ATrain Education

 

Continuing Education for Health Professionals

Alcohol Use Disorders and Opioid Dependence Treated in Primary Care

Module 2

Screening, Brief Interventions, and Treatment

The US Preventive Task Force recommends screening all patients for alcohol misuse and addressing hazardous or harmful use through a brief intervention [10]. Screening instruments and evaluation protocols are important initial tools needed in addressing alcohol use/dependence and drug abuse [2, 3, 11, 12]. Screening instruments such as the AUDIT, ASSIST, CAGE questionnaire, or other validated tool can be utilized to determine hazardous or harmful alcohol use, as well as identifying drug abuse and opioid dependence to help inform the primary care provider in determining the level of care and treatment setting for the patient [13–15]. Screening and brief interventions to reduce alcohol use have been shown to be both acceptable to patients and effective in primary care, but barriers do exist [14–16]. For primary health care providers trained in screening, brief interventions, and referral to treatment, these barriers include lack of organizational support, lack of physician time, and inconsistent communication [16]. Training of primary health care providers in screening and brief interventions is most accepted using web-based training programs; however, curriculum-based traditional training programs of residents have been well received [17, 18]. Evidence supporting the application of universal screening and brief intervention for drug use is lacking [19, 20]. However, screening and brief intervention of adolescents, a time early in the use of illicit drugs such as cannabis, has shown some effectiveness [21, 22]. Keeping in view the high prevalence and associated morbidity and mortality of chronic drug and alcohol dependence [16], the impact of unidentified substance-related and addictive disorders on the management of comorbid conditions such as diabetes, heart disease, and liver disease [23], the natural history of substance-related and addictive disorders [4], and the availability of effective pharmacotherapies, the primary care health professional may give serious consideration to applying the same or similar screening and brief intervention strategies to all substance-related and addictive disorders. It would be good clinical practice, from the point of view of efficiency and utility, to implement and maintain a screening and brief intervention process that is comprehensive addressing not only alcohol use disorders, but also tobacco and other substances use and misuse [17].

Assessment and Referral

Screening and brief intervention for harmful or hazardous alcohol use is an important clinical tool for primary care providers to utilize and successfully deliver in their clinical practice. Beyond training and delivery of a brief intervention, an important component of primary care is the assessment of the patient and subsequent diagnosis of alcohol or drug dependence. Brief interventions may not be efficacious for individuals who are heavy drinkers, alcohol-dependent, or who have a severe co-occurring mental health problem [16, 24]. For those co-occurring disorder patients, providing screening and brief interventions through a trained psychologist may be a preferable clinical option. The option for the primary care provider is to assess which type of care, primary or referral specialty addiction treatment will be most beneficial to the patient. This assessment should also determine the patient’s need, motivation for and choice of treatment as well as establishing a baseline against which patient response to and choice of treatment (pharmacotherapy) or disease progression can be measured. This assessment should also note the likelihood of relapse during chronic management. While these complex issues might suggest a better clinical outcome from specially addiction treatment, a recent clinical trial of alcohol care management delivery in primary care compared to specialty addiction treatment suggests otherwise [25]. The results of this randomized clinical trial suggest that providing intensive care and pharmacotherapy in a primary care setting provides better clinical outcomes for patients with alcohol use disorders than those obtained in addiction specialty care. Thus, providing alcohol care management, including pharmacotherapy in primary care, can be an alternative to brief intervention and referral to addiction specialty care.

For opioid-dependent patients, the option for the primary care provider and patient is pharmacotherapy in primary care with either buprenorphine (partial opioid agonist) or naltrexone (opioid antagonist) or referral to an opioid treatment program where methadone (opioid agonist) or other controlled medications are dispensed under federal regulation [26]. An important consideration in this assessment is the common occurrence of fatal opioid overdose by patients in maintenance treatment on relapse to illicit opioid use [27].

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