Module III Screening and Assessment

1
Module IIIScreening and Assessment
Project MAINSTREAM
November 2005
2
Learning Objectives

• Health Care Professionals will be able to
• Describe the substance use continuum and
  recommendations for generalist care
• Cite data on the need for and effectiveness of
  screening
• Choose a screening instrument
• Screen and assess
• Teach others to conduct screening and assessment

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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, phys. dep.
- - -
- -
-/ -


4
Standard Drink
5
At-Risk Drinking

• Per Week Per OccasionMen gt14 drinks gt4
  drinksWomen gt7 drinks gt3 drinksElders gt7
  drinks gt1 drink

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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, phys. dep.
- - -
- -
-/ -


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Rationale for Generalist Care

• Why should health care and social services
  professionals who do not specialize in the
  addictions attempt to identify and assist
  patients and clients with risky or problem
  substance use?

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1. Brief Interventions and Specialized Treatment
Are Effective

• For individuals with at-risk use or abuse, brief
  interventions decrease substance use, reduce
  health care utilization, and save on health care
  expenditures
• For individuals with dependence, treatment
  reduces substance use, frequency and severity of
  relapses, and criminal recidivism
• See Module IV for more information

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2. Risky and Problem Substance Use Is Common
Among the General Population

• In 2004, of all Americans ages 12 and over
• 22.8 were binge drinkers(had 5 drinks on 1
  day in past 30 days)
• 6.9 were heavy drinkers(had 5 drinks on 5 of
  the past 30 days)
• 7.9 used an illicit drug in the past 30 days
• 9.4 had 1 alcohol or drug use disorder(abuse
  or dependence)

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3. Risky and Problem Substance Use Causes Death,
Illness, and Suffering

• In 2000, there were 92,000 alcohol- and
  drug-related deaths/year
• 40 of all fatal vehicular crashes are related to
  alcohol 18 to drugs
• Risky drinking contributes to hypertension, high
  cholesterol, heart disease, and stroke
• Risky drinking raises risk of cancers of the
  mouth, pharynx, larynx, esophagus, breast, colon,
  and liver
• Illicit drug use and risky drinking raises the
  risk of HIV/AIDS
• Alcohol and drug use are linked to most cases
  domestic violence and child abuse

(Mokdad et al., 2004)
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4. There Is a Wide Treatment Gap
23.48 millionAmericans neededtreatment in 2004
(National Survey on Drug Use and Health, 2004)
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4. There Is a Wide Treatment Gap (continued)
13
4. There Is a Wide Treatment Gap (continued)
1.23 million (5.3) felta need for treatment
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4. There Is a Wide Treatment Gap (continued)
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4. There Is a Wide Treatment Gap (continued)
Most eligible Americans do not receive brief
interventions

• Less than 25 of Americans in general medical,
  primary care, and mental health care settings
  receive brief interventions
• Most physicians do not routinely perform
  screening and intervention

(Arndt et al., 2002 Weisner Matzger, 2003)
(Friedmann et al., 2000)
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Generalist Care for Substance Use Related
Disorders
Screen if positive, perform brief assessment
Abstinence or low-risk use
At-risk use or abuse
Dependence
Refer to treatment
Prevention message
Brief intervention



Motivational Interviewing
Follow-Up
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Evidence on Screening

• Screening instruments are usually tested by
  concurrent validity
• Screen is compared to a gold standard criterion
  measure
• Gold standard is usually a lengthy diagnostic
  interview

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Evidence on Screening (continued)
Diagnostic Interv.
Total
Screen



True Pos
False Pos
TP FP

True Neg
False Neg
FN TN
Total
TP FN
FP TN
N
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Evidence on Screening (continued)
Screen
Diag. Int.
Diag. Int.
Total

True Pos
False Pos
TP FP

False Neg
True Neg
FN TN
Total
TP FN
FP TN
N
Sensitivity True Pos / (TPFN)Of those who
truly have a disorder,what proportion has a
positive screen?
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Evidence on Screening (continued)
Screen
Diag. Int.
Diag. Int.
Total

