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Screening Adults with Substance Use Problems

According to SAMHSA's National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4 percent of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2007. Of these individuals, 2.4 million (10.4 percent of those who needed treatment) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation or mental health center). Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it. (NIDA InfoFacts: Treatment Approaches for Drug Addiction)

A small percentage of our population meets actual diagnostic criteria for dependence on alcohol or other drugs. A much greater percentage has problems associated with their use or are at risk for developing dependency. The impact on and costs to our health, legal, social, familial, and workplace systems by those of us who have problematic usage and high risk factors for dependency are enormous and the benefits of prevention, early identification, education, and referral for treatment when indicated can greatly reduce those impacts and costs.

A national initiative known as SBRT (Screening, Brief Intervention and Referral to Treatment) has been underway for several years and is demonstrating the benefits of promoting these practices in many settings where people seek help or services. Doctors offices, public health clinics, emergency rooms, trauma centers, veterans centers, and college health centers as well as community settings such as behavioral health clinics, schools, social service offices, probation offices, and non-profit organizations provide opportunity for screening and education which can encourage individuals to change their behaviors and/or seek treatment.

Screening is a quick, simple way to identify patients who need further assessment or treatment for substance use disorders. It does not establish definitive information about diagnosis and possible treatment needs. (SAMHSA SBIRT website: Core Components/Screening) Use of scientifically validated screening tools is recommended and this website contains lists of screening instruments that Virginia DMAS will reimburse Medicaid providers for using. Most of these instruments are brief and easy to train staff to administer.

Screening provides an opportunity for education, regardless of the results. If someone screens positive, the next steps are to provide a brief intervention and referral. These interactions can “motivate” a person to think differently about their current behavior and to consider taking steps to explore the situation further with someone who has treatment expertise.

For specialized information regarding screening with pregnant women or with adults 65 and older, please see those sections of this Web site.

Tools for Adults Age 18-65

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Informing Your Discussion with “Stages of Change” Information

There are resources for helping you become more comfortable with discussing the results and recommending next steps and most of that information derives from our work in the area of motivational enhancement which includes approaches that help identify the “stage of change” an individual may be in and targets communication to match those stages. This approach often results in the person feeling less defensive and more open to considering the information and recommendations you are offering.

The Stages of Change Model was originally developed in the late 1970’s and early 1980’s by James Prochaska and Carlo DiClemente at the University of Rhode Island when they were studying how smokers were able to give up their habits and has been used to help people with a broad range of behaviors. The basic premise is that a change in behavior does not happen in one step. Rather, people tend to progress through different stages on their way to successful change. Also, each of us progresses through the stages at our own rate.

The Stages are: (More information can be found here:

Precontemplation - Not yet acknowledging that there is a problem behavior that needs to be changed
Contemplation - Acknowledging that there is a problem but not yet ready or sure of  wanting to make a change
Preparation/Determination - Getting ready to change
Action/Willpower - Changing behavior
Maintenance - Maintaining the behavior change and
Relapse - Returning to older behaviors and abandoning the new changes

Possible Behavior for Each Stage of Change in Plain English …

Precontemplation - “You may think this is an issue, but I don’t, and even if I do, I don’t want to do deal with it, so don’t bug me”.
Contemplation - “I’m willing to think with you, and consider if I want to change, but have no interest in changing, at least not now.”
Preparation/Determination - “I’m ready to start changing but I haven’t started, and I need some help to know how to begin.”
Early Action - “I’ve begun to make some changes, and need some help to continue, but I’m not committed to maintenance or to following all your recommendations.”
Late Action - “I’m working toward maintenance, but I haven’t gotten there, and I need some help to get there.”
Maintenance - “I’m stable and trying to stay that way, as life continues to throw challenges in my path.”

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Co-Occurring Substance Use and Mental Health Disorders

People with substance use problems often have more than one issue that they could use help with. National studies have taught us that complexity is the norm. “In general, these studies have found that around five million U.S. adult citizens have a serious mental illness and a co-occurring sub-stance use disorder (SAMHSA, 2006); more than 9 percent of adults have past year mood disorders (Grant et al., 2004; Kessler et al., 2005a); and more than 9 percent of individuals have past year substance use disorders (SAMHSA, 2006; Grant et al., 2004)… another study reports that 73 percent of persons with a drug dependence disorder in substance abuse treatment had a co-occurring mental disorder at some point during their lifetime (Compton et al., 2000). (Summarized by Sacks et al., 1997), those conducted in mental health settings found 20 to 50 percent of their clients had a lifetime co-occurring substance use disorder, while those conducted in substance abuse treatment agencies found 50 to 75 percent of their clients had a lifetime co-occurring mental disorder (however, usually not at a level that impairs a person’s ability to function normally and safely).” [“The Epidemiology of Co-occurring Substance Use and Mood Disorders”, SAMHSA/Co-occurring Center for Excellence, Overview Paper 8]

Upon making a decision to screen clients for substance use problems we recommend that, when possible, you use a screening instrument that will also screen for co-occurring concerns. Some of the highest rates of COD occur with persons who have experienced trauma or who are homeless. Trauma can be related to many life experiences. It can be the result of domestic violence, sexual assault, serving/living in a war zone, natural disaster, becoming homeless, witnessing a traumatic event, and more. Many persons who experience trauma “self medicate” to manage or cope with their distress and may screen positive for substance use problems. If your screening protocols include screening for trauma, staff should be trained in how to ask questions and provide follow up. Pressing individuals for more details about a traumatic experience than usual screening seeks may “trigger” symptoms of PTSD.

Please see below for a sample brief intervention.

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Setting up for Screening and Brief Intervention

If your office or organization is considering screening for substance use disorders and brief intervention, it is recommended that you put basic protocols in place to insure consistency, respect for the client relationship and follow through of results. The preparation steps described in “Alcohol Screening and Brief Intervention for Trauma Patients” (Alcohol Screening and Brief Interventions for Trauma Patients: Committee on Trauma Quick Guide, US Dept. of HHS/SAMHSA/CSAT) parallel the recommendations found in many resources:

IDENTIFY - staff who will conduct screening

DEFINE    - the target population of patients who will be screened

DEVELOP - Protocol for screening that includes which evidence-based instruments will be used and when and where screening will occur.

DEVELOP - Protocol for the Brief Interventions to patients who screen positive. Discussion of screening results and brief interventions must be done by staff who are considered qualified providers by DMAS or other sources of reimbursement.

DEVELOP - Protocol for record keeping that confirms that referral or other follow up has occurred and establishes mechanisms to ensure patient protection and confidentiality.

DEVELOP - reimbursement strategy.

Sample brief intervention
Additional resources

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