Primary Care Screening for Alcohol Misuse & Alcohol Use Disorders

1. Primary Care Screeningfor Alcohol Misuse& Alcohol Use Disorders

2. Agenda • Why is this important? • Origins • Policy & Requirements • Frequency & Location • Screening, Assessment, & Intervention Process

3. Why is this important inPrimary Care? • Heavy alcohol use is common and associated with significant health & behavior problems • Alcohol problems often undetected • Behaviors are changeable • Providers influence patient behavior

4. Origins • FE Warren’s Responsible Drinking Campaign • Scientific, broad-based, community-oriented program • 0-0-1-3 is a slogan that is part of a larger program • No underage drinking, No DUIs, 1 drink/hour, 3 drinks/sitting • Results: • 68% reduction in alcohol related incidents • 24% reduction in DUI arrests • 93% reduction in underage drinking arrests • 70% reduction in Article 15’s • 8% increase in available-for-duty rate • 90 SVS turned a profit for first time in years

5. Policy & Requirements • CSAF: Adapt 0-0-1-3 for AF-wide use • AF committed to reducing alcohol misuse • MDG plays key role in this campaign • Culture of Responsible Choices (CoRC) • Integrated base-wide effort • SG role is screening, assessment, & treatment

6. When & Where? • Screen every Airman at least once annually at annual Preventive Health Assessment and/or routine clinic visits

7. Primary Care Screening, Assessment, & Intervention • Step 1: Initial Screening • Step 2: Additional Screening • Step 3: Further Assessment • Step 4: Intervention (& Referral, when indicated) • Step 5: Follow-up • Follow Primary Care Alcohol Screening Flowchart

8. Step 1:Initial Screening • Ask: “Do you drink alcohol?” • If yes, and underage, refer to ADAPT program • If yes, and of age, go to Step 2 (Additional Screening) • If no, no further action necessary

9. Step 2:Additional Screening • Ask: “In the past 30 days, have you consumed four or more drinks in one day?” • If yes, go to Step 3 (Further Assessment) • If no, offer preventive education • Reinforce patient’s current healthy drinking behavior • Educate about health & behavior risks of high risk drinking • Recommend staying within healthy drinking limits • Recommend lower drinking limits or abstinence as indicated clinically

10. Step 2:Additional Screening • Healthy Drinking Limits per NIAAA: • Healthy Men < 65: • No more than 4 drinks/day, 14 drinks/week • Healthy Men > 65: • No more than 3 drinks/day, 7 drinks/week • Healthy Women: • No more than 3 drinks/day, 7 drinks/week • Modify as indicated based on health status • Staying within these guidelines lowers the risk of injury or illness

11. Step 3:Further Assessment • Choose one or more of the following screening tools: • AUDIT C (positive screen = 3 or greater) • AUDIT (positive screen = 7 or greater) • CAGE (positive screen = 2 or greater) • Other Options: Clinical interview, MAST, UNCOPE, DSM Screener • Refer to Alcohol Screening Tools Chart for comparison of various tools • AUDIT C is recommended

12. Step 3:Further Assessment • If patient screens negative: • Offer preventive education • Educate patient about health & behavioral risks of continued high risk drinking

13. Step 3:Further Assessment • If patient screens positive, make appropriate fitness for duty determinations and go to Step 4 (Intervention) • Consider PRP, flying, weapons bearing status, etc. • If provider suspects fitness for duty issues, alcohol abuse, or alcohol dependence, the patient must be referred to ADAPT program (IAW AFI 44-121)

14. Step 4:Intervention • Use empathic, non-confrontational style • Offer patient choices about how to make changes • Emphasize patient’s responsibility for changing drinking behavior • Convey confidence in patient’s ability to change drinking behavior

15. Step 4:Intervention • Brief Intervention: Advise & Assist • State your concern • “I’m concerned about your drinking.” • Give your advice • “I think you should stop drinking.” • “I think you should cut back.” • Gauge readiness • “What do you think?”

16. Step 4:Intervention • Ask “As part of your healthcare, are you interested in changing your level of drinking?” • If no, educate patient about health & behavioral risks of continued high risk drinking • If yes, conduct the brief intervention, set a goal, and schedule follow-up

17. Step 4:Intervention • Recommend lower limits or sobriety, as indicated • Help patient set a goal • Keep patient involved in goal setting • Encourage self evaluation & reflection • Weigh what they like about drinking against reasons for cutting down • Provide educational materials • www.familydoctor.org • Schedule follow-up appointment

18. Step 4:Intervention • Reasons to recommend or consider abstinence: • Diagnosis of alcohol dependence or abuse • Pregnant or trying to conceive • Contraindicated medication • History of blackouts • History of repeated, failed attempts to cut down • Family history of alcohol problems • History of injuries or psychosocial problems related to drinking • Presence of medical or psychiatric condition that could potentially be aggravated by alcohol use

19. Step 4:Intervention • Some patients may be willing to stop, but may be unable to do so without more intensive support • Consider referral for substance abuse rehabilitation services • Both inpatient & outpatient available • Schedule referral appointment with patient in the office

20. Step 4:Intervention • Where available, consider utilizing behavioral health provider in BHOP to help develop intervention plan • Consider referral to Life Skills Support Center if you suspect patient has a significant co-morbid behavioral health condition • Consider referral to ADAPT if you suspect alcohol use disorder in the absence of any significant co-morbid behavioral health conditions

21. Step 5:Follow-up Care • Encourage & support patient’s efforts • Review results • Congratulate & reinforce positive changes • Acknowledge difficulties in making changes • Reassess motivation for change • Revise goals as indicated • Follow-up as often as needed until goals met

22. Step 5:Follow-up Care • Monitor patient for symptoms of depression or anxiety • Symptoms may resolve after 2-4 weeks of abstinence • Monitor GGT as appropriate • Potential indicator of treatment compliance • Maintain contact with treatment center and/or counselors to whom you referred patient • Request periodic updates on patient progress

23. Questions?