True Pos
False Pos
TP FP

False Neg
True Neg
FN TN
Total
TP FN
FP TN
N
Specificity True Neg / (FPTN)Of those who
truly do not have a disorder,what proportion has
a negative screen?
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Evidence on Screening (continued)
Screen
Diag. Int.
Diag. Int.
Total

True Pos
False Pos
TP FP

False Neg
True Neg
FN TN
Total
TP FN
FP TN
N
Positive Predictive Value TP / (TPFP)Of
those who have a positive screen,what proportion
has a disorder?
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Evidence on Screening (continued)
Screen
Diag. Int.
Diag. Int.
Total

True Pos
False Pos
TP FP

False Neg
True Neg
FN TN
Total
TP FP
FP TN
N
Negative Predictive Value TN / (FNTN)Of
those who have a negative screen,what proportion
does not have a disorder?
23
Evidence on Screening (continued)

• Higher PPV - Less False NegativesLess people
  with disorders missed
• Higher NPV - Less False PositivesLess time spent
  on assessments for people without disorders

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Evidence on Screening (continued)
Prev 50/1000 0.05Sens 45/50 0.90Spec
760/950 0.80PPV 45/140 0.32NPV 760/860
0.88
Prev 200/1000 0.20Sens 180/200 0.90Spec
640/800 0.80PPV 180/340 0.53NPV
640/660 0.97
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Evidence on Screening (continued)

• Higher prevalence of disorderHigher of
  positive screens are true positive
• Lower prevalence of disorderHigher of
  positive screens are false positive

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Barriers to Involvement

• Not seen in purview of profession
• Stereotypes and pessimism, because most
  clinicians recognize only the most severely
  affected individuals
• Stigma and discomfort
• Early disorders manifest few clues
• Deficient knowledge and skills
• Time and inadequate reimbursement

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Definition of Screening

• Procedure to recognizeindividuals with a
  disorderbefore obvious manifestationsof the
  disorder are apparent.
• Examples
• Cancer and depression

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Choose Screens By ...

• Number of items
• Method of administration
• Substances covered
• Accuracy by age group, gender, pregnancy status,
  ethnic group

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AUDIT

• 12 questions - multiple choice
• Administered in writing
• Alcohol only
• Screens for at-risk drinking, abuse, and
  dependence
• Accurate across many cultures/nations
• Sens 51 - 97 Spec 78 - 96

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CAGE

• 4 yes/no questions (1 yes positive)
• Administered by interview
• Alcohol only
• Screens for abuse and dependence
• Add quantity and frequency questions to screen
  for at-risk drinking
• Sens 43 - 94 Spec 78 - 96

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CAGE-AID

• 4 yes/no questions (1 yes positive)
• Administered by interview
• Alcohol and drugs
• Screens for abuse and dependence
• Add quantity and frequency questions to screen
  for at-risk use
• Sens 79 Spec 77

32
CRAFFT

• 6 yes/no questions (weighted score)
• Administered by interview
• Alcohol and drugs
• Validated for adolescents
• Sens 92 Spec 82

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SMAST-G

• 10 yes-no items
• Administered by questionnaire
• Covers alcohol only
• Validated for ages 55 to 81
• Sens 89 Spec 72

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DAST

• 28 questions
• Administered by questionnaire
• Covers drugs only
• Validated and most useful for inpatients

35
Trauma Questions

• 5 questions on trauma, including one question on
  trauma after drinking
• Administered by questionnaire
• Covers alcohol only
• Sens 45 - 53 Spec 80 - 93

36
TWEAK

• 5 questions
• Administered by interview
• Covers alcohol only
• Screens for abuse and dependence for pregnant
  women
• Sens 59 - 87 Spec 72 - 94

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Two-Item Conjoint Screen

• 2 yes/no questions (1 yes positive)
• Administered by interview
• Covers alcohol and drugs
• Screens for abuse and dependence
• Add quantity and frequency questions to screen
  for at-risk use
• Sens 81 Spec 81

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Q/F Questions on Alcohol

• How many days a week do you drink some alcohol?
• How much do you typically drink when you do
  drink?
• Whats the most youve had to drink at one time
  in the past 3 months?

