Drug Use and Problems
A broad range of treatment approaches are available and necessary for the management of persons with problem drug and/or alcohol use. Individuals with problem substance use can present anywhere along a continuum, from early stage problems associated with acute, recreational, or binge use to severe dependence with major physical and psychosocial problems. This latter group commonly has multiple health problems with poor or negligible non–drug-using social support and requires intensive intervention, often with the objective of achieving abstinence. Traditionally, most therapeutic resources were directed at the management of this group. These interventions have generally been intensive in nature and costly to deliver and have failed to reach the majority of individuals using these substances.
Although the impact of drug and alcohol dependence on health and society is widely recognized, the effects of nondependent excessive drug use are often underestimated by the community and the health care system. For example, the number of nondependent heavy drinkers far outweighs the number of dependent people. Most alcohol-related problems result from people drinking below levels that cause major physical dependence. Nevertheless, the societal, family, and health impacts of nondependent drinking have a greater influence than dependent drinking on the community’s burden of alcohol problems: the so-called prevention paradox.
A report by the Institute of Medicine recommended that given the number of people with mild or moderate alcohol problems, a range of therapeutic approaches needed to be developed to cover the full gamut of alcohol use problems. Similar conclusions could be drawn concerning clinical and subclinical use of other types of substances. Table 43.1 summarizes key definitions for problematic use of alcohol or other substances.
|Dependence: DSM-5 (APA 2013)||“…a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (p. 483). Symptoms are grouped as relating to impaired control (e.g., inability to reduce use), social impairment (e.g., extensive time spent obtaining, using, and recovering from use), risky use (e.g., use in a situation that is physically hazardous, such as driving), and pharmacological issues (e.g., craving). Severity is categorized as mild (2–3 symptoms), moderate (4–5), or severe (6 or more symptoms).|
|Dependence: ICD-10 (WHO 2016)||A syndrome of behavioral, cognitive, and physiological symptoms subsequent to repeated use of a substance. The criteria cover impaired control, withdrawal, tolerance, and preoccupation with use of the substance and persistent use despite evidence of the harmful consequences.|
|Harmful: ICD-10 (WHO 2016)||Clear evidence of physical or psychological harm, including impaired judgment or dysfunctional behavior from substance use.|
|Additional ICD-10 diagnoses (WHO 2016)||The ICD-10 diagnostic categories also include Acute Intoxication, Withdrawal State, Withdrawal State with Delirium, Amnesic Syndrome, Psychotic Disorder , and Residual and Late Onset Psychotic Disorder.|
|Hazardous||Used by the WHO but not a diagnosis. Use of a drug that will probably lead to harmful consequences for the user if it continues at the same level.|
|Risky||Those who drink/use other substances in a way that creates a risk of harm to themselves or others.|
Drug Treatment in Primary Care and Nonspecialist Settings
People who consume hazardous levels of alcohol (use that will probably lead to harmful consequences for the user if it continues) rarely seek treatment. Indeed, less than 30% of individuals with alcohol use disorders are likely to have sought professional care in the previous year, and only 14% of those with other substance use disorders seek professional help. People with early stage problem drug use commonly present to general practitioners or community health services for reasons that are not drug-related. Health workers in hospital emergency departments typically encounter a greater proportion of cases, such as acute trauma presentations, accident, injury, and overdose that are common consequences of drug use.
The nondependent population, unlike their dependent counterparts, typically have an intact psychosocial fabric and, therefore, do not require the intensive interventions directed at dependent individuals. The identification and effective management of these individuals before the development of more significant use, dependence, and associated major physical and/or psychosocial problems is clearly desirable. Individuals who have early problem substance use but who are not dependent are a major target group for early identification. The importance of this approach has resulted in screening, brief intervention, and referral to treatment (SBIRT) being mandated in the United States for level 1 and 2 trauma centers.
