TIPS & TOPICS
Volume 3, No.1
In this issue
– Until Next Time
In April 2003, the very first edition of TIPS and TOPICS “rolled off the presses”. It is hard to believe that this edition starts our third year. Thanks for reading all those months and if you are a new subscriber, welcome to what is becoming perhaps an “institution”.
The American Society of Addiction Medicine (ASAM) had its annual Medical Scientific meeting this month. I attended a symposium on the challenges of implementing screening for alcohol and substance abuse and brief intervention in primary care settings. There is increased interest in, and focus on integrating addiction and mental health services; as well as behavioral health into primary care settings.
Here is some interesting and relevant SAVVY I gleaned from that symposium.
- Remember the 4A’s for Alcohol Screening and Brief Intervention
Step 1: Ask about alcohol use – brief screening questions
Step 2: Assess – brief assessment to determine the severity of the problems and the appropriate action
Step 3: Advise and Assist – brief intervention to advise to cut down or abstain; and to set goals
Step 4: Arrange follow-up – monitor the patient’s progress
I had not heard about the National Institute on Alcohol Abuse and Alcoholism (NIAAA) “one question” approach to screening: What is the maximum number of drinks you had on any given day in the past month?
For men – more than 4 drinks on any one day- and for women – more than 3- means that the client may be at risk for developing alcohol-related problems. If below those cutoffs, screening can stop here unless the person is:
–>Pregnant or trying to conceive (they need advice to abstain) or
–>Over age 65, frail, or taking medications that interact with alcohol. (They may experience problems at lower drinking levels, thus may need advice to cut down, as described in Step 3)
–>Other drinkers below the cutoffs may benefit from reminders that no drinking level is risk free, and any drinking can impair driving tasks.
Nearly one third of U.S. adults engage in risky drinking patterns, and thus need advice to cut down, or a referral for further evaluation. 12% of U.S. adults aged 18 years or older never have more than 4 (men) or 3 (women) drinks on any one day; and have less than 1 in 100 chance of having an alcohol use disorder. But even occasionally (less than once a week) men having 5 or more drinks, or women 4 or more drinks in any one day increases the chance of an alcohol disorder to 1 in 14 – that’s a 79% chance versus just 1%.
There are other approaches to screening and many screening instruments. But the bottom line is that you can gain important information to intervene and give brief advice even from just one question. That is a good start to screening for healthcare and mental health professionals.
Reference and Resource:
For Written Request:
Orders for Helping Patients With Alcohol Problems: A Health Practitioner’s Guide and the Pocket Guide can be placed by writing to NIAAA:
National Institute on Alcohol Abuse and Alcoholism
Publications Distribution Center
P.O. Box 10686
Rockville, MD 20849-0686
- Brief interventions of 5 to 15 minutes can be effective. Peer interventions can make it even more effective.
Dr Richard Blondell of the Department of Family Medicine in Buffalo, New York reminded us of what you have probably observed also.
–> It is hard to get healthcare professionals to ask even one screening question, and to do a brief intervention no matter how effective it has been shown to be.
–> Most professionals are inadequately prepared and require significant training to implement SBI.
–> It is expensive to have a consultation team, and often difficult to make a referral to addiction treatment even if the patient in a hospital is willing to pursue treatment.
Dr. Blondell’s study
He told the audience of a study conducted in Louisville, Kentucky.
The question was asked: Can recovering alcoholics help hospitalized patients with alcohol problems?
The researchers evaluated the relative effectiveness of two approaches for patients with alcohol problems.
Three groups of patients were compared. One group had no brief intervention and got usual hospital care. This was the control group. The second group had a 5- to 15-minute physician-delivered message (brief intervention); and the third study group got the physician message plus a 30- to 60-minute visit by a recovering alcoholic (peer intervention). Telephone follow-up obtained up to 12 months after hospital discharge focused on patient behaviors during the first 6 months following discharge.
A “Hospital Angel Program” was developed where volunteer peers in recovery visited with hospitalized patients. This was an alternative to an expensive, labor-intensive addiction consultation service. The study included 314 patients with alcohol-related injuries admitted to an urban teaching hospital. Researchers measured complete abstinence from alcohol during the entire 6 months following hospital discharge, abstinence from alcohol during the sixth month following hospital discharge, and initiation of alcohol treatment or self-help within 6 months of hospital discharge.
Results of the Study:
Valid responses were obtained from 140 patients (45%). Observed success rates were: 34%, 44%, and 59% (P=.012) for abstinence from alcohol since discharge in the usual care group, the brief intervention group, and the peer intervention group, respectively; 36%, 51%, and 64% (P=.006) for abstinence at the sixth month following hospital discharge; and 9%, 15%, and 49% (P <.001) for initiation of treatment/self-help. During the telephone follow-up interview, several patients in the “Hospital Angels” peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital. A few patients dramatically changed their lives. They went from being unemployed and homeless to full-time employment and having a permanent residence. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. One of these individuals serves as a volunteer, visiting hospitalized patients with drinking problems.
