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Download 36. Risk Management: Brief Intervention (McPherson)
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Case ID _____ SBIRT FLO Checklist PATIENT INFORMATION: o o o o o o Date _______/_______/_______ Staff Initials of Person Conducting SBIRT _______ Patient Age ______ yrs old Patient Sex/Gender _______ Patient Race ________ Patient Health Plan/Payer Source ________________________ (if no insurance, write in “uninsured”) OPENING <1 minute _______ Identify self and role on the team ______ Get patient’s permission to talk to them for a few minutes: o I’d like to ask you some personal questions. o Your answers are completely confidential. o You don’t have to answer if you feel uncomfortable. o We ask everyone these questions so we can provide the best care. _______ REFUSED screening PRESCREEN (AUDIT-C): Questions 0 1 2 1. How often do you have a drink Never Monthly 2-4 times containing alcohol? or less per month 2. How many drinks containing alcohol do you have on a typical day 1 or 2 3 or 4 5 or 6 of drinking? 3. How often do you have five or Never Less than Monthly more drinks on one occasion? monthly Scoring: 4+ for men and 3+ for women = positive alcohol screen for hazardous use. 3 2-3 times per week 4 4 or more times per week 7 to 9 Weekly 10 + Daily or almost daily Add items 1-3 PRESCREEN (DAST-2): 1-2 minutes Questions 1. Have you used drugs other than those required for medical reasons? 1-3 minutes Score 0 No 2. Do you abuse more than one drug No at a time? Scoring: 1+ for men and women = positive drug prescreen for risky use. 1 Score Yes Yes Add items 1-2 Recommended Level and Focus of Brief Intervention based on Screening Results: NEGATIVE SCREEN Inform client they screened negative for hazardous alcohol/drug use and are at low risk for health and other problems. Congratulate clients and encourage them to remain that way. Simple Advice can be offered. –STOP HERE POSITIVE SCREEN Inform client they screened positive for hazardous alcohol/drug use and are at risk for health and other problems. Provide BI. Conduct Referral. BRIEF INTERVENTION: For patients who screen positive. _______ REFUSED Brief Intervention (check here is patient refuses BI at any point after screening) _______ PURPOSE OF THIS SESSION is to: 1) Give you information about your drinking/drug use 2) Get your opinion about your drinking/drug use 3) Talk about what if anything you want to change about your drinking/drug use Case ID _____ “F” FEEDBACK USING BAC (Blood Alcohol Concentration) [Adapt for OTHER BIOASSAYS, e.g., urine)] ______ ______ ______ ______ ______ ______ Range: BAC can range from 0 (sober) to .4 (lethal) Anybody knows: .08 defines drunk driving, which is actually heavy drinking Normal drinking: is .03-.05 Give result: Your BAC was… Elicit reaction: What do you make of that? “WHAT ROLE IF ANY DO YOU THINK ALCOHOL PLAYED IN YOUR ______ (e.g., injury, getting arrested)?” “F” FEEDBACK USING AUDIT-C ______ ______ ______ ______ ______ ‘L’ 1-2 minutes [Adapt for DAST-2] 1-2 minutes Range: AUDIT-C can range from 0 (non-drinkers) to 12 (hazardous, harmful, risk use of alcohol) AUDIT has been given to thousands of people, so you can compare your drinking to others. Normal AUDIT-C scores are 0-4 for men and 0-3 for women, which is low-risk drinking Give result: Your score was…which places you in the category for higher risk of harm. Elicit reaction: What do you make of that? LISTEN AND ELICIT 1-5 minutes ______ Explore pros and cons of drinking/drug use (What do you like about drinking/drug use? What do like less about drinking/drug use?) ______ Summarize both sides (On the one hand…On the other hand…) ______ Ask about importance. (circle #) On a scale of 1-10, how important is it to you to… (change)? Why did you give it that number and not a lower number? What would it take to raise that number? (Not at all Important) 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 (Very Important) ______ Ask about confidence. (circle #) On a scale of 1-10, how confident are you that you can change successfully? Why did you give it that number and not a lower number? What would it take to raise that number? (Not at all Confident )1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 (Very Confident) “O” OPTIONS (Goal Setting) 1-5 minutes _______ Ask key questions: WHAT do you want to change? WHAT is your goal? (Offer MENUS of Options below) _______ Manage your drinking/drug use _______ Eliminate drinking/drug use from your life _______ Never drink/use drugs and drive _______ Utterly nothing _______ Seek help _______ Other goals __________________________________________________________________________ _______ If goal is set, ASK about the plan (How will you do that? Who will help you? What might get in the way?) CLOSE ON GOOD TERMS <1 minute ______ Summarize patient’s statements in favor of change ______ Emphasize their strengths EDUCATION & REFERRAL ______ ______ ______ <1 minute Give patient education brochures (e.g., “Rethinking Drinking: Alcohol and Your Health”) Give referral based on payer (i.e., health plan, self/uninsured) Identify referral resource (e.g., staff psychiatrist, health educator, social worker), specify here________________________ _______ THANK PATIENT for speaking with you. Recommended Reference: McPherson, T.L. & Goplerud, E. (March, 2014) FLO SBIRT Checklist. BIG Initiative: Spartanburg, SC training handout. For more information: Contact Dr. Tracy McPherson at NORC at the University of Chicago at [email protected] or visit http://bigsbirteducation.webs.com and http://hospitalsbirt.webs.com. Harmful Interactions mixing alcohol with medicines ct. . effe r SS his ca NE t a SI nsify ting OW nte era . DR y i op ery se ma en hin au L wh ac y c HO RE s m Ma LCO CA rou A E ge US r dan o Harmful interactions You’ve probably seen this warning on medicines you’ve taken. The danger is real. Mixing alcohol with certain medications can cause nausea and vomiting, headaches, drowsiness, fainting, or loss of coordination. It also can put you at risk for internal bleeding, heart problems, and difficulties in breathing. In addition to these dangers, alcohol can make a medication less effective or even useless, or it may make the medication harmful or toxic to your body. Some medicines that you might never have suspected can react with alcohol, including many medications which can be purchased “over-thecounter”—that is, without a prescription. Even some herbal remedies can have harmful effects when combined with alcohol. This pamphlet lists medications that can cause harm when taken with alcohol and describes the effects that can result. The list gives the brand name by which each medicine is commonly known (for example, Benadryl ® ) and its generic name or active ingredient (in Benadryl ® , this is diphenhydramine). The list presented here does not include all the medicines that may interact harmfully with alcohol. Most important, the list does not include all the ingredients in every medication. 1 Medications typically are safe and effective when used appropriately. Your pharmacist or other health care provider can help you determine which medications interact harmfully with alcohol. D I D YO U K N OW … Mixing alcohol and medicines can be harmful. Alcohol, like some medicines, can make you sleepy, drowsy, or lightheaded. Drinking alcohol while taking medicines can intensify these effects. You may have trouble concentrating or performing mechanical skills. Small amounts of alcohol can make it dangerous to drive, and when you mix alcohol with certain medicines you put yourself at even greater risk. Combining alcohol with some medicines can lead to falls and serious injuries, especially among older people. MEDICINES MAY HAVE MANY INGREDIENTS Some medications—including many popular painkillers and cough, cold, and allergy remedies—contain more than one ingredient that can react with alcohol. Read the label on the medication bottle to find out exactly what ingredients a medicine contains. Ask your pharmacist if you have any questions about how alcohol might interact with a drug you are taking. 2 SOME MEDICINES CONTAIN ALCOHOL Certain medicines contain up to 10 percent alcohol. Cough syrup and laxatives may have some of the highest alcohol concentrations. ALCOHOL AFFECTS WOMEN DIFFERENTLY Women, in general, have a higher risk for problems than men. When a woman drinks, the alcohol in her bloodstream typically reaches a higher level than a man’s even if both are drinking the same amount. This is because women’s bodies generally have less water than men’s bodies. Because alcohol mixes with body water, a given amount of alcohol is more concentrated in a woman’s body than in a man’s. As a result, women are more susceptible to alcohol-related damage to organs such as the liver. OLDER PEOPLE FACE GREATER RISK TIMING IS IMPORTANT Older people are at particularly high risk for harmful alcohol– medication interactions. Aging slows the body’s ability to break down alcohol, so alcohol remains in a person’s system longer. Older people also are more likely to take a medication that interacts with alcohol—in fact, they often need to take more than one of these medications. Alcohol and medicines can interact harmfully even if they are not taken at the same time. REMEMBER... Mixing alcohol and medicines puts you at risk for dangerous reactions. Protect yourself by avoiding alcohol if you are taking a medication and don’t know its effect. To learn more about a medicine and whether it will interact with alcohol, talk to your pharmacist or other health care provider. Commonly Used Medicines (Both Prescription and Over-the-Counter) That Interact With Alcohol Symptoms/ Disorders Medication (Brand name) Medication (Generic name) Allergies/ colds/flu • Alavert® • Atarax® • Benadryl® • Clarinex® • Claritin®, Claritin-D® • Dimetapp® Cold & Allergy • Sudafed® Sinus & Allergy • Triaminic® Cold & Allergy • Tylenol® Allergy Sinus • Tylenol® Cold & Flu • Zyrtec® Loratadine Hydroxyzine Diphenhydramine Desloratadine Loratadine Angina • Isordil® (chest pain), coronary heart disease Some possible reactions with alcohol Drowsiness, dizziness; increased risk for overdose Brompheniramine Chlorpheniramine Chlorpheniramine Chlorpheniramine Chlorpheniramine Cetirizine Isosorbide Nitroglycerin Rapid heartbeat, sudden changes in blood pressure, dizziness, fainting 3 Commonly Used Medicines (Both Prescription and Symptoms/ Disorders Anxiety and epilepsy Medication (Brand name) • Ativan® • BuSpar® • Klonopin® • Librium® • Paxil® • Valium® • Xanax® Medication (Generic name) Some possible reactions with alcohol Lorazepam Buspirone Clonazepam Chlordiazepoxide Paroxetine Diazepam Alprazolam Drowsiness, dizziness; increased risk for overdose; slowed or difficulty breathing; impaired motor control; unusual behavior; memory problems • Herbal preparations (Kava Kava) 4 Liver damage, drowsiness Arthritis • Celebrex® • Naprosyn® • Voltaren® Celecoxib Naproxen Diclofenac Ulcers, stomach bleeding, liver damage Attention and concentration (Attention deficit/ hyperactivity disorder) • Adderall ® Amphetamine/ dextro-amphetamine Methylphenidate Dizziness, drowsiness, impaired concentration (methylphenidate, dexmethylphenidate); possible increased risk for heart problems (amphetamine, dextroamphetamine, lisdexamfetamine); liver damage (atomoxetine) • Concerta ®, Ritalin ® • Dexedrine ® • Focalin ® • Strattera ® • Vyvanse ® Dextroamphetamine Dexmethylphenidate Atomoxetine Lisdexamfetamine Warfarin Occasional drinking may lead to internal bleeding; heavier drinking also may cause bleeding or may have the opposite effect, resulting in possible blood clots, strokes, or heart attacks Blood clots • Coumadin® Cough Dextromethorpan Drowsiness, dizziness; • Delsym®, increased risk Robitussin Cough® Guaifenesin + codeine for overdose • Robitussin A–C® Over-the-Counter) That Interact With Alcohol Symptoms/ Disorders Depression Diabetes Enlarged prostate Medication (Brand name) Medication (Generic name) • Abilify® Aripriprazone • Anafranil® Clomipramine Citalopram • Celexa® • Clozaril® Clozapine Duloxetine • Cymbalta® • Desyrel® Trazodone Venlafaxine • Effexor® Amitriptyline • Elavil® • Geodon® Ziprasidone Paliperidone • Invega® ® • Lexapro Escitalopram Fluvoxamine • Luvox® Phenelzine • Nardil® Desipramine • Norpramin® ® • Parnate Tranylcypromine • Paxil® Paroxetine • Pristiq® Desevenlafaxine • Prozac® Fluoxetine • Remeron® Mirtazapine Risperidone • Risperdal® Quetiapine • Seroquel® • Serzone® Nefazodone • Symbyax® Fluoxetine/Olanzapine • Wellbutrin® Bupropion Sertraline • Zoloft® Olanzapine • Zyprexa • Herbal preparations (St. John’s Wort) • Diabinese® • Glucotrol® • Glucophage® • Glynase®, DiaBeta®, Micronase® • Orinase® • Tolinase® Chlorpropamide Glipizide Metformin Glyburide • Cardura® • Flomax® • Hytrin® • Minipress® Doxazosin Tamsulosin Terazosin Prazosin Tolbutamide Tolazamide Some possible reactions with alcohol Drowsiness, dizziness; increased risk for overdose; increased feelings of depression or hopelessness (all medications); impaired motor control (quetiapine, mirtazapine); increased alcohol effect (bupropion); liver damage (duloxetine) Monoamine oxidase inhibitors (MAOIs), such as tranylcypromine and phenelzine, when combined with alcohol, may result in serious heartrelated side effects. Risk for dangerously high blood pressure is increased when MAOIs are mixed with tyramine, a byproduct found in beer and red wine Abnormally low blood sugar levels, flushing reaction (nausea, vomiting, headache, rapid heartbeat, sudden changes in blood pressure); symptoms of nausea and weakness may occur (metformin) Dizziness, light headedness, fainting 5 Commonly Used Medicines (Both Prescription and Symptoms/ Disorders