OfficeBased Prevention and Treatment Part 1: Screening and Assessment

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Office-Based Prevention and Treatment Part
1Screening and Assessment
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Objectives

• Participants will
• understand the concepts of validity, reliability,
  sensitivity, specificity and predictive values
• be able to describe screening methods for the
  detection of alcohol and drug problems
• be able to perform a brief assessment and develop
  an appropriate initial treatment plan
• select a screening and assessment method to be
  implemented into their practices

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ROC Curve SMAST-13 and AUDIT using Current
DSM-III Criteria
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Self-Administered Screening Tests

• Quantity/frequency, binge use
• CAGE
• S-MAST (Short Michigan Alcohol Screening Test)
• AUDIT (Alcohol Use Disorders Identification Test)
• HSS (Health Screening Survey)
• Computerized lifestyle questionnaires

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Why Ask Quantity/Frequency Questions?

• Common
• Sensitive
• Epidemiological research
• Continuum of risk

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Screening

• ASK

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ASK

• How much alcohol do you drink?

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ASK

• How many days per week do you drink?

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ASK

• On a day when you drink alcohol, how many drinks
  do you have?

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ASK

• C Cut
• A Annoyed
• G Guilty
• E Eye opener

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Detection of At-Risk Drinkers

• CAGE will miss 50 of at-risk drinkers
• CAGE is designed to detect alcohol dependence

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Alcohol Use Disorders Identification Test (AUDIT)
Introduce this structured interview by telling
the patient that you will be asking questions
about his/her use of alcoholic beverages during
the past year. Circle the number that comes
closest to the patient's answer. 1. How often do
you have a drink containing alcohol? (0) NEVER
(1) MONTHLY (2) TWO TO FOUR (3) TWO TO THREE
(4) FOUR OR MORE OR LESS TIMES A
MONTH TIMES A WEEK TIMES A WEEK 2. How many
drinks containing alcohol do you have on a
typical day when you are drinking? CODE NUMBER
OF STANDARD DRINKS (0) 1 OR 2 (1) 3 OR
4 (2) 5 OR 6 (3) 7 TO 9 (4) 10 OR
MORE 3. How often do you have six or more drinks
on one occasion? (0) NEVER (1) LESS THAN
(2) MONTHLY (3) WEEKLY (4) DAILY
OR MONTHLY
ALMOST DAILY 4. How often during the last year
have you found that you were not able to stop
drinking once you had started? (0) NEVER
(1) LESS THAN (2) MONTHLY (3) WEEKLY
(4) DAILY OR MONTHLY
ALMOST DAILY
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Alcohol Use Disorders Identification Test (AUDIT)
5. How often during the last year have you failed
to do what was normally expected from you because
of drinking? (0) NEVER (1) LESS THAN (2)
MONTHLY (3) WEEKLY (4) DAILY OR
MONTHLY ALMOST
DAILY 6. How often during the last year have you
needed a first drink in the morning to get
yourself going after a heavy drinking
session? (0) NEVER (1) LESS THAN (2)
MONTHLY (3) WEEKLY (4) DAILY OR
MONTHLY ALMOST
DAILY 7. How often during the last year have you
had a feeling of guilt or remorse after
drinking? (0) NEVER (1) LESS THAN (2)
MONTHLY (3) WEEKLY (4) DAILY OR
MONTHLY ALMOST
DAILY 8. How often during the last year have you
been unable to remember what happened the night
before because you had been drinking? (0)
NEVER (1) LESS THAN (2) MONTHLY (3)
WEEKLY (4) DAILY OR MONTHLY
ALMOST DAILY
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Alcohol Use Disorders Identification Test (AUDIT)
9. Have you or someone else been injured as a
result of your drinking? (0) NO (2) YES,
BUT NOT IN THE LAST YEAR (4) YES, DURING THE
LAST YEAR 10. Has a relative or friend or a
doctor or other health worker been concerned
about your drinking or suggested you cut down?
(0) NO (2) YES, BUT NOT IN THE LAST YEAR
(4) YES, DURING THE LAST YEAR In determining
the response categories it has been assumed that
one "drink" contains 10g alcohol. In countries
where the alcohol content of a standard drink
differs by more than 25 from 10g, the response
category should be modified accordingly.
Record sum of individual item scores here
_____________. A score of 8 or greater may
indicate the need for a more in-depth assessment.
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Detection of Other Drug Use

• In the last year, have you ever drank or used
  drugs more than you meant to?
• Have you felt you wanted or needed to cut down
  on your drinking or drug use in the last year?
• Have you used marijuana, cocaine, etc. five or
  more times in your lifetime?

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Techniques to Increase Sensitivity

• Context
• Approach
• Nonverbal cues

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Screening Opportunities

• Routine exams
• Alcohol health effects
• Acute care visits
• Family member visits

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Assess for Evidence of Physical Dependence

• Do you ever drink in the morning to get over a
  bad hangover?
• Do you develop shakes when you stop drinking for
  more than a day?
• Have you ever been in DTs, been detoxed, or had
  an alcohol withdrawal seizure?
• Have you ever been treated for alcohol or drug
  withdrawal?
• How many days a week do you drink in the
  morning?

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Assess for Health Problems

• Ask about alcohol-related problems
• Perform a focused physical exam
• Consider laboratory tests

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History of Alcohol-Related Problems
Assess for Health Problems

• liver dysfunction
• chronic abdominal pain
• sexually transmitted diseases
• suicide ideation
• trauma

• hypertension
• depression
• sleeping problems
• headaches
• pancreatitis
• anxiety, panic attacks

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Physical Exam
Assess for Health Problems

• blood pressure
• mouth lesions
• mental status
• cardiac rhythm
• skin changes

• liver and spleen size
• dental condition
• needle tracks
• auscultation of the
• chest for broncho spasm

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Laboratory Tests
Assess for Health Problems

• Blood Alcohol Levels
• Breath
• Urine
• Blood
• Skin
• Indication
• Interpretation
• Legal issues

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Assess for Health Problems
Laboratory Tests

• Urine Toxicology Screens
• Indications
• Methodology
• Collection techniques
• Legal issues

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Assess for Health Problems
Laboratory Tests

• GGT
• MCV
• SGOT
• HDL
• CDT

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Carbohydrate Deficient Transferrin (CDT)
Assess for Health Problems
Laboratory Tests

• 60 grams/day
• Less useful in women
• False positives

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Assess for Use of Other Drugs

• Tobacco products
• Prescription drugs
• Illicit drug use

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Assess for Family/Social/Employment Problems

• Have you ever been arrested for driving while
  under the influence of alcohol?
• Have any family members, friends, or people at
  work ever asked you to change your drinking
  habits?
• Has your drinking caused any problems in your
  life?
• Have you ever participated in a work-related
  alcohol treatment program?
• Have you ever had a problem with your job
  because of drinking?

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Steps for Alcohol Screening Brief Intervention
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Implementation Issues

• Select a screening test
• Select office procedures
• Assign staff responsibilities
• Assess cost and effects on other prevention
  activities