Organization, Department of CAADAC, and NASW. Mental Health & Substance Dependence. http://www1.alcoholcme.com/ AUDIT—Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care • NIAAA—The College Drinking Prevention This manual, written primarily for health care Curriculum for Health Care Providers professionals, describes how to use the AUDIT to This NIAAA web-based curriculum is aimed at identify those with harmful alcohol consumption campus based health clinics and other health care patterns. Those in other professions who encounter professionals. The curriculum covers screening, alcohol-related problems may find this manual helpful brief interventions, and motivational interviewing as well. http://whqlibdoc.who.int/hq/2001/ along with a workbook, role play scenarios and an WHO_MSD_MSB_01.6a.pdf attitude exercise. It can be downloaded as a PDF document. http://www.collegedrinkingprevention.gov/ • World Health Organization, Department of NIAAACollegeMaterials/trainingmanual/contents.aspx Mental Health & Substance Dependence— Brief Intervention: For Hazardous and Harmful • NIAAA. Social Work Curriculum on Alcohol Drinking: A Manual for Use in Primary Care Use Disorders This manual describes how to conduct brief This curriculum includes chapters on screening and interventions for those with alcohol use disorders and motivational interviewing for social work professionals. those at risk for developing them. While designed http://pubs.niaaa.nih.gov/publications/Social/main.html primarily for health care professionals, this manual • Pennsylvania Screening, Brief Intervention, can also be used by others working with people with Referral and Treatment (SBIRT) alcohol related problems. http://whqlibdoc.who.int/ Pennsylvania’s Screening, Brief Intervention, Referral hq/2001/WHO_MSC_MSB_01.6b.pdf and Treatment (SBIRT) web site provides a variety of clinical tools, including some of the curricula noted on continued on page 15 15

Resources for SBIRT issues; collaborating with international, national, state, and local institutions, organizations, agencies, and continued from page 14 programs engaged in alcohol-related work; translating and disseminating research findings to health care providers, 3) PA SBIRT BDAP Sponsored Web site: Contains researchers, policymakers, and the public the monthly PA SBIRT newsletters and brochures that physicians can utilize with their patients. 13) NIAAA's College Drinking—Changing the Culture: http://www.dsf.health.state.pa.us/health/cwp/view. http://www.collegedrinkingprevention.gov/ asp?A=173&Q=246606 resource for comprehensive research-based information on issues related to alcohol abuse and binge drinking among 4) Alcohol Medical Scholars Program: college students. http://www.alcoholmedicalscholars.org/ promotes optimal education in medical schools regarding 14) NIAAA's Health Practitioner's Guide to Helping the identification and care of people with alcohol use Patients with Alcohol Problems: disorders and other substance-related problems. http://www.pubs.niaaa.nih.gov/publications/Practitioner/ CliniciansGuide2005/guide.pdf 5) Alcoholscreening.org: written for health care and mental health practitioners to help http://www.alcoholscreening.org/ increase knowledge, comfort and skill in dealing with issues self screening test for alcohol use; provides score and around appropriate and inappropriate use of substances recommendations and link for treatment locator and includes screening and intervention guidelines 6) American Society of Addiction Medicine: 15) National Institute on Drug Abuse: http://www.asam.org/ http://www.nida.nih.gov/ increase access to and improve quality of addiction for researchers & clinicians to exchange information & treatment ; educate physicians, other health care providers collaborate on research and the public; support research and prevention; promote the appropriate role of physicians in the treatment of addiction; 16) Office of National Drug Control Policy and establish addiction medicine as a primary specialty http://www.whitehousedrugpolicy.gov/ The principal purpose of ONDCP is to establish policies, 7) Association for Medical Education and Research in priorities, and objectives for the Nation's drug control Substance Abuse: program. The goals of the program are to reduce illicit drug http://www.amersa.org/ use, manufacturing, and trafficking, drug-related crime improving education in the care of individuals with and violence, and drug-related health consequences. To substance abuse problems achieve these goals, the Director of ONDCP is charged 8) Center for Alcohol and Addictions Studies with producing the National Drug Control Strategy. (Brown University): The Strategy directs the Nation's anti-drug efforts and http://www.caas.brown.edu/ establishes a program, a budget, and guidelines for promote the identification, prevention, and effective treatment cooperation among Federal, State, and local entities. of alcohol and other drug use problems in our society through 17) Physician Leadership on National Drug Policy research, education, training, and policy advocacy http://www.plndp.org/ 9) Ensuring Solutions to Alcohol Problems: Physicians and Lawyers for National Drug Policy (PLNDP) http://www.ensuringsolutions.org/ is a non-partisan group of the nation's leading physicians teach the difference between safe and risky drinking, and attorneys, whose goal is to promote and support screen for alcohol problems, cover treatment through public policy and treatment options that are scientifically- health insurance, and supports treatment and recovery based, evidence-driven, and cost-effective. 10) Join Together: 18) Project Cork: http://www.jointogether.org/ http://www.projectcork.org/ advancing effective alcohol and drug policy, prevention and assemble and disseminate current, authoritative information treatment on substance abuse for clinicians, health care providers, human service personnel, and policy makers. Project 11) Leadership to Keep Children Alcohol Free: Cork produces a bibliographic database, offers current http://www.alcoholfreechildren.org/ awareness services, produces resource materials, responds prevent the use of alcohol by children ages 9 to 15. to queries, and collaborates in professional education efforts. The CORK database of more than 75,000 holdings 12) National Institute on Alcohol Abuse and Alcoholism is searchable online. (Dartmouth University) (NIAAA): http://www.niaaa.nih.gov/ 19) Project Mainstream: leadership in the national effort to reduce alcohol-related http://www.projectmainstream.net/ problems by conducting and supporting research in modules addressing skills that generalist care professionals a wide range of scientific areas including genetics, could perform in their settings: screening, brief intervention, neuroscience, epidemiology, health risks and benefits and referral to treatment; identifying and assisting children of alcohol consumption, prevention, and treatment; of parents with substance use disorders; and helping coordinating and collaborating with other research communities implement effective prevention programs. institutes and Federal Programs on alcohol-related The material, developed for Project MAINSTREAM, is continued on page 16 16

Resources for SBIRT 28) http://www.csam-asam.org/pdf/misc/FlemingArticle.pdf easy review included on the five essential steps of BI continued from page 15 29) http://www.csam-asam.org/pdf/misc/FlemingArticle.pdf presented in a teacher-friendly format that you are free to an SBIRT document on BI adapt, but please cite the source. There are also links to 30) http://www.ed.bmc.org/sbirt/slides/rationale. other useful materials. pps#328,10,Trauma%20Center%20Results 20) PubMed: has a piece on the efficacy of motivational interviewing— http://www.ncbi.nlm.nih.gov/sites/entrez/ power point presentation service of the U.S. National Library of Medicine that 31) http://www.aafp.org/online/etc/medialib/aafp_org/ includes over 17 million citations from MEDLINE and other documents/clinical/pub_health/alcoholscreening/step3. life science journals for biomedical articles back to the Par.0001.File.tmp/publichealth_alcoholkitstep3.pdf 1950s. PubMed includes links to full text articles and other review of the steps of BI related resources. 32) http://www.health.nsw.gov.au/sd/igfs/hp/ccc/team_ 21) Substance Abuse and Mental Health Services resources/draftbrief_interven_4substnce_use.pdf Administration (SAMHSA): manual from WHO—stages of change, MI, FRAMES http://www.samhsa.gov/ included in good style The Substance Abuse and Mental Health Services Administration (SAMHSA) has established a clear vision for 33) http://www.dva.gov.au/health/younger/mhealth/alcohol/ its work—a life in the community for everyone. To realize training/session6.htm this vision, the Agency has sharply focused its mission on excellent overview that includes FRAMES and another building resilience and facilitating recovery for people with called FLAGS or at risk for mental or substance use disorders. SAMHSA is gearing all of its resources—programs, policies and 34) http://www.mayatech.com/sbirt/tools-resources/ grants—toward that outcome. references.htm extensive list of references and resources regarding SBIRT 22) SAMHSA's National Clearinghouse for Alcohol and compiled by Mayatech Drug Information/Prevline: http://ncadi.samhsa.gov/ 35) http://www.aadac.com/documents/review_of_ clearinghouse for publications related to all aspects of assessments.pdf drug and alcohol issues; documents can be ordered and summary report of two review articles compiled for the shipped from this web site Alberta Alcohol and Drug Abuse Commission in 2002 and 2003. A Review of Addictions-Related Screening and 23) www.niaaa.nih.gov/publications/social/maintext.html Assessment Instruments: Measuring the Measurements. or at www.cabhr.uwm.edu NIAAA Social Work Curriculum: Murray P, Begun. Alcohol 36) http://www.ed.bmc.org/sbirt/NASD-d-zin.cfm and Other Drug Abuse Training: Essentials for All Health site for newsletter Professionals, April, 2005. 37) http://lib.adai.washington.edu/ 24) http://motivationalinterview.org/clinical/index.html screening instruments Curriculum and CME programs 38) http://www.ensuringsolutions.org/about/ 25) http://www.utexas.edu/research/cswr/nida/workshops/ cpt and hcpcs codes D%27Onofrio.ppt#330,1,Screening, 39) http://www.mayatech.com/sbirt/tools_resources/online.htm Brief Intervention and Referral to Treatment— excellent resource powerpoint from a presentation 40) http://gunston.gmu.edu/730/SBIRT/default.asp 26) http://www.utexas.edu/research/cswr/gcattc/First%20 cost effectiveness analysis Friday%20SBIRT.ppt#273,1,Screening, Brief Intervention, Referral to Treatment in a Medical 41) http://hsc.unm.edu/telemedicine/Program/Newsletters/ Setting—power point from a presentation newsletter0505/newsletter_SBIRT.htmnew Mexico telehealth 27) http://ncadi.samhsa.gov/govpubs/BKD341/34d.aspx complete text of one of the SAMSHA TIPS on brief intervention and brief therapy - excellent resource 17 Pennsylvania County Drug and Alcohol Programs

Allegheny County MH/MR Cambria County MH/MR Crawford County D&A Drug and Alcohol Program Drug and Alcohol Program Executive Commission, Inc. Mr. James Allen, SCA Administrator Mr. James Bracken, SCA Administrator Ms. Deborah J. Duffy Wood Street Commons Central Park Complex Executive Director 304 Wood Street 110 Franklin Street, Ste. 200 920 Water Street, Downtown Mall Pittsburgh, PA 15222-1900 Johnstown, PA 15901 Meadville, PA 16335 (412) 350-6956 (814) 536-5388 (814) 724-4100 Armstrong-Indiana Cameron Elk McKean Counties Cumberland Perry Drug and Alcohol Commission Inc Alcohol and Drug Abuse Services Inc Drug and Alcohol Commission Ms. Kami Anderson, Executive Director Mr. Andrew Lehman Mr. Jack Carroll, SCA Administrator 10829 US Route 422, PO Box 238 SCA Executive Director Human Services Building Shelocta, PA 15774 120 Chestnut Street 16 West High Street, Ste. 302 (724) 354-2746 Port Allegany, PA 16743 Carlisle, PA 17013 Beaver County MH/MR (814) 642-9541 (717) 240-6300 Drug and Alcohol Program Carbon Monroe Pike Dauphin County Ms. Kate Lichius, SCA Administrator Drug and Alcohol Commission Drug and Alcohol Services (DCDAS) 1050 8th Avenue Mr. Richard Mroczka M.S. Ms. Mavis Nimoh, SCA Administrator Beaver Falls, PA 15010 Executive Director 1100 South Cameron Street (724) 847-6225 Penn Square, Ste. A, 724 Phillips Street Harrisburg, PA 17104-2531 Berks County Council Stroudsburg, PA 18360 (717) 635-2254 on Chemical Abuse (570) 421-3669 Delaware County Office Mr. George Vogel Jr., Executive Director Centre County Office MH/MR of Behavioral Health 601 Penn Street, Ste. 600 Drug and Alcohol Mr. Ed Sulek, SCA Administrator Reading, PA 19601 Ms. Catherine Arbogast 20 South 69th Street, 3rd floor (610) 376-8669 SCA Administrator Upper Darby, PA 19082 Blair County MH/MR/D&A Program Willowbank Building, 420 Holmes Street (610) 713-2365 Ms. Judith A. Rosser Bellefonte, PA 16823 Erie County Office of Drug & Alcohol Program Administrator (814) 355-6744 Drug and Alcohol Abuse Blair County Courthouse Chester County Mr. Richard Seus, Executive Director 4th Floor, Ste. 441 Department of D&A Services 155 West 8th Street, Ste. 401 423 Allegheny Street Ms. Kim Bowman, Executive Director Erie, PA 16501 Hollidaysburg, PA 16648-2022 Government Services Center, Ste. 325 (814) 451-6877 (814) 693-3023 601 Westtown Road, PO Box 2747 Fayette County Bradford/Sullivan West Chester, PA 19380 Drug and Alcohol Commission Inc Drug and Alcohol Programs (610) 344-6620 Ms. Deanna Sherbondy Mr. Phil Cusano, SCA Director Clarion County SCA Executive Director 220 Main Street, Unit 1 Drug and Alcohol Administration 100 New Salem Road, Ste. 106 Towanda, PA 18848 Mrs. Nicole Salvo, SCA Administrator Fayette County Health Center Building (570) 265-1760 214 South Seventh Avenue Uniontown, PA 15401 Bucks County Clarion, PA 16214 (724) 438-3577 Drug and Alcohol Commission, Inc. (814) 226-5888 Forest Warren Cos Department of Ms. Margaret E. Hanna Clearfield Jefferson Human Services Drug and Alcohol Executive Director Drug and Alcohol Commission Program 600 Louis Drive, Ste. 102A Ms. Mary Lash, Executive Director Ms. Betsy Miller, SCA Director Warminster, PA 18974 PO Box 647, 104 Main Street 27 Hospital Drive (215) 773-9313 Falls Creek, PA 15840 North Warren, PA 16365 Butler County MH/MR Drug and Alcohol (814) 371-9002 (814) 726-2100 Donna Jenereski Columbia Montour Snyder Union Franklin Fulton County MH/MR Acting Drug & Alcohol Administrator Ms. Barbara Gorrell, Administrator D&A Program 124 West Diamond Street Terrace Building State Hospital Ms. Jodi Wadel, SCA Administrator PO Box 1208 PO Box 219 425 Franklin Farm Lane Butler, PA 16003-1208 Danville, PA 17815 Chambersburg, PA 17201-3064 (724) 284-5114 (570) 275-5422 (717) 263-1256

continued on page 18 18

Resources for SBIRT Lycoming Clinton West Branch Schuykill County Drug and Alcohol Drug and Alcohol Abuse Commission Ms. Susan Farnsworth, Administrator continued from page 17 Ms. Shea Madden, Executive Director 108 South Claude A Lord Blvd., 2nd Fl 213 West Fourth Street Pottsville, PA 17901 Greene County Human Services Williamsport, PA 17701 (570) 621-2890 Program (570) 323-8543 Ms. Cheryl Andrews, SCA Administrator Somerset County Fort Jackson Building, 3rd Floor Mercer County Drug and Alcohol Commission Mr. Robert King, SCA Director 19 South Washington Street Behavioral Health Commission Inc. Ms. Kim Anglin, SCA Administrator 300 North Center Avenue, Ste. 360 Waynesburg, PA 15370 8406 Sharon Mercer Road Somerset, PA 15501 (724) 852-5276 Mercer, PA 16137 (814) 445-1530 Juniata Valley Tri-County (724) 662-1550 Susquehanna County Drug and Alcohol Abuse Commission Mr. S. Raymond Dodson Montgomery County MH/MR Drug and Alcohol Commission Ms. Robin Kaminski-Waldowski SCA Administrator, 68 Chestnut Street D&A Programs Ms. Barbara A. Dery SCA Administrator Lewistown, PA 17044 Drug and Alcohol Administrator Seven Lake Avenue, 2nd Floor (717) 242-1446 Montgomery County PO Box 347 Lackawanna County Human Services Center Montrose, PA 18801 Commission on D&A Abuse 1430 Dekalb Pike, PO Box 311 (570) 278-1000 Ms. Ann Marie Santarsiero Norristown, PA 19404 Tioga County Executive Director (610) 278-3642 135 Jefferson Avenue, 2nd Floor Department of Human Services Mr. Samuel Greene III, SCA Director Scranton, PA 18503 Northampton County MH/MR 1873 Shumway Hill Road (570) 963-6820 D&A Division Ms. Mary Carr, Executive Director Wellsboro, PA 16901 Lancaster County Martin J. Bechtel Building (570) 724-5766 Drug and Alcohol Commission 520 East Broad Street Venango County Mr. Richard A. Kastner Bethlehem, PA 18018 Executive Director Substance Abuse Program (610) 997-5800 Ms. Bonnie Summers, SCA Administrator 150 North Queen Street, Ste. 402 City Plaza Building Lancaster, PA 17603 Northumberland County 21 Seneca Street, Ste. 201 (717) 299-8023 Drug and Alcohol Program Mr. George Florey, MH/MR Administrator Oil City, PA 16301 Lawrence County Northumberland Co. Drug & Alcohol (814) 678-6580 Drug and Alcohol Commission Inc Human Senior & Social Services Building Ms. Judy Thompson, Executive Director Washington D&A Commission, Inc. 217 North Center Street Mrs. Donna Murphy, Executive Director First Merit Plaza, Ste. 303 Sunbury, PA 17801 90 West Chestnut Street, Ste. 310 T 25 North Mill Street (570) 495-2154 Washington, PA 15301 New Castle, PA 16101 (724) 223-1181 (724) 658-5580 Office of Addiction Services Mr. Marvin Levine,Deputy Director Wayne County Lebanon County Commission Office of Addiction Services Drug and Alcohol Commission on Drug and Alcohol Abuse 1101 Market Street, 8th Floor Ms. Bonnie Tolerico, Executive Director Ms. Susan F. Klarsch, Executive Director Philadelphia, PA 19107 318 10th Street 220 East Lehman Street (215) 685-5404 Honesdale, PA 18431 Lebanon, PA 17046 (570) 253-6022 (717) 274-0427 PA Association of County Drug and Alcohol Administrators (PACDAA) Westmoreland Lehigh County Drug & Alcohol Services Ms. Michele Denk, Executive Director Ms. Darbe George, D&A Administrator Drug and Alcohol Commission, Inc. 17 North Front Street Ms. Colleen Hughes, Executive Director Government Center Harrisburg, PA 17101 Mon Valley Community Health Center 17 South Seventh Street (717) 232-7554 Eastgate 8 Allentown, PA 18101 Monessen, PA 15062 (610) 782-3556 Personal Solutions Inc (Bedford) Ms. Dawn Housel, Executive Director (724) 684-9000 Luzerne Wyoming Counties 145 Clark Building, Ste. 5 York Adams Drug and Alcohol Program Drug and Alcohol Program Bedford, PA 15522 Mr. Steve Warren, Mr. Michael D. Donahue, Administrator (814) 623-5217 County MH-MR/D&A Administrator Penn Place Building 3410-B East Market Street 20 N. Pennsylvania Ave., Ste. 218 Potter County Drug and Alcohol Ms. Colleen Wilber, SCA Director York, PA 17402 Wilkes-Barre, PA 18701-3509 62 North Street (717) 840-4207 (570) 826-8790 Roulette, PA 16746-0241 Robin Rothermel (814) 544-7315 Director of Treatment and Acting Director Bureau of Drug and Alcohol Programs Pennsylvania Department of Health (717) 783-8200 [email protected] 19 Identification of Alcohol Use Disorders in the Primary Care Setting

The Pennsylvania Medical Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Pennsylvania Medical Society designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)™. Physician should only claim credit commensurate with the extent of their participation in the educational activity. Faculty and all others who have the ability to control the content of continuing medical education activities sponsored by the Pennsylvania Medical Society are expected to disclose to the audience whether they do or do not have any real or apparent conflict(s) of interest or others relationships related to the content of their presentation(s). The Pennsylvania Osteopathic Medical Association, an American Osteopathic Association accredited sponsor for continuing medical education has designated this activity for 3 credit hours in Category 2B. To receive credit for the exam, a grade of 70 percent must be achieved. Upon completion, unless completed online, the exam should be faxed (717)-558-7848 or mailed no later than December 31, 2010, to: The Pennsylvania Medical Society, 777 East Park Drive, P.O. Box 8820, Harrisburg, PA 17105-8820

Name______Signature______Address______Circle the correct answer(s). 1. Alcohol is the third most prevalent cause of death in the 6. It is important for alcohol dependent individuals to receive a United States with an estimated economic cost in excess of higher level of care for their alcohol use, especially if it interferes $184 billion a year. with or endangers his/her or another individual’s well-being. a. True a. True b. False b. False

2. Which of the following is/are the role(s) of the physician? 7. Non-pharmacologic treatments are the mainstay of treatment a. Support a patient’s low-risk consumption for hazardous drinking, however pharmacologic treatments b. Provide education and guidance regarding patient’s have been developed to serve as an adjunct to reduce alcohol high-risk consumption consumption and/or establish abstinence. c. Provide referral services for alcohol dependence a. True d. All of the above b. False

3. Since one of the overall goals of SBIRT is to improve the 8. In the primary care setting, what per cent of outpatients drink identification of substance misuse in the non-dependent, at-risk alcohol at hazardous levels? use, which of the following has the advantage of providing more a. 5 percent comprehensive information to both physicians and patients? b. 10 percent a. AUDIT c. 15 percent b. CAGE d. 20 percent c. CRAFFT e. 35 percent d. MAST e. TWEAK 9. Use of pharmacologic therapy treatment is limited in primary care settings because there is lack of awareness that effective therapy 4. What are the three essential components of a Brief Intervention? exists. a. Provide feedback a. True b. Engage patient feedback b. False c. Negotiate/advise a plan for behavioral change d. A and C 10. What non-pharmacologic therapies work best with the use of e. All of the above pharmacotherapy to enhance alcohol consumption reduction? a. 12-Step Program 5. Which of the following are not examples of Brief Intervention b. Motivational Enhancement Therapy Questions? c. Behavior Therapy a. Help me understand what you enjoy about drinking. d. Physical Therapy b. Do you think your medical condition/behavior may be e. A, B, C directly related to your drinking? f. All of the above c. Have you ever thought about your drinking and how it might affect your life? d. How ready are you to change any aspect of your drinking on a scale of 1 to 10? e. A, C, D f. All of the Above PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA PERMIT NO. 922

777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 (800) 228-7823 • (717) 558-7750 fax: (717) 558-7848 e-mail: [email protected]

Patient Safety CME

This issue has been developed in partnership with the Pennsylvania Department of Health, Bureau of Drug and Alcohol Programs, The Screening, Intervention, Brief Treatment and Referral to Treatment Project and supported by the Federal Center for Substance Abuse and Treatment. Evaluation: Identification of Alcohol Use Disorders in the Primary Care Setting Identification of Alcohol Use Disorders in the Primary Care Setting—The following evaluation will guide the development of future programs for Pennsylvania clinicians. Please take a few moments to reply and fax your response to (717) 558-7848.

1. Using a rating of 1-5, with 5 meaning very satisfied and 1 not 3. What one thing that you learned about treatment of alcohol use satisfied at all, please identify whether the monograph met the disorders do you plan to implement in your practice?______following objectives to enhance the primary care clinicians ability to: ______

Very Not Satisfied 4. Do you expect to implement the SBIRT Program into your practice? Satisfied at All  Yes  No Use effective communication skills to help patients understand the risks of 5 4 3 2 1 5. What topics would you like to learn about in the future? hazardous drug and alcohol use. ______Integrate effective motivation building 5 4 3 2 1 ______techniques to the patients at risk Identify emerging medications to 6. Overall, the information in this issue was: 5 4 3 2 1 treat alcohol use disorders  Very helpful  Not very helpful Identify key resources available  Helpful  Not helpful of all 5 4 3 2 1 to the patient needing assistance  Somewhat helpful

7. Please indicate your professional license type by checking the 2. Was the information provided in an unbiased, credible manner? appropriate box.  Yes  No  MD  DO  PA  CRNP  Other, specify______If no, why is it biased?______