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Single Alcohol Screening Question

• When was the last time you had more than
• Women 4 drinks in one day?
• Men 5 drinks in one day?
• Positive response within the past 3 months
• Sensitivity and specificity are 86 for hazardous
  drinking, alcohol abuse, or alcohol dependence

(Williams Vinson, 2000 Vinson, 2004)
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Other Questions to Consider

• Have you ever tried or experimented with-
  Marijuana? - Inhalants?- Cocaine? - Pills?-
  Shooting Up? - Any other drugs?
• Drug use days per week and usual quantity
• Have you ever gotten any help for an alcohol or
  drug problem?
• Has anyone ever suggested that you get help?

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Transitions to Screening

• Routine questions
• Tie into patient's/client's concern
• Questions on preventive health
• Family medical or social history
• Diet history
• Leisure activities
• Stresses and ways of coping

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Sample Adult Screening Protocol

• Transition Stresses and ways of coping
• Do you drink alcohol?
• Have you ever experimented with any drugs?
• Ask CAGE or CAGE-AID questions
• Ask Q/F questions on alcohol
• Usually takes less than one minute

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Non-Verbal Cues

• Interpret significant changes in a patient's
  client's non-verbal cues as a positive screen for
  abuse or dependence
• Eye contact
• Fluidity and tone of speech
• Posture
• Movements
• Affect

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For Especially Sensitive Situations

• First ask about friends
• Ask about substance use in the past before asking
  about the present
• Make normalizing statements before asking
  questions

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Screen Results and Actions

• Abstinence or Preventionlow-risk
  drinker message
• At-risk drinker or Briefdrug user with
  other- interventionwise negative screen
• Positive screen for abuse Briefor
  dependence assessment

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Prevention Messages

• Brief
• Relevant information
• Culturally appropriate
• Reinforcing

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Compose a Prevention Message

• 22-year-old unmarried pregnant woman
• Abstains from all substances
• Lives with sister who smokes cigarettes and
  marijuana

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Compose a Prevention Message (continued)

• 35-year-old male
• Parents are alcohol dependence
• Coworkers often drink after work
• Avoids most work parties
• Drinks very rarely

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NON-PROBUSE
AT-RISKUSE
ABST
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, phys. dep.
- - -
- -
-/ -


50
Definition of Assessment

• A process intended to identify precisely the
  category of substance use on the continuum

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Assessment Tools

• Alcohol levels and drug tests
• Tests for excessive alcohol use - liver function
  tests, blood counts
• Physical examination
• Collateral report
• Self-report

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Alcohol and Drug Tests

• Show use, not abuse or dependence
• Poor sensitivity and specificity for substance
  use disorders
• Show use in past few hours to 3 days
• Expensive
• Easily circumvented by sophisticated individuals

53
LFTs and CBCs

• Elevated liver function tests, especially
  gamma-glutamyl transferase (GGT), and
  macrocytosis can suggest excessive alcohol use
• Sensitivity 25 most affected individuals have
  normal tests
• Positive tests can have other explanations
• If present, abnormalities are helpful

54
Carbohydrate-Deficient Transferrin (CDT)

• Under study as a biomarker for alcohol use
  disorders
• Sens 32 to 92 Spec 71 to 100
• Slower reversion to normal with abstinence than
  GGT
• Confounders iron deficiency, chronic illness,
  menopausal status
• False negatives females, episodic abstinence,
  trauma

(Anttila, 2005 Fleming, 2004 2004 Godart
2005 Schwan, 2005)
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Physical Examination

• Most findings occur only with late, severe
  disorders
• Most individuals with disorders have no findings
• If present, findings are helpful
• If absent, do not rule out disorder