This approach has a sound rationale. Screening clients to identify at-risk users combined with brief interventions provides an efficient way of reaching a larger portion of clients with alcohol or other drug problems than provided by traditional intensive interventions, and may be especially suited to clients with less severe diagnoses. By using opportunistic screening, brief interventions may reach a proportion of individuals who would not normally present at specialist treatment facilities. Moreover, screening in primary care for subclinical alcohol consumption or other drug use to identify at-risk individuals allows preventive measures or treatment to be initiated before clinical-level disorders and the associated health and social problems develop.
A large number of short screening tests are available to aid in the systematic identification of alcohol or other drug use problems in primary care. Two of the most commonly used tests are the Drug Abuse Screening Test and the 10-item Alcohol Use Disorders Identification Test (AUDIT). The latter was developed by the World Health Organization and validated in numerous countries and populations. It is also available in three shortened versions and has been used widely. The Drug Abuse Screening Test is available as a 28-item form or a 10-item short form and screens for general drug abuse rather than a specific class of drug. The brevity of these instruments and their ease of use make them suitable for a range of general medical settings. Biological screening tests (e.g., breath, hair, urine, saliva, laboratory markers) would appear to offer a more robust assessment, but to date, these are of limited use in primary care, where results are needed quickly, must be inexpensive, and must show more than just recent use. Therefore, biological assays may be more appropriate in specialist settings, clinical trials, or where they are required to comply with legal requirements.
What Is Screening and Brief Intervention?
Screening and brief intervention (SBI) is generally used as part of a consultation in a primary care setting—for instance, general practice or a community health service. However, as is explored in more detail below, some brief interventions may be initiated at a teachable moment such as in general hospital emergency, medical, or surgical departments, when individuals may be highly motivated to change their behavior.
Brief interventions are sometimes described as minimal interventions due to the less-intensive nature of the intervention required to effect changes toward more positive substance use patterns in nondependent individuals, or as early interventions because they are directed at individuals who have not progressed to more serious drug use patterns. However, even at the extreme end of the spectrum, SBI has a role in identifying people with dependence and enhancing referral for treatment.
There is no universally accepted definition of what constitutes a brief intervention. Babor provided a convenient heuristic where a single client contact with a professional constitutes a minimal intervention, 1–3 sessions constitute a brief intervention, 5–7 sessions a moderate intervention, and 8 or more an intensive intervention. Miller and Wilbourne suggested that 1 or 2 sessions of treatment constitute a brief intervention, whereas Moyer and colleagues used a threshold of 4 sessions to define brief interventions. In the first section of this chapter, the focus is on interventions that can be delivered in 4 or fewer sessions. In the second section, the focus is on brief interventions to increase compliance with pharmacotherapies used in the treatment of problem alcohol or other drug use, which often extend over 12 or more sessions.
Notably, none of these definitions delineate the length or content of the intervention. Interventions are typically of 30- to 45-minute duration; however, within a community/primary care setting, interventions can be incorporated within a 5- to 10-minute physician consultation. Five key elements have been identified for inclusion in an intervention. First, the clinician assesses the quantity and frequency of alcohol or other drug use and provides direct feedback to the client regarding health or psychosocial morbidity relevant to his or her level of use. Second, goals for alcohol or other drug use are established that are acceptable to both provider and client. These goals may be a reduction in consumption, such as using alcohol in a low-risk fashion, or complete cessation, as is commonly employed with tobacco use. Third, the provider uses behavioral modification techniques—for example, to help the client identify high-risk situations and develop strategies to deal with these. Fourth, the clinician should supply support material on problems associated with substance use plus self-help techniques. Fifth, the provider should offer ongoing support. Others have summarized the content under the acronym FRAMES —that is, F eedback on personal risk, personal R esponsibility for the problem, A dvice that is clear and explicit, a M enu of options on how to change, an E mpathic style of counseling to avoid coercion or authoritarianism, and enhancement of the client’s S elf-efficacy.
Babor and colleagues provided a thorough discussion of the psychological principles and behavioral change strategies thought to underlie early or brief intervention programs; these incorporate principles from social, cognitive, and behavioral psychology to increase motivation and commitment to change. For example, a health care professional can be seen as having social power, and, as a credible source of relevant health information, the provision of normative information allows social comparison and support networks to use social influence to modify behavior.
A concept that often arises in the screening and brief intervention literature is that of the teachable moment when a person is particularly likely to be open to changing his or her behavior—for example, when a major health event or hospitalization related to substance use occurs. McBride and colleagues suggested a model to help determine whether a given event, such as hospitalization for a substance-related morbidity, will cue the client to reduce his or her substance use. First, does the event (e.g., hospitalization or ill health) serve to increase perceived risk from the client’s use of the drug and the potential for positive outcomes to occur if the use is reduced or ceased? Second, does the event provoke a strong emotional response? Third, does it lead to redefining the person’s self-concept? For instance, a child being diagnosed with asthma may be associated with smoking by a parent, leading to the parent reevaluating his or her role as a protective caregiver. Even in the presence of all these factors, preexisting individual factors may override the impact of the event. Nevertheless, delivering interventions at a teachable moment is likely to amplify greatly the impact of the intervention—for example, increasing cessation of smoking by up to 70% compared with a background quit rate of about 5%.
Some have contended that the stress associated with a hospital presentation and the often chaotic environment in hospital emergency departments may mean that this is not a conducive setting in which to deliver an intervention. However, it may still be appropriate to use the opportunity to arrange a follow-up intervention, and there is the possibility of using motivational techniques to encourage people to attend treatment rather than attempting to deliver treatment under these difficult conditions.
Screening and Brief Intervention—Effectiveness and Delivery
Of all the strategies and pharmacotherapies for treating alcohol use problems, there is more evidence, particularly from studies of high methodological quality, to support the use of SBI than any other type of intervention. Brief interventions are also the highest ranked intervention in clinical populations, although this form of intervention is most effective when individuals with more severe disorders are excluded. The focus on clients with less-severe alcohol use problems means that low-risk use of alcohol can be the goal of the intervention rather than complete abstinence, which has been the traditional goal of more intensive interventions.
Although there is robust and extensive literature on the use of SBI for alcohol use problems, a criticism has been raised that these conclusions were based on select populations and from tightly controlled clinical trials. From a health care perspective, a critical concern is whether this type of intervention can be translated into the clinical setting of primary care. A meta-analysis of trials conducted in primary care using interventions that would be suitable for inclusion in clinical practice (i.e., physician interventions of 5–15 min or nurse interventions of 20–30 min) identified 28 trials, including 5 that used the motivational interviewing approaches. Overall, brief interventions reduced alcohol consumption by 41 g/week at 1 year. Brief interventions also seem to be effective at reducing binge drinking and heavy drinking, albeit these conclusions are based on a limited number of studies and that the studies used different definitions to categorize heavy use of alcohol (criteria ranged from 20 to 35 drinks/week for men and 13 to 35 for women). The main caveat identified by the research was the lack of a significant reduction in alcohol use by women, but this may be related to lack of statistical power, with only 499 of 7286 female participants included in the review. This is a potentially important limitation, as women are more likely than men to seek help from primary care providers. On the other hand, a recent meta-analysis did not find gender differences in the effectiveness of SBI, suggesting that lack of statistical power may indeed be the explanation.
e-Health interventions cover a range of approaches that are mediated by electronic technology. At its most basic, this can be telephone support, but more frequently, interventions are provided via stand-alone computers, the Internet, smart phone applications, or text messages. Therefore, SBI can now be delivered by computers or remotely over the Internet (e-SBI) and can be accessed by nearly the entire population. e-SBI typically uses the same therapeutic approaches as a face-to-face intervention. Thus components may include a screening questionnaire, normative information, motivational enhancement, skills building, and relapse prevention. Although most data have been collected from tertiary student populations, benefits have also been demonstrated in the general adult population, with outcomes of a magnitude similar to those achieved by face-to-face brief interventions. e-SBI has also been evaluated in hospital emergency departments to address youth alcohol consumption and violence.
Brief interventions including e-SBI also have a sound health economics rationale, with a positive cost-benefit ratio, with significant savings through reduced health costs as well as reduced costs to society—for instance, in reducing vehicle accidents. The magnitude of this effect has been estimated at 5.6:1 at 12 months and 4.3:1 at 48 months when considering reduced health system costs alone. Thus an intervention that cost $205 per individual to deliver resulted in an average benefit of $1151. Including savings to the wider community, the total benefit was $7985 per intervention.