Medication (Brand name) Some possible reactions with alcohol Heartburn, • Axid® indigestion, • Reglan® sour stomach • Tagamet® • Zantac® Nizatidine Metoclopramide Cimetidine Ranitidine Rapid heartbeat; increased alcohol effect; sudden changes in blood pressure (metoclopramide) High blood pressure • Accupril® • Calan® • Capozide® • Cardura® • Catapres® • Cozaar® • Hytrin® • Lopressor® HCT • Lotensin® • Minipress® • Norvasc® • Prinivil®, Zestril® • Vaseretic® Quinapril Verapamil Hydrochlorothiazide Doxazosin Clonidine Losartan Terazosin Hydrochlorothiazide Benzapril Prazosin Amlodipine mesylate Lisinopril Dizziness, fainting, drowsiness; heart problems such as changes in the heart’s regular heartbeat (arrhythmia) • Advicor® • Altocor® • Crestor® • Lipitor® • Mevacor® • Niaspan® • Pravachol® • Pravigard™ Liver damage (all medications); increased flushing and itching (niacin), increased stomach bleeding (pravastatin + aspirin) • Zocor® Lovastatin + Niacin Lovastatin Rosuvastatin Atorvastatin Lovastatin Niacin Pravastatin Pravastatin + Aspirin Ezetimibe + Simvastatin Simvastatin • Acrodantin® • Flagyl® • Grisactin® • Nizoral® • Nydrazid® • Seromycin® • Tindamax® • Zithromax® Nitrofurantoin Metronidazole Griseofulvin Ketoconazole Isoniazid Cycloserine Tinidazole Azithromycin Fast heartbeat, sudden changes in blood pressure; stomach pain, upset stomach, vomiting, headache, or flushing or redness of the face; liver damage (isoniazid, ketoconazole) High cholesterol • Vytorin™ Infections 6 Medication (Generic name) Enalapril Over-the-Counter) That Interact With Alcohol Symptoms/ Disorders Mood stabilizers Medication (Brand name) • Depakene®, Depakote® • Eskalith®, Eskalith®CR, Lithobid Medication (Generic name) Valproic acid Lithium Some possible reactions with alcohol Drowsiness, dizziness; tremors; increased risk for side effects, such as restlessness, impaired motor control; loss of appetite; stomach upset; irregular bowel movement; joint or muscle pain; depression; liver damage (valproic acid) Muscle pain • Flexeril® • Soma® Cyclobenzaprine Carisoprodol Drowsiness, dizziness; increased risk of seizures; increased risk for overdose; slowed or difficulty breathing; impaired motor control; unusual behavior; memory problems Nausea, motion sickness Meclizine Dimenhydrinate Promethazine Drowsiness, dizziness; increased risk for overdose Pain • Advil® (such as • Aleve® muscle ache, • Excedrin® minor arthritis pain), fever, • Motrin® inflammation • Tylenol® Ibuprofen Naproxen Aspirin, Acetaminophen Ibuprofen Acetaminophen Stomach upset, bleeding and ulcers; liver damage (acetaminophen); rapid heartbeat Seizures Phenytoin Gabapentin Drowsiness, dizziness; increased risk of seizures (levetiracetam, phenytoin); unusual behavior and changes in mental health (such as thoughts of suicide) (topiramate) • Antivert® • Dramamine® • Phenergan® • Dilantin® • Horizant®, Neurontin® • Keppra® • Klonopin® • Lamictal® • Lyrica® • Tegretol® • Topamax® • Trileptal® Levetiracetam Clonazepam Phenobarbital Lamotrigine Pregabalin Carbamazepine Topiramate Oxcarbazepine Barbiturates 7 Commonly Used Medicines (Both Prescription and Over-the-Counter) That Interact With Alcohol Symptoms/ Disorders 8 Medication (Brand name) Medication (Generic name) Some possible reactions with alcohol Drowsiness, dizziness; Propoxyphene increased risk for overdose; Merepidine Butalbital + codeine slowed or difficulty breathing; impaired motor control; unusual behavior; Oxycodone memory problems Hydrocodone Severe pain from injury, postsurgical care, oral surgery, migraines • Darvocet–N® • Demerol® • Fiorinal® with codeine • Percocet® • Vicodin® Sleep problems Zolpidem • Ambien® Eszopiclone • Lunesta™ Estazolam • Prosom™ ® Temazepam • Restoril Diphenhydramine • Sominex® Doxylamine • Unisom® • Herbal preparations (chamomile, valerian, lavender) Drowsiness, sleepiness, dizziness; slowed or difficulty breathing; impaired motor control; unusual behavior; memory problems Increased drowsiness Additional resources MedlinePlus A service of the U.S. National Library of Medicine and the National Institutes of Health. http://www.nlm.nih.gov/medlineplus/ druginformation.html Provides information on prescription and over-the-counter medications. National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov Phone number: 301–443–3860 Makes available free informational materials on alcohol use, alcohol abuse, and alcoholism. U.S. Food and Drug Administration Center for Drug Evaluation and Research http://www.fda.gov/cder Phone numbers: • Main FDA for general inquiries: 1–888–INFO–FDA (1–888–463–6332) • Drug