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Collateral Report

• Collateral report is often less than
• self-report
• Surreptitious collateral report can hinder
  trusting relationship

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Self-Report

• Interview is usually the most accurate source of
  information
• Accurate assessment is usually possible even with
  minimization
• Appropriate assessment techniques can build
  rapport

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Brief Assessment Interview

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

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Later Consequences

• Cirrhosis, cardiomyopathy, AIDS, chronic
  pancreatitis, CAD, cancer
• Severe neuropsychiatric disorders
• Family dissolution, social isolation
• Unemployment, homelessness
• Incarceration
• Oral cancers and tooth loss

60
Earlier Consequences
Identify problem before irreversible
consequences

• Work
• Legal
• Financial
• Religious/Spiritual

• Psychological
• Family
• Friends
• Biomedical

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Early Consequences Psychological

• Earliest category of consequences
• Dysphoria, depression, or anxiety
• Irritability, mood swings, hostility
• Paranoia, psychosis
• Any psychiatric symptom can be related to
  intoxication, overdose, or withdrawal

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Conventional Explanatory Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
63
Another Possible Model
1
2
Psychological Symptom
Stressful Circumstances
3
Substance Use
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Another Possible Model (continued)
PsychologicalDisorder
Stressful Circumstances
Substance Use Disorder
Cycle can start anywhere
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Dual Diagnosis

• Co-existing substance use disorder and another
  psychiatric disorder
• Identify primary and secondary disorder, if
  possible
• If SUD may be primary, and if psychiatric
  symptoms are not pressing, try abstinence without
  medications

66
Early ConsequencesFamily

• Marital/family dysfunction
• Childhood behavior/school problems
• Mental health problems and somatic symptoms among
  family members

67
Early ConsequencesFriends

• Alienation and loss of old friends
• Gravitation toward others who use substances
  heavily

68
Early ConsequencesBiomedical

• Gastritis, peptic ulcer, pancreatitis, vague
  abdominal pain, diarrhea
• Hypertension
• Weight gain for alcohol
• Weight loss for cocaine and amphetamines
• Accidents and injuries
• Sleep and sexual dysfunction
• Unplanned pregnancies, unwanted sexual advances,
  STD's
• Periodontal disease

69
Early ConsequencesWork/School

• Frequent lateness and absences
• Requests for work excuses
• Decline in performance
• Frequent job changes

Preservation of function for highly
motivatedindividuals, such as many health care
professionals
70
Early ConsequencesLegal

• Domestic and other violence
• Arrests for disturbing the peace
• DWIs / DUIs
• Arrests for possession and dealing
• Burglary, robbery

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Early ConsequencesFinancial

• Spending more than one can afford on obtaining
  substances
• Financial strain
• Indebtedness
• Selling possessions

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Early ConsequencesReligious/Spiritual

• Feelings of
• Disconnection
• Alienation
• Shame
• Disgrace

73
Brief Assessment Interview

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

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Brief Assessment Interview (continued)

• Loss of control
• Setting rules about substance use
• Having difficulty adhering to rules
• Physical dependence
• Withdrawal symptoms
• Substance use to avoid withdrawal

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Brief Assessment Interview (continued)

• Consequences and repetition
• Physical dependence and loss of control
• Quantity and frequency

76
Brief Assessment Interview (continued)

• How many days a week do you drink some alcohol?
• How much do you typically drink at one time when
  you do drink?
• Whats the most youve had to drink at one time
  in the past 3 months?
• Take responses at face value

77
For Patient/Client Discomfort

• Change topic and ask again later
• Ask more about social context and establish more
  rapport
• Ask about discomfort and request cooperation
• Explain need for questions

78
Summary

• Most individuals with risky or problem substance
  use are not getting help
• All generalist health professionals should screen
  routinely for substance use and related disorders
• Use an appropriate screen for the population
• Positives screens should lead to further
  assessment
• Quantity-frequency questions identify risky
  alcohol use
• Assessment focuses on consequences and dependence
  symptoms
• Accurate assessment guides treatment