There is some concern over the long-term effectiveness of e-SBI. In their meta-analysis, Donahue et al. found a significant reduction in alcohol consumption between 3 and less than 12 months, but at 12 months and longer there was no significant difference between e-SBI and control groups. Similar findings were reported by Dedert et al., who reported that low-intensity e-interventions produced small reductions in alcohol consumption at 6 months, but there was little evidence for longer-term, clinically significant effects. Harris and Knight conducted an extensive review of the use of e-SBI for alcohol use in medical settings, and found that although it was feasible and accepted by both staff and patients, the highly variable quality of data did not allow conclusions to be drawn regarding efficacy.
All forms of intervention to encourage the cessation of tobacco use are cost-effective in terms of cost per life-year saved, with the cost of these interventions comparing favorably with virtually any other health care program. Although improved rates of cessation accrue from more intensive interventions, these improvements do not keep pace with increased costs. However, this should not be used as a reason for not delivering more intensive interventions, which may be particularly efficacious in those with more severe problems, for whom brief interventions are typically less effective.
Guidelines are available for primary care practitioners, such as physicians, nurses, and dentists, to aid in the development of screening procedures and the delivery of appropriate interventions for users of tobacco. The United States guidelines evaluate a range of different psychosocial and pharmacological interventions as well as the management strategies for identifying and treating smokers in different primary care settings. The guidelines emphasize the importance of screening all patients for tobacco use and recommend strategies for approaching those willing to quit, those unwilling to quit, and those who have recently quit. However, it also has been suggested that repeated advice to asymptomatic smokers may be counterproductive, contrary to the guideline recommendation that smokers should be asked about their use of tobacco on every visit. Potentially, the importance of this guideline may be derived from the development of systems that help to ensure that cessation of tobacco use is thoroughly integrated into clinical practice rather than through increased benefits to an individual.
The initial approach recommended is a brief intervention that can be delivered in approximately 3 minutes, summarized under the mnemonic the 5 A’s (Ask, Advise, Assess, Assist, and Arrange). These guide the practitioner to ask every client about tobacco use at each visit, to advise them clearly and in a personalized manner to quit tobacco use, to assess their current willingness to quit, to assist them in forming a cessation plan, to provide them with access to counseling and appropriate pharmacotherapies, and, finally, to arrange a follow-up appointment, if possible within a week of the agreed-upon quit date.
If the client is not willing to quit, a further brief intervention can be delivered that focuses on increasing the motivation to quit (see Chapter 39 for detailed information on motivational interviewing). This brief intervention is formulated under the mnemonic the 5 R’s (Relevance, Risks, Rewards, Roadblocks, and Repetition). Thus the intervention should focus on aspects that are personally relevant, such as current health problems, and should encourage the smoker to identify the risks of tobacco use and the rewards that will accrue with cessation. Any potential roadblocks to cessation should be addressed and solutions generated. Finally, the intervention should be repeated on each occasion that the client is seen.
Given the chronic relapsing nature of nicotine dependence and other addictive disorders, it is important also to plan and deliver relapse prevention interventions, especially in the first 3 months after a person has quit smoking. This typically involves the use of open-ended questions to encourage discussion of benefits, successes, and problems encountered as well as providing encouragement and help with significant problems, such as depression, weight gain, or withdrawal symptoms.
A meta-analysis of randomized trials with at least 6 months follow-up of brief interventions by physicians found that a single session lasting up to 20 minutes, plus up to one follow-up session, increased the rate of cessation by 1%–3% over the background rate of cessation (2%–3%). The rate of mortality and morbidity due to smoking means that even small improvements in cessation result in noticeable benefits. However, the effectiveness of this approach is derived from screening all participants and intervening with those who are smokers. The main drawback identified was the difficulty of persuading physicians to incorporate systematic screening and intervention into regular practice. The development of online or smart phone cessation applications means that clinicians can easily advise clients to access additional supports or incorporate them with a face-to-face intervention.
Brief interventions by nursing staff are also effective at producing small but significant increases in successful quitting. However, the authors of the analysis stress that statistical heterogeneity indicates that this finding may not generalize to all patient groups or clinical settings equally. Nevertheless, the US guidelines recommend that interventions by all nonphysician clinicians (i.e., nurses, psychologists, and dentists) can be justified empirically compared with no treatment or self-help. As with alcohol, there are now effective online smoking cessation programs, plus other electronic interventions such as text messages or smart phone applications. These interventions yield small but important improvements in cessation.
Smoking cessation interventions delivered in a hospital would appear to be an ideal opportunity, particularly with the expansion of smoke-free hospital policies in many developed countries. However, a meta-analysis concluded that high-intensity behavioral interventions initiated in a hospital that included at least 1 month of postdischarge support were effective, but that lower-intensity and shorter-duration interventions were not found to be effective. A more recent meta-analysis of trials that sought to reduce tobacco smoke exposure among hospitalized children found significant effects only in trials that measured maternal postpartum smoking relapse prevention.
The weight of evidence supporting the utility of brief interventions in treating alcohol use or cigarette smoking is in striking contrast with the limited studies on the use of these techniques for illicit substance use problems. Two Cochrane reviews of psychosocial treatments for opiate use and of psychosocial and pharmacological treatment for opioid detoxification did not identify any studies that used brief interventions for the psychosocial component. Similarly, a Cochrane review of psychosocial interventions to treat cocaine and other psychostimulant disorders failed to identify any brief interventions that matched the inclusion criteria. A third Cochrane review of interventions to reduce drug use by young people conducted outside the school setting and an earlier review of interventions for adolescent alcohol, tobacco, and other drug use identified one brief intervention with adolescent substance users.
In 2007, the National Institute on Drug Abuse concluded that there were too few data to support the use of screening, brief intervention, referral, and treatment (SBIRT) for illicit drug use and no research to support this with respect to prescription drug use. Subsequently, a major trial was initiated with 459,599 people screened across a range of settings, including emergency departments, hospitals, community clinics, and schools. Nearly 23% screened positive for heavy alcohol and or illicit drug use. By 6 months there were significant declines in use across all major categories (alcohol, cannabis, methamphetamine, and heroin).
It is estimated that 15 million Americans misused prescription drugs in 2014. The misuse of prescription and over-the-counter medications resulting in emergency department visits and other adverse outcomes, is a cause of concern that has resulted in calls for research funds to be directed to this area, including the evaluation of SBIRT programs to identify and intervene with the users of these licit substances. The study by Madras and colleagues reported reductions in other drug use, which included prescription medications, but further work focused on this category is required.
More recently, a number of studies have found SBI in illicit drug using populations to be both ineffective and costly. Roy-Byrne et al. found no effect of a one-time brief intervention on illicit drug use among patients in a safety-net (low income) primary care setting. Another large and significant trial conducted among licit and illicit drug users in a primary care setting found no effect of SBI on any outcome measure. The authors concluded that SBI is not effective for this patient group. Of interest, investigators examining the effect of access to an e-SBI site for illicit drug users, found no significant effects at 3- and 6-month follow-up, but did find a significant reduction in alcohol use in the intervention group at 12 months. A review of online interventions for cannabis use or prevention of cannabis initiation identified 10 studies, of which one was a single-session brief intervention and one a face-to-face brief intervention plus online cognitive behavioral therapy. Neither study achieved significant effects. It is important to note that although SBI is seemingly not effective in this patient group, the screening component should not be abandoned as an integral component of clinical assessment for at-risk groups.
An alternative approach is to use the screening and referral approach to encourage people to attend external agencies for treatment. This method has been used with adolescents presenting to emergency departments with alcohol or other drug problems. The authors reported that this type of intervention could be successfully delivered in emergency departments but noted that the yield (proportion of adolescents attending treatment), although significant compared with usual care, was low. Further work is required to determine the best referral processes for specialist treatment for individuals who do not respond to brief interventions.