Referral To Treatment for Drug & Alcohol Part I -...
Transcript of Referral To Treatment for Drug & Alcohol Part I -...
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
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
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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)
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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
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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
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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
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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
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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
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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
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DSM IV-TR Substance Use Disorders
• Substance Intoxication
• Substance Withdrawal
• Substance Abuse
• Substance Dependence
16 5/17/2013 DSM IV-TR
Screening Tools
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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
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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
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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
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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
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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)
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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
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