Referral To Treatment for

Drug & Alcohol Part I

Geneva Sanford, MSW, LSW, LICDC

Substance Abuse Coordinator

Grant Medical Center

111 S. Grant Ave, 2nd FL.

Columbus, Ohio 43213

(614) 566-9863

gsanford@ohiohealth.com

May 15, 2013

Objectives

• To explore where patients commonly seek treatment interventions

• To present common barriers of why patients do not receive treatment services

• To examine how to identify patients who need a referral for further evaluation

and/or treatment

• To point out essential collaborative efforts between medical and treatment

providers within communities

• To identify ASAM treatment levels of care

• To examine treatment options for specific patient populations

2

SBIRT

• Screening

• Brief Intervention

• Referral

• Treatment

• Comprehensive,

integrated, public

health approach to the

identification of, and

early intervention for,

persons who are

misusing substances

• 5-15 minutes (plus)

3

Settings/Locations

• Hospitals (ER, Trauma

Centers, Medical floors,

CCU, ICU)

• Primary Care Physician

• Healthcare Clinics

• Specialty Providers (Neuro,

Ortho, Plastics, etc)

• Older Adult Providers

• Skilled Nursing Facilities

• Rehab Facilities

• Home Healthcare

• Dentist Office

• Schools

4

Current, Binge, and Heavy Alcohol Use among Persons Aged 12

or Older, by Age: 2010

5 NSDUH

Substance Dependence or Abuse in the Past Year among Persons

Aged 12 or Older: 2002-2011

6 NSDUH

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment

among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit

Drug or Alcohol Use: 2011

7 NSDUH

8

NASW Standards: Clients with Substance Use Disorder

Standard 3. Screening, Assessment and Placement

• Social workers shall screen clients for SUDs

• When appropriate, complete a comprehensive

assessment

• If needed, development of a service plan for

recommended placement into an appropriate txp

program.

9 NASW

SCREENING

10

Identification of Risk Factors

• Alcohol & Drug Labs

• Clinical indications

(biomarkers)

• ER documentation

• H&P documentation

• Consultation Note

• Nursing Triage/Admission

Assessment

• Quick Screen

• OARRS Report

• Purpose for referral

• Family/Friend concerns

11

What does toxicology testing not tell us?

• Patterns of use

– Use, abuse, physical

dependence, addiction,

– legitimate prescribed

medications

– Heroin falls under opiate

category

• Use of substances not

tested

– Alcohol, tobacco, newer

illicit drugs

12

13 homedrugtestingkit.com

14 McLellan & Dembo, 1992, Tarter, Ott &

Mezzich, 1991

Screening Basics

• Screening ≠ Assessment/Diagnosis

• Opportunity to prevent, identify and intervene

• Screening assessment/diagnosis if criteria is

indicated/met

• To provide more intensive services where specifically needed

15

DSM IV-TR Substance Use Disorders

• Substance Intoxication

• Substance Withdrawal

• Substance Abuse

• Substance Dependence

16 5/17/2013 DSM IV-TR

Screening Tools

17

Substance Use Screening Tools

Tool Format Administer/Time Training

ASSIST 1 item for lifetime use, 6

items for each of 10

substances used, and 1

item on injection use

Depends on number of

substances used

Yes

AUDIT-C 3-item screening

questionnaire

Less than 1 minute to

administer and score

Yes

AUDIT 10-item screening

questionnaire

2 minutes to administer/

1 minute to score

Yes

CAGE (alcohol) 4 yes/no questions

Less than 1 minute/ not

scored

No

CAGE-AID

(drugs)

4 yes/no questions Less than 1 minute/ not

scored

No

DAST 20 yes/no questions

about current and past

use

1-2 minutes to

administer / not scored

No

MAST 24 yes/no questions

10 minutes to

administer/ 5 minutes to

score

No

18

CRAFFT

CRAFFT Scoring:

Each “yes” response in

Part B scores 1 point.

A total score of 2 or

higher is a positive

screen, indicating a

need for additional

assessment.

19 JAMA

20

Case example: Melanie

• 17 yo, single white female, level II trauma, MVC (multiple car rollover), broken leg, head trauma, BAC = .157, 18 yo friend died at the scene, parent unsure what to do, family history of alcohol and drug addiction in the family (mother, father, grandparents):

– CRAFFT = 4/6

– Drinks on weekends, 6 pack or more on each occasion, sometimes 2 to 3 shots

– Injury directly related to alcohol consumption, friend was driving

– Family history of addiction, mother in recovery

– Prior legal charge @ 16 yo (underage consumption)

– “I do not have a problem, get me out of here so I can go to my boyfriend’s funeral”

– Results: • Validated desire to attend funeral, expressed concern of use in relation to

prescription medications needed for current injury

• Supported father who has been in recovery for over 10 years (Al-Anon)

• Helped father access insurance provider to initiate referral for evaluation

GMC

AUDIT

SCORE: ZONE I 0-7

(Education)

ZONE II 8-15

(Advice)

ZONE III 16-19

(Counseling)

ZONE IV 20 -40

(Referral for evaluation)

21 NIAAA

“I don’t drink everyday”

• A 31 yo single white male, level II trauma, ATV accident, head

trauma, multiple facial fractures, pt. appears intoxicated

– AUDIT = 19

– Drinks 3 times weekly, 8 or more beers on each occasion

– Patient acknowledges that injury is related to his alcohol use

– Parents, particularly mother, has voiced great concern of his

drinking

– Results:

• Pt willing to seek further evaluation

• Pt had insurance, instructed him on how to access his insurance for

substance abuse services

22 GMC

“It was my birthday”

• 70 yo divorced white male, level ll trauma, fall (lost balance on sidewalk), head injury, facial abrasions, pt reports that he went to the bar to celebrate his 70 birthday, BAC = .27, adult children are very concerned about incident, pt resides alone:

• AUDIT = 21

• Drinks twice monthly(?), consuming 6 to 8 mixed drinks on each occasion

• Reports past history of excessive drinking, cut down due to medical problems

• Past legal charges (3 OVI)

• Medical problems – HBP, COPD, Arthritis, taking meds as prescribed

• Results: – Monitor for alcohol withdrawal (CIWA)

– Resistant to referral for further evaluation BUT willing to further discuss alcohol use with his primary care physician due to medical hx and medications

23 GMC

24

January 2012 SBIRT Results

24 GMC

Past Year Initiates of Specific Illicit Drugs among

Persons Aged 12 or Older: 2011

25 NSDUH

January 2012 SBIRT Results

26 GMC

“I am in PAIN”

• 20 yo, single female, level II trauma, MVC passenger, boyfriend driving under

the influence, pelvic fracture

– AUDIT = 3, rarely drinks

– History of abusing prescription medications

– Completed inpatient treatment program in Florida within the year, did not

complete aftercare

– Now resides in OH

– Mental health diagnosis (Bi-polar, OCD), has not been on medications for a

month

– Major tension and conflict with mother

– I do not need anymore txp, get me out of here!!

– Results:

• Pain Management Consult due to opioid tolerance and withdrawal (COWS)

• provided support to patient during her hospital stay, addressed hx of abusing

prescriptions medications due to current injury and course of txp, identified

potential txp providers, medication monitoring/management post d/c

• Supported mother while maintaining pt confidence (Al-Anon)

27 GMC

Brief Intervention

Treatment Improvement Protocol – 34 (SAMHSA)

Hazelden Publications

28

Brief Intervention Model

(FRAMES)

• Feedback

• Responsibility of Patient

• Advice to Change

• Menu of Strategies

• Empathetic Counseling Style (Motivational Interviewing)

• Self-Efficacy (Optimism of Patient)

29 Treatment Improvement Protocol-

34, SAMHSA

FRAMES

Component Explanation

Feedback reason for testing, lab/screening results,

recommendations, explore pts response to

findings

Responsibility of Pt Honesty related to substance use, prior txp

interventions, follow-up care, abstinence of

AOD while taking medications, willingness to

sign release of information

Advice to Change Referral for further evaluation, consult primary

care physician, therapist, take meds as

prescribed

Menu of Strategies Treatment levels of care, medication assisted

txp, community resources, legal, insurance

provider, strategies to cut down drinking

Empathetic Counseling Compassion, supportive, encourage, validate

potential fear, honor decision – plan of action

Self-Efficacy Non-traditional attempts to address substance

use, confidence scale (0-10 scale)

30

Five A’s Model

5 A’s Description

ASK

Screening is the first A because it asks one or more questions

related to drug use.

ADVICE The second A involves strong direct personal advice by the

provider to the patient to make a change, if it is clinically

indicated.

ASSESS The third A refers to determining how willing a patient is to

change his or her behavior after hearing the provider’s advice.

ASSIST The fourth A refers to helping the patient make a change if he/she

appears ready.

ARRANGE The final A is to refer the patient for further assessment and

treatment, if appropriate, and to set up follow-up appointments.

31 US Public Health Service 31

Motivational Interviewing (Clinical Approach)

• Patient centered communication style that enhances motivation for change by helping the patient clarify & resolve ambivalence about behavior change.

• Patient-centered

• Collaborative

• Focus on motivation

• Explore ambivalence

• Individual feedback

• Elicit reasons to change

• Listen, Listen, Listen

32 Rollnick, Miller, Butler 2008

33 Grimley 1997 and Prochaska 1992

January 2012 SBIRT Results

34 GMC

Educational Material

35 NIAAA

36