Screen, then Intervene: Conducting a Brief Intervention

Step 4: Advise, Assess, Assist and Arrange

This brief intervention gives patients a chance to learn about their drug use—especially as it pertains to their health—from an objective third party with medical training. It relies on the premise that advice from an expert has been shown to promote change.^11,12

Begin by reviewing screening results with the patient.

• Ask permission to have a short discussion about the screening results.
• Report back the types and amounts of use reported (giving patients the NIDA-Modified ASSIST tally sheet may be helpful).
  • Allow the patient to correct omissions so you get the full picture of use.
  • Prompt the patient: "Tell me more about your use of drug X and Y" (for each drug the patient reported).
• If the patient has used within the past 3 months, review other ASSIST responses.

ADVISE—Provide medical advice about the patient's drug use.

• Explain that it is your role as his/her medical provider to convey health recommendations
• Recommend quitting before problems (or more problems) develop. Give specific medical reasons.
  • Medically supervised detoxification may be necessary for discontinuing use of some drugs (e.g., benzodiazepines).

• Reminder:

  The screen is only one indicator of a patient's potential drug use problem. It is not a substitute for clinical judgement, which you should use to determine when an intervention is warranted.

  When appropriate, educate patients on the following:
  • Use of even small amounts of drugs or tobacco may negatively impact health and performance (e.g., driving or operating machinery).
  • Because drug intoxication can lead to impaired judgment and risky behaviors, refer all sexually active patients for confidential testing for HIV and other sexually transmitted diseases or provide an onsite testing opportunity, if they do not know their status or have not been tested recently. Encourage all patients to practice safe sex.
  • Refer all patients with past or current injection drug use (Question 7) for HIV and Hepatitis B/C testing if they have not been tested twice over a 6-month span following their last injection.
• Make referrals to evaluate suspected co-occurring conditions (e.g., psychiatric consultation for depressed, inattentive, or anxious patients or pain specialist consultation for patients seeking narcotic prescriptions for chronic nonmalignant pain).
• Provide recommendations based on risk level:

* Providers should be aware that many States mandate reporting of drug use during pregnancy and that failure to do so may be a prosecutable offense.

ASSESS the patient's readiness to quit.

• Have a conversation about whether the patient is ready to quit. For example, you might say something like, "Given what we've talked about, do you want to change your drug use?"
• If the patient is unwilling to quit, raise awareness about drugs as a health problem. Let patients who are not ready know that you will revisit the issue at future visits and have resources available when he/she decides to pursue making a change.
• If the patient is ready to quit, reinforce current efforts and then assist patient in their efforts to make changes that will help them reduce and/or quit their drug use.

ASSIST patient in making a change.

• Jointly complete a progress note form (Appendix 2) with the patient to document the screening results and create a followup plan.
• Help set concrete (and reasonable) goals for making a change (see Appendix 3: Change Plan Worksheet, for more information).
  • Ask interested patients to complete a change plan before they go home.
  • Make a copy without their name or the name of your office on it, give it to them to take home, and tell them you will check in on their progress at the next visit.
  • For patients who do not complete a change plan, schedule a second appointment to continue the discussion and to complete the change plan. You may provide a blank copy for them to take home and ask them to return with it, but some patients may need to start again with a fresh copy during their second appointment.
  • For patients not interested in completing a change plan, encourage them to set a few brief change goals (e.g., cutting back, trying a self-help group); record the goals to check progress at the next visit.
• Prescribe medications for office-based treatment of tobacco, alcohol, or opiate addiction, as appropriate.

ARRANGE specialty assessment, drug treatment, followup visit.

• Refer patients as appropriate.
  • Because the screening does not provide a diagnosis of abuse or dependence, refer high-risk patients for a full assessment. For moderate-risk patients and low-risk patients with special concerns (e.g., pregnant women, past injection drug users), use clinical judgment to determine whether additional assessment is necessary. Use SAMHSA's treatment locator (see additional resources, http://findtreatment.samhsa.gov/) or NIDA's National Drug Abuse Treatment Clinical Trials Network List of Associated Community Treatment Programs (see additional resources, www.drugabuse.gov/about-nida/organization/cctn/ctn) to locate assessment resources.
  • If nearby treatment resources are not available, consider providing support group contact information and self-change materials, as well as counseling resources—clergy or mental health referrals.
  • Obtain a written information release to send the screening results to all providers who will receive referrals.
• Schedule a followup appointment within 1–2 weeks for moderate and high-risk patients and low-risk patients in certain groups.
• Offer continuing support at followup visits.
  • Annual rescreening is indicated for patients who report any drug use at baseline (even with scores of 0–3) and for any other patients about whom you remain concerned. For moderate- and high-risk patients, rescreen at next appointment.
  • At followup, make targeted recommendations to moderate-, high- and select lower-risk patients accordingly: