Hi everybody, I'm going to be presenting on Screening Evaluation and Diagnosis of Substance Use Disorders. My name is Antoine Doué, I'm a professor of psychiatry and medicine at the University of Pittsburgh School of Medicine. My big focus has been on substance use disorders as well as psychology of behavior change. These are my disclosures and research grants. They include funding from NIDA, NIMH, HRSA, SAMHSA, CDC, AFSP, and I get also royalties for academic books published by Oxford University Press, Springer, and PSI Publishing, as well as Get Oakstone CME royalties. So the focus of the lecture today is on the Screening Evaluation and Diagnosis of Substance Use Disorders, and the learning objectives will include, at the conclusion of the presentation, the participants will be able to first always maintain an empathic approach while doing even an evaluation and even before the screening approach, which is a big predictor of the empathic approach as a positive outcome in treating substance use disorders in general. In fact, the best predictor of a positive outcome is the empathic approach. To apply safety, confidentiality, and transparency in approaching substance use problems, to use motivational strategies as an approach to facilitate sharing and decreasing the discord in the therapeutic relationship, and to be familiarized with the screening of substance use disorders and the particular screening tools that we use for alcohol and drug use, and also to discuss the elements of brief intervention and screening and SBIRT, the brief intervention, as well as referral to treatment. What stands for SBIRT is Screening, Brief Intervention, and Referral to Treatment. And also we'll explain briefly the purpose of the ASAM criteria, the American Society for Addiction Medicine. And I know there will be separate lectures on that, but I will be very much presenting very briefly on the criteria. And also I'll describe the multidimensional components of an evaluation for substance use disorders. And very briefly also, I will review the screening instruments for substance withdrawal syndromes that will be also addressed in a different lecture. And also we'll discuss at the end the diagnosis of substance use and other substance-related disorders based on the most recent DSM-5 criteria. So the interrelated tasks, when you think about really the process of where it starts, it starts with the screening, and it leads to potentially, based on the screening itself, if the screening is positive, for an evaluation. I don't know that there's interchange of evaluation and assessment. I would prefer to use the word evaluation because evaluation has more of that quality of collaborating with patient. Assessment seems to be like more getting questions. Evaluation is really, yes, you get the material, you get the data, at the same time you engage the patient, and that could lead to the diagnosis. And as a result of having a diagnosis, it will inform a change plan, what the patient is really looking for in terms of making changes, and also it will really formulate what we call the addiction treatment. Remember, I said the first learning objective is to maintain always an empathic approach while even we're doing a screening tool and a screening task itself. And one of the strongest predictors of a practitioner's effectiveness in treating SUD treatments is the interpersonal empathic skills. And what I'm referring to with the accurate empathy is more that transposing yourself into the patient's world and trying to understand what they are going through, but that will incorporate basically the unconditional positive regard as well as genuineness and being present with the patient. And the way it is really done is through what we call reflective listening. Reflective listening is really guessing and having a hypothesis about what the patients mean and what the patient is saying. And the statements and the questions should avoid any sort of labeling, shaming, persuading, coercing, or warning, or using scare tactics, or sympathizing. Because these are all what we call roadblocks that can interfere with the ability for the patient to be honest and open about how they feel. And also, they feel judged and they feel that what they are really struggling with is not validated. So again, we need to be very, very careful about the language we use, even while we're doing the screening questions or instruments. And we need to focus on behaviors and experiences and avoiding being judgmental of patients. And most importantly, that therapeutic approach of empathy would create an atmosphere of safety and trust, and the patient would feel more comfortable sharing and opening up. In fact, you know, it's meeting the patients where they are. So this is really very crucial when I talk about establishing safety and confidentiality and transparency. The patient needs to feel safe to be able to engage and share what they are struggling with. And it's always very crucial to explain to the patients when you are doing a screening task, when you're engaging in the screening questions or instruments, to really be giving some kind of a few guidelines that can be helpful in presenting and discussing that. And discussing the purpose of the screening and even the evaluation if needed. And particularly, it refers to give a clear instruction as needed to complete the screening task, provide appropriate and accurate assurances about privacy and confidentiality, like whatever they're going to be sharing with us is going to be maintaining private and confidential, and explain as appropriate that this is a routine procedure that is used with almost all patients in that particular clinic. And this is very crucial because you don't normalize the fact that you're really engaging patients in that screening task because it's something that is done routinely in that clinic. And always remembering, you know, to listening and reflecting any concerns that they have. So you don't want it to be like a robotic approach. You want it to be more having the patients feel comfortable if they have some questions about the screening tool, to really share very openly about it. And you have to answer the patient's, you know, questions and concerns very honestly and in a very transparent way. We need to do whatever we can to minimize the impact of stigma. And as I mentioned, the exceptions to confidentiality would include the suicidality, homicidality, any situations related to child abuse or geriatric, you know, older patients abuse. Involvement of family and concerned significant others is crucial that the patient determine who the patient would determine as important supportive people in their lives. And ending an evaluation simply because the patient is not reluctant to share is totally inappropriate and it's not therapeutic. So again, you need to figure out also what is the reason, also what patients, you know, struggle with really sharing and talking about how they feel. Even starting with the screening process. The transparency, as I mentioned, includes clarification about why the practitioner is willing to be flexible in working with the patient. And always emphasizing that it's up to the patient to decide what they want to do, what change they want to make. This is what we call the self-determination theory, which is they decide what is right for them to do and also supporting their autonomy. There's going to be a lot of challenges in handling that sort of a process. At the same time, as long as we are really open and empathic with the patient, transparent, the patient is going to feel more safe and comfortable to discuss any potential challenges or obstacles that can really interfere with the whole process. Remember, I mentioned, you know, that in any sort of screening or even the evaluation piece, you know, using a motivation-interviewing approach. The motivation-interviewing approach really encompasses what we call that, you know, the interpersonal motivation, which really comes from the interaction with the person. So motivation itself, clinical motivation, is not a trait, it's a state. And we need to always keep in mind that there's going to be a lot of patients who are going to be less motivated to change, and we need to understand what they are ambivalent about. Ambivalence is normal, and some parts of them, part of the patients, feel that they want to change, the other part of them doesn't want to change for whatever reason, some part of them wants to quit using drugs, the other part of them doesn't want to quit using. We need to understand and explore that and help them, help the patients resolve their ambivalence. In the motivation-interviewing approach, there are two pieces, you know, in a way, two components. Relational piece, the relational piece is the accurate empathy that I talked about earlier, and the genuineness on condition of positive regard, and then the technical components and how it's done. It's not through really particular skills, as what we call the skills of open-ended questions, reflective listening, I already talked about, affirming people's efforts, as well as summarizing what they have shared with you. Always you need to keep in mind, pay attention to the patient's language, and because the patient's language is very crucial, it can be very predictive of change or not. For example, the change talk versus really sustained talk, the patient expressed more change talk about desire to change, reasons to change, ability to change is more predictive of change, and if they expressed sustained talk, we need to really soften that and really kind of help the patients move in the direction where we want to hear more change talk. And this can be incorporated in the evaluation feedback, you know, and how we do it basically is by kind of pointing out, you know, to the patients about really, you know, their ambivalence, pointing out to the patient about the reasons why they want to really change, and this is really very crucial because we want to really pay attention to the patient's change talk and patient's language, and make it therapeutic, make that evaluation therapeutic. Remember I said I prefer the word evaluation versus assessment because it would make it more kind of, the evaluation more therapeutic, you know, so you will be evaluating what they are struggling with at the same time, you will be trying to elicit some change talk from the patient. Okay, so next now is the screening tools. You know, in general things about the screening tools, most unfortunately screening instruments are too long to be used in clinical practice, too much of a burden on the patient, and too much of a burden on the practitioners, so we need to always remember to use any kind of instruments or tools that are really short, brief, simple, and it's more for identifying if a disorder is potentially present, which really requires, you know, post-screening the evaluation itself. It could be clinical questions and instruments, and we need to always keep in mind that there is a validity also of self-reports, when patients report how much they are really using and everything, there is a self-validity, there is a validity to that, and we need to choose valid and reliable screening tools, and the goal is to determine whether the patients should be referred for further evaluation based on the results of the screening, and two potential mistakes that can be related to sensitivity and specificity, it's basically false positive and false negative, which what you can see sometimes with some of the screening tools. The screening tools can be filled out by either the patient or the practitioner themselves, and as I mentioned, it's always sometimes or always confused with evaluation diagnosis. The screening is a screening more to initiate the process, whether the evaluation is needed, and if the evaluation is needed, as a result of that evaluation, what are really the criteria for the diagnosis. I'm going to review each one of those screening tools, but one of the things I want to mention actually is, with the screening tool, there are clinical questions, like the clinical questions is that, I'll discuss in the details a little bit about the NIAAA single question screen, and it's been recommended by the National Institute on Alcohol Abuse and Alcoholism back in 2005, but there are newer now guidelines that came out very recently. There is a single question about heavy drinking, and I will discuss it in a bit, and sometimes a single screening question is enough, it's sufficient in many settings. Some of the commonly used screening tools, the NIAAA, as I mentioned, single screening question screen, there is the CAGE, Audit, DAST, there is the ASSIST and NIDA Modified ASSIST, National Institute on Drug Abuse, there is the CRAFT, there are other screens, I'll talk about it in older adults as well as adolescents, and some of the screens are used in research tools, for example, there is the ACASI that we use sometimes, and it's called the Audio Guided Computer Assisted Self-Interview version of the ASSIST, and there are some biological markers that can be used, and there are also screening tools for co-occurring substance use and psychiatric disorders, or sometimes you know that you can do screening tools for substance use and the psychiatric disorders separately. So the first, as I mentioned, the NIAAA single question screen from the National Institute on Drug, on Alcohol Abuse and Alcoholism. So this is really studies done back in 2005, over 400 patients were screened in multiple family practice clinics. The one question is, do you sometimes drink beer, wine, or other alcoholic beverages? If they answered no, the screening is complete. If they answered yes, then you follow it with the next question, how many times in the past year have you had five or more drinks in a day for men, four or more drinks in a day for women? The response of one or more is a positive result, and then the patient should be referred for further evaluation. And in fact, you know what, the simple NIAAA screening question accurately identifies patients with an unhealthy alcohol use in a primary care setting. So we need to keep in mind that we need to be more informed about the standard, really drink what we consider as a standard drink too here. And you would want to probably explain to the patient what we mean by standard drink. And so they would give you an accurate description of how many drinks or how many times, you know, or what they drink particularly. So, and this is really important to keep in mind, apparently one study also showed that single question identified around 85% of individuals who had an alcohol use disorders and with very good sensitivity and good sensitivity and as well as good specificity. Specificity was in the 100 and specificity in the 75% in primary care settings. So I would recommend that you go on the website. I included here the newer kind of guidelines, you know, that NIAAA put together recently and that explains, you know, about also the single question screen, but also give a lot of details about alcohol use disorders. The CAGE questionnaire. The CAGE questionnaire is very short and easy to administer. Four questions. It takes five minutes to administer. It's usually helpful in initiating first conversation about substance use and the need for further evaluation. They are as followed. It stands, the CAGE, the C stands for cut down. Have you ever felt that you ought to cut down on your drinking or drug use either? Annoyed is for the A. Have people annoyed you by criticizing your drinking and your drug use? The guilt, which is for the G. Have you ever felt bad or guilty about your drinking or drug use? The eye opener is the E. Have you ever had a drink or used drink first thing in the morning to steady your nerves or get rid of a hangover? So it is really commonly, you know, seen, you know, the CAGE, you know, in fact, you know, it's the first thing that is really learned in medical school. And usually the cutoff point indicating a need for further evaluation post screening is two yes answers. And let me go here. It's been adapted to include drugs and it used to screen for what we call the alcohol dependence. Drugs under alcohol use disorder, which under severe, you know, and does not identify a harmful or hazardous drinking. It's been extensively validated. And as I mentioned, answering yes to one or more questions, usually, you know, like it's even two questions to, you know, in a sense, two yes answers is considered like a positive screen, which really kind of need to be referred for further evaluation. So the interesting part is that the specificity goes up when you have two or more questions answered as yes. One or more question answer yes had a specificity of 0.77 and sensitivity 0.79. For the two or more questions, there is more specificity than sensitivity. So we need to keep that in mind. So the next one is the audit. Audit is really commonly used, developed by the World Health Organization back in 93. Ten brief questions and the audit is the alcohol use disorder identification test that screens for hazardous and harmful drinking, suitable for primary care settings, maybe self-administered or done via an interview. Ten questions scored on a scale of 0 to 4, 0 to 7 low-risk abstainers. And all what you need to do is just more educational messages, put it this way, but it has to be done in a little bit of a motivational way, not to really tell people you shouldn't be drinking or, but just really to give them a feedback on the results of the test. 8 to 15 indicates a moderate risk in hazardous. Here the brief interventions could be very helpful and I'll talk about it. And 16 to 19, this is really very moderate to high risk. Here it will include probably multiple brief interventions over time or even referral to specialty care, because we're talking about really getting close to the severe alcohol use disorder as defined by the SM-5, as defined by earlier, you know, as a severe dependence. And when it comes to that point, brief interventions is helpful, but also sometimes medical intervention, even referral to treatment is very much needed. This is the audit, the regular audit, you know, here with all the questions. So there is a version of the audit, Audit C, you know, that is really, has three questions. And it's more sensitive than the original audit in detecting alcohol use disorder, particularly with women. The frequency of drinking is reduced to four or more drinks on occasion rather than six or more drinks as in the original questionnaire. So it really changes the sensitivity in a way. How often do you have a drink containing alcohol in the past year? How many drinks on a typical day? And how often did you have four or more drinks on one occasion? These are the main three questions of the Audit C, and it's scored on a scale of zero to 12. Each Audit C question has five answer choices. They valued from zero points to four points. In men, a score of four is considered positive and optimal for identifying hazardous drinking, risky drinking, or active use disorders, you know, in a sense, active alcohol use disorders. In women, a score of three or more is considered positive. Generally, the higher the score, the more likely it is that a person drinking is affecting their health and safety. So we need to keep that in mind. The Audit is really very much used on a regular basis, you know, and the version obviously of the Audit C versus really the regular Audit. And it's very quick, very easy, you know, to really use and very practical. I included, in fact, all these really references at the end of the lecture on the references slides. The DAST-10. The DAST-10 is a drug used in these years called Drug Abuse Screening Test. This is an old one. That's why the language is still abused. You know, it contains the screening question for at-risk drug use. It was developed by the Center for Addiction and Mental Health and self or practitioner administered. It does not include alcohol abuse, establishes a pattern of use for the last 12 months, which is really good. It gives you some kind of a sense of what's been going on in the past 12 months. It's a very sensitive screening tool for at-risk drug use and gives you a quantitative index of problems related to drug misuse. And the questions are answered on a yes or no basis with a scoring of one point for every yes answer. This is the screening, you know, in the link there. And the cumulative score of all answers is used to rate the degree of intensity of the drug use problem. And it's used to direct the recommended type of intervention. So this is really important to keep in mind. And it's been used, you know, the DAST for a long time. It was the DAST-20 that we're using, then the modified version with the DAST-10. And so you would need that kind of scoring here. Zero, no problems reported, no intervention needed. One to two, low risk, just to monitor, reassess later on for any worsening of drug use. Three to five, moderate risk, requires virtual evaluation. Six to eight, substantial risk, requires intensive assessment. These are the questions of the DAST, you know, and the 10, have you used drugs other than those required for medical reasons? Do you abuse more than one drug at a time? Are you always able to stop using drugs when you want to? Have you had blackouts or flashbacks as a result of drug use? Do you ever feel bad or guilty about drug use? You know, and the answer is, as I mentioned, yes or no. Does your spouse or parents ever complain about your involvement with drugs? Have you neglected your family because of the use of drugs? Have you engaged in illegal activities? Have you experienced withdrawal symptoms? Have you had medical problems as a result of your drug use? So these are really kind of gives you, you know, the sense of what these questions are about. And this refers to the past 12 months. The next screening tool is the ASIST, Alcohol, Smoking and Substance Use, Substance Involvement Screening List. It's been developed by WHO and asks seven questions on 10 substances, including one question about IV drug use. It's a kind of an extensive kind of test in a way. I'll tell you why that is now we use a modified version. It includes questions about alcohol and tobacco use. So it's very comprehensive from that aspect. It provides feedback about each level of risk to the patient with continued use. Low, which is 0 to 3, moderate 4 to 26, high 27 and plus. Keep that in mind. So 0 to 3, low 4 to 26, moderate high 27 plus. Cumulative score for each substance except for alcohol were low 0 to 10, moderate 11 to 26. So if the low risk scoring would require education, validation and encouragement and affirmation, you know that there is no major concerns here. The moderate risk, you know, we're talking about hazardous drinking. It requires a brief intervention and follow up. And any harmful behavior requires more intensive intervention, more series of brief interventions and refer to treatment if the person meets the criteria for substance use disorders. And if it's a high risk, which is 27 plus, it requires referral to specialize. I mean, you can do like a brief intervention to really brief motivational intervention to really kind of, in a sense, encourage or really motivate the person to follow through with treatment. So the NIDA modified assist came about, you know, and show you that. That will give you a little bit of a sense, you know, of how we do the NIDA quick screen and NIDA modified assist. First of all, you know, we introduced ourselves. We introduced what the screening tool is about. You know, remember I talked about it at the beginning, how much it's important to clarify that. And we make it very clear that it will only record those who you have, if you have taken them for reasons or in doses other than prescribed, which is crucial. And as you can see here from the slide, there is the alcohol, tobacco, prescription drugs for non-medical reasons and illegal drugs. And the way in terms of the past year, 12 months, again, in the past year, never once or twice, monthly, weekly, daily, or almost daily. So if the patient says no for all the drugs in the quick screen, you're going to need to really reinforce abstinence. This is the educational piece. And the screening is complete. If there is a yes to one or more days of heavy drinking, then the person is an at-risk drinker. And then you use the NIAAA that I mentioned, you know, website, which is how to help patients who drink too much. And this is, there is a newer version that I connected you with through the link there. And so you, for information about really the tobacco piece, you're talking about really also that can be used also for the alcohol. You kind of, in a way, assist, you advise, you assist, sorry, you assess, you advise, you assist, and you arrange. And if the patient says yes to the use of tobacco, again, let's consider, you know, that they are at risk. And obviously, you kind of do the brief interventions with the motivational advice to really quit using. And if the patient says yes to use of any illegal drugs or prescription drugs for non-medical reasons, and there is the question, one of the NIDA modified assist. So that's why, you know, it's really kind of there. And I've also included that in the, you know, references where you can go and see, you know, how it is really whole thing is divided. So again, the key things, you know, that there is the 12 months, you know, past year, you know, and there is really the presence of or absence of various diagnostic signs of alcohol and drug use. So this is really kind of the NIDA quick screen that can be used, you know, in any kind of a sort of settings, and it doesn't take really much time. The older adults, you know, in fact, you know, the older adults we need to keep in mind always that the blood testing for abnormal markers, ASD, AFD, MCB, are less specific because of medical issues that older adults have. The basic screening test may not work due to decreased patient's cognitive abilities and mental functioning, so we need to keep that in mind. We use the SBIRT, the Screening Brief Interventional Preferred Treatment, and we can use the NIDA modified assist, and, you know, in fact, since the patients have higher incidence of medical issues such as the falls, the best place to really use, to administer, you know, the SBIRT would be in the urgent care or emergency department setting. And older adults, the patients, you know, have different sensitivity and specificity to the screening test. I'm going to give you, for example, the MAST, you know, which is really the Michigan alcoholism screening test, you know, that is really used, you know, that, which has very much of a reasonable good track record in screening for alcohol, is really, sensitivity is one and specificity is .83. The CAGE can be used also, and, you know, which is .91 sensitivity and .48 specificity. So these are kind of, these specificity and sensitivities could be really basically seen on the exam too, you know, and we need to keep that in mind, and, you know, so, but the bottom line is that with older adults, we see the sensitivity and specificity as different for the screening tests themselves. So obviously screening for substance use in adolescents, usually the brief screening tools measuring past year frequency of use, effectively they identify SUD among youth, they are validated screening tools, screening to brief interventions, again, the SBIRT, the brief screener, you know, for tobacco, alcohol and drugs, you know, that is used also, and we need to always keep in mind that we have to screen for the tobacco vaping and all this alcohol prescription medication and other substances. There is basically a tool, the CRAFT screening tool interview, and usually it's a primary vehicle for screening children below the age of 21, and it's a two-part questionnaire. If the patient answers yes to any of the first three questions, the patient will be asked a set of six questions that correspond to each letter in the name, like I'll show you the next slide here. So after completing the screen, the total cumulative score is given. Score of more, you need to think about score of more or two, sorry, score of two or more is a positive screen and indicates that the adolescent is at high risk for having an alcohol or drug-related use, so that requires further assessment or evaluation. And those who report any use of alcohol or drugs have a CRAFT score of zero or one should be given the brief advice or brief intervention. So the brief intervention should be done even at a score of 0 to 1. A score of 4 to 6 have had an 80% of higher predictive value for a full-blown substance use disorders, obviously all terminology of use over dependence, but that is a full-blown. Let me show you the CRAFT screening. So here again you want to explain what the screening is about. I'm going to ask you a few questions that I ask all of my patients. I would appreciate you being honest and open about it. I'll keep your answers confidential and private. The Part A, during the past 12 months, did you drink any alcohol? No. More than a few sips. Did you smoke any marijuana or hashish? Did you use anything else or get high? If you answer yes, no. So the question is, did the patient answer yes to any questions in the Part A? Let's say they answered yes. You ask all the six CRAFT questions which are in the Part B. Have you ever ridden in a car driven by someone, including yourself, who was high, who has been using alcohol or drugs? Do you ever use alcohol or drugs to relax, feel better about yourself, fit in? Do you ever use alcohol or drugs when you are by yourself alone? Do you ever forget things you did while you're using alcohol or drugs? Number five, do your family or friends tell you that you should cut down on your drink or drug use? Number six, have you ever gotten into trouble while you were using alcohol or drugs? You know, that kind of really stands for the CRAFTS. If they answer no, then you stop, as I said, and you still do the brief intervention. So they end up saying really, you know, yes, but after you need like a further evaluation. For the pregnant and childbearing age patients, two screening questionnaires, the tweak and the taste, and that's limited to risky alcohol use. And there is the four Ps, you know, that plus screens for a range of substance can detect pregnant women with lower levels of alcohol, drug use, which can be putting them at risk, you know, for the medical issue, for problems during pregnancy. And the TAs and the tweak, the TAs and the tweak, you know, basically have a higher sensitivity for detecting preconceptual risky drinking than the audit or the mast. And this is the TAs, just to give you an idea about, it's the tolerance, cutback, and eye opener. Each yes answer scores one, except for tolerance question, which scores two points when answered yes. Any score greater than two, they should be referred for a full evaluation and assessment. It has a higher sensitivity than the audit for finding current use during pregnancy, risk for lifetime alcohol use disorder, risky drinking behaviors. So it has an advantage, you know, to really do it. The tweak, this is another really one, you know, it's kind of really another really screening tool. Patients are asked about tolerance. How many drinks can you hold? The greater than six drinks is positive. Worried about how, have close friends worried about your drinking, the eye openers, the amnesia, not remembering, obviously the the blackouting. And the K, which is the C, have you ever desired to cut down your drinking? Each yes answer scores one point, except as I mentioned before, tolerance scores two, cutback scores two for a yes answer. Any patient who scores two or more points should be referred for a full evaluation. The four Ps, you know, of the plus screen, the parents, partner, past, pregnancy. So these are the really the four, you know, that you want to think about in a sense, you know, and it's designed specifically to identify women who have substance use levels that fall below the DSM-4 that was, you know, prior to the DSM-5. So that was, so the level that fall below the DSM-4 criteria, but they are still at risk for any level of use of alcohol or illicit drugs. And the whole point of it, the screen is to identify women early in pregnancy treatment, brief intervention and prevention services are needed at that point in time for that population that should be available as a big part of a resource here. So again, we need to think about it. I included also this under the references, you know, just gives you an idea about, you know, that there are different type of ways to screen for the substance use during pregnancy. You remember, I kept talking about the brief intervention, the brief intervention, the BI, you know, originally it has been conceptualized as a frames, you know, and it's a public health approach that to deliver, you know, delivery of early intervention and treatment services. It's an early intervention treatment services for persons with substance use disorders to really also prevent them from really ending up with severe, moderate to severe substance use disorders. And it has been proven to be most effective for alcohol screening, but also can be helpful for drug use, but mostly for alcohol. So the originally it was conceptualized as a frames, frames was as feedback. You give the feedback about the screening in a, in a, in a very, you know, motivational way, or it's basically, you know, what you would have to really basically do is that, you know, you know, like it's the patient's responsibility pointing out that it's up to them to decide. So the R is for responsibility. A is basically the advice, you give the advice in a motivational way, as I said. M is a menu of options. Like these are the things that you could really do, what fits you the best. E, always maintaining an empathic approach. And S, it stands for self-efficacy, which is really really the self-confidence. So you want to really booster that, you know, and this is what, what the components of the early brief intervention. It's a form of treatment when you think about it. For some patients, it may be all what they need. And, and in fact, you know, it has, as I mentioned to you earlier, more a harm reduction impact, you know, how do they work? It is fascinating. There has been a lot of studies about that. The way it works, you know, it kind of activates what we call self-regulatory systems, which means people start thinking when you're really intervening and start talking about what they are struggling with, you know, how much they are drinking, what they are using, and then giving that feedback, they start kind of wondering, you know, should I change, not change? You know, so it kind of kindles that and activates what we call self-regulatory processes. It's been seen by the U.S. Preventive Services Task Force as the most clinically effective and cost-effective preventive service screen for alcohol use disorder in primary care. The referral to treatment approach, you know, piece is very much challenging because, you know, this is when you do it, when you really kind of identify that the patient might have an alcohol use disorder as severe or drug use disorder that requires specialized treatment, and it is not always to find these resources in the community. But it found that it's as effective as a screening tool for colorectal cancer, hypertension, with an average of 30 to 40 days savings for every 10 invested in screening. It's a secondary prevention. As I mentioned, it detects risky use, hazardous use, before it gets to a point where it's severe alcohol use disorder or drug use. So just to give you also a little bit more of the details about the SBIRT, the brief intervention, particularly, you know, and it can help reduce alcohol use as well at risk drinking by 10 to 30 percent during 12 months follow-up, and some reports even, you know, the extended impact over like 48 months. In trauma settings, you know, the screening and brief interventions, the SBI, seems to reduce drinking and drinking-related current injuries requiring emergency department care for hospitalization among identified at-risk drinkers. As I mentioned to you, it's mostly found effective for alcohol use. It has been inconclusive evidence in inpatient and adolescent patients. It uses the motivation-interviewing spirit, the skills and strategies. Remember, we talked about when you give feedback, you give the feedback in the positive way. So this is the result of your alcohol consumption, you know, what do you think about that, engaging information. You identify the risk and consequences on the patients present use, including the consequences it has others have had with similar results on their screen. It provides the patient with non-judgmental, motivationally-driven advice, as I mentioned earlier. Engage the patient so you can elicit motivation for change and strengthen that motivation. And remember, we talked about the importance of the language and the change talk needs to be elicited more. And it solicits the patient's commitment to what the treatment plan is going to be based on the level of motivation. If they are still ambivalent, they are still going to go back and forth. They are not going to come up with a treatment plan. But what the main central goal and aim of it is reduce the drinking and abstinence or even reduce the drug use. Remember, I talked about briefly, I would like to review the ASAM criteria, you know, the American Society of Addiction Medicine. It's in the fourth edition now. It used to be ASAM placement criteria. It includes three core components, the level of care assessment, decision rules, and continuum of care. So what would happen here is that when you're seeing a patient, you know, then you would have to decide where they fit in under the ASAM criteria, continuum of care, you know, for adults, you know, where at which level would make the most sense. And but the three components, as I mentioned, are the level of care, the decision rules, and the continuum of care. It has to be a person-centered approach. So you do not really basically match treatment to people, you match people to treatment. Based on where the patients are, you kind of review some menu of options. So it facilitates care for patients who require more extensive and intensive treatment that can be provided in primary care setting. It ensures access to appropriate levels of care by a practitioner who can do a specialized and complete assessment. And unfortunately, the scientific evidence is somewhat weak, because, you know, patients are the best, you know, people to know about what works best for them. I mean, yes, we want to kind of tell them that this is what could be potentially helpful in terms of pursuing treatment, but they might say, you know, I don't want to pursue, for example, inpatient rehabilitation program now, I would like to prefer intensive outpatient treatment. You're not going to tell them because based on the criteria that I'm going to put you in that category, you're going to go with whatever they believe they are willing to do and might really work for them. I would suggest this is the link here that you can visit and see, you know, how the fourth edition has evolved. These are the different levels that I'm talking about. Level one outpatient, outpatient therapy, medically managed outpatient, level two intensive outpatient, high intensity outpatient, level three is residential, and level four is medically managed. The level four medically managed, people who present, you know, with severe alcohol withdrawal, for example, they would need to be in a, you know, withdrawal management program that is really medically managed. So the complexity here is to keep in mind, you know, what makes it much more complex is the intoxication, the withdrawal, and the substance abuse disorders, and the dimensions of motivations. Remember, I talked about that before, that when we're moving from the screening to the evaluation, you know, we need to also get a sense of where they are in terms of their readiness for change. They're really, and the different dimension of motivation, I mentioned them to you, the language of change, you know, the, what we call it, and motivation to viewing, the D.A.R.N., the D.A.R.N., you know, acronym, which is the desire, ability, reasons, and need. Patients need to be expressing more that I need to change, these are the reasons I need to change, and the commitment piece, the commitment piece with what we call like the D.A.R.N. cats, the cats is commitment, you know, commitment is more than I need to change, this is how I'm going to do it, this is commitment, and there is A, which is the activation piece, and then the taking steps. Taking steps is that, let's say I want to really stop really drinking, and my first thing I'm going to really be doing is setting up an appointment with the drug and alcohol counsel. Ambivalence always kicks in at any point in time, we need to really normalize it and validate from that aspect, and obviously where they are in terms of the readiness for change that dictates that approach. So, when it comes to the evaluation components, what are the things that we evaluate, and it's a very multidimensional. First, you always need to think of treatment as beginning with the very first contact you have with the patient. You can bypass the therapeutic alliance, and always establishing safety and confidentiality as we discussed before, maintaining an empathic approach throughout the evaluation, assessing the nature and severity of substance use, where they are in terms of their motivation, so the dimension of motivation, what we identified as their strengths and resources, social support, who they identified as really available resources for them, always keeping in mind cultural factors that can play into it, functional analysis. Functional analysis is exactly trying to understand what has been really, what they've been using it for. You know, there are always really reasons people end up engaging in drug or alcohol use, and you want to get a better sense of really these reasons, you know, and the functional analysis seeks to understand what roles or functions these substances are playing in the person's life, and without that understanding, then you're not going to be able to really navigate the process of what sort of best treatment approach would be. You know, we look at them as, you know, obviously it includes the antecedents, you know, like triggers and stimuli that increase drug use and the likelihood of using, and the consequences of substance use, so we need to keep that in mind. There's the medical and psychiatric comorbidities, always we need to evaluate for that, because, you know, that kind of gives a different perspective if there's a co-occurring psychiatric disorder, trauma disorder, anxiety disorders, and the treatment matching and planning. The treatment matching and planning is going to depend on the patient motivation for change, and also engaging them in that kind of a conversation to see what they believe would be helpful for them. The screening for withdrawal symptoms, as I mentioned, you know, there are screening tools that are used for the withdrawal symptoms, you know, I'm going to mention the CIWA AR here, you know, and the, for the alcohol withdrawal, and there's the one for the cocaine selective severity assessment, the CSSA, there is the, for the opioid, the sows and the cows, you know, that are the most used. Again, they were reviewed more in details in other presentations. Just to give you an idea about the CIWA here. The next line is, I'm not sure if you can, okay, so screening, evaluation, evaluation, determining the diagnosis, diagnosis, informing the change plan, and the addiction. Diagnosis is based on the DSM-5 now and reflects significant changes in how substance use disorders are defined. You remember before, the whole classifications of abuse, dependence. We don't use the word addiction anymore, even though it's really still valid as a description, but in the DSM-5, it's more substance use disorders. The substance abuse and substance dependence category have been replaced by the substance use disorders. 11 diagnostic criteria for substance use disorder, I'm going to go through them. The DSM-40 current legal problems criteria has been dropped because every state has different kind of a really legal, you know, approach to it. There's a new criterion that was added, which is a craving or strong desire to use a substance, and the substance use disorder is measured on a continuum spectrum from mild to moderate to severe, and each specific substance other than caffeine is addressed as a separate disorder, but most substances are diagnosed based on the same overarching criteria. These are the criteria, you know, you need more than two items in 12 months, you know, you see here from the DSM-4, DSM-5, you know, now they are in the DSM, sorry, the DSM-4 abuse, the DSM-4 dependence, now they are all incorporated under substance use disorder. One is failure to fulfill responsibilities, two, use in physically hazardous situations, legal problems deleted, change to craving and urges to use, four, social and interpersonal problems, using larger amounts or longer than intended, six, cannot get down, seven, increased time spent to get used and recover, eight, give up or decrease other important part of life, nine, ongoing use despite consequences, negative consequences, problems, 10 tolerance, 11 withdrawal. So how would we rate that in terms of measuring on a spectrum? Mild two to three criteria, moderate four to five criteria, severe six criteria. These are the substance related disorders. You have a lot of them. The one I want to really kind of add here is that has been in the DSM-5 is a stimulant induced, you know, mild neurocognitive disorder. And this is really kind of, you know, was added, you know, and it's still kind of not clear how to really define it. But I mean, as you know, it's a mild neurocognitive disorder as a result of cocaine and methamphetamines. You know, before I want to move back to one thing that I, okay. So the whole diagnosis of substance use disorder, the purpose of the screening is determining whether further evaluation is warranted, right? We talked about that. And the evaluation is the ongoing process that begins with the first contact. Diagnosis has a different purpose. Diagnosis is meant to establish the seriousness of the condition and ideally determine the treatment approach. We compare the individuals presenting current symptoms with the specified criteria, and they would have to meet a predetermined criteria. And I went through all these criteria, the 11 criteria of the DSM-5. And usually a clinical interview provides a diagnosis. And some of these instruments were used mostly in research, which is the SCID, the Structured Clinical Interview for DSM-5. One thing I want to mention here, the criteria for substance-induced mental disorders. And this is in the DSM-5. The substance involved must be known to be capable of causing the disorder, like let's say cocaine or methamphetamine causing psychotic symptoms. Substances can be members of the 10 classes of drugs that typically cause substance-related disorders. And the criteria that should appear within one month of the use of a substance, whether intoxication or withdrawal, leading to significant impairment in functioning, not have manifested before the use of the substance, not happening solely during acute delirium caused by the substance, and not persisting for a substantial period of time. Initially, they said, you know, maybe 30 days or something, keeping in mind that if somebody would present with a substance-related mental disorder and they are in distress for a week, two weeks, let's say presenting with psychotic symptoms, you're not going to wait also that period of time to really treat them, you know, treat their condition aggressively. These are my references. And that's it. Thank you very much.

Substance Use Disorders

Screening Tools

Evaluation Components

Empathic Approach

Motivational Strategies

ASAM Criteria

DSM-5 Diagnostic Criteria

Brief Interventions

Motivational Interviewing

Treatment Planning