Harnessing the power of consumers and other people in recovery along with professional interventions can not only improve effectiveness, but use resources wisely.
Blondell RD, Looney SW, Northington AP, Lasch ME, Rhodes SB, McDaniels RL.: “Can recovering alcoholics help hospitalized patients with alcohol problems?” J Family Practice 2001 May;50(5):447.
To supplement the screening and brief interventions SAVVY above, consider these SKILLS:
- Ask “How much?” and “How often?” questions, rather than “Do you?” or “Have you?” questions
When screening for or assessing substance use disorders, clients may well be reluctant to be open about substance use for which they have endured nagging, arrests, family problems in a society that still stigmatizes addiction illness. In a monotone, routine, matter-of-fact, “I-ask-everyone-these- questions” manner, try asking:
–> “How much do you drink a day?” rather than “Do you drink alcohol?”
–> “How often in a week do you get into family fights over alcohol or other drugs?” rather than “Have you had any family arguments over drinking or drugging?”
–>”How many times have you lost jobs or gotten into legal problems with alcohol or other drugs?” rather than “Have you ever lost a job or been arrested over drinking or drugging?”
If you want a screening instrument that asks questions more in this kind of manner, take a look at the Alcohol Use Disorders Identification Test: Interview Version
Go to the World Health Organization website, and search on AUDIT. You will find this pdf.
- If the client seems particularly cautious, try putting down your pen and paper.
One of the speakers at the symposium suggested something I’d never thought of before. He wants to create as open an environment as possible to allow the client to be as honest as possible. So before he asks questions about substance use, he deliberately and purposively closes the chart, places it on the desk, puts away his pen, and turns to the patient with his back to the medical record or computer. Rather than asking substance use questions with pen poised over the assessment form, the clinician communicates the clear message: “I am not recording every word.” This helps the client feel safer to open up.
I can think of some problems with that, but it is a tip that he certainly finds clinically useful and you may too.
- Get used to listing quickly the various drug classes so you jog the client’s memory.
If you ask a client do they use drugs, they may be thinking only of illicit drugs. If you ask a client what is the longest time they have been sober, they may think that being on Percodan and Xanax doesn’t count. So it is good to get in the habit of asking:
–> “What drugs do you use? And I mean what uppers, downers, sleeping pills, pain pills, tranquilizers, alcohol, nicotine, over the counter drugs, other illegal drugs?”
–>”What is the longest time you have been totally drug-free? And I mean when you haven’t been doing uppers, downers, sleeping pills, pain pills, tranquilizers, alcohol, nicotine, over the counter drugs, other illegal drugs?”
Many clients have not had any significant time when they were totally drug-free. That can be helpful to know, especially if you are trying to assess the difference between a substance use disorder, a substance-induced disorder, or a co-occurring mental disorder.
It has been nearly nine years now that I have been doing training and consulting full-time. I am committed to what I do and enjoy it. But there is no perfect job, and the air travel part of this job sometimes messes up my “commute”. Today’s experience reminded me why I appreciate the Serenity Prayer so much.
All was going well. I got my free first class upgrade. Even though the security line was long, I arrived at the gate ready to board the plane in good time. Everything was on track for my connection in Denver, to then arrive at a civilized time in New Jersey. You can perhaps relate to what happened next: weather problems around Denver International Airport; diversion to Colorado Springs for refueling; Denver airport closed; late arrival; missed connection—–will I make it to Atlantic City to present the plenary session first thing the next day?
Just being late is no big deal, but to mess up a conference and hundreds of people would not be pretty. In my anxiety to get going, I could feel the stress and impatience rising fast – the pilot wasn’t giving enough timely information; the refueling was taking too long. Why can’t the weather change? Can we beat the approaching thunderstorm? Why aren’t there more flights to reassure me that I would get there in time?
God, grant me the serenity to accept the things I cannot change—
I can’t remember the last time I was able to change the weather; or the flight schedules; or the last time I got a person to give me information they don’t have.
Courage to change the things I can—
Like someone once said: “In my life I’ve had thousands of worries and one or two of them even came true”. It’s hard to change a worrywart. One call to the airline got me “protected” on a later flight. I would make it, even if I missed my connection.
The wisdom to know the difference—
Old Chinese proverb: The wise man learns from the mistakes of others. The foolish man learns from his own mistakes. Thanks to everyone who has made the mistake of forgetting the Serenity Prayer. I nearly made the same mistake again today.
Until Next Time
Again, welcome to Year 3 of TIPS and TOPICS. Please join me in May and the rest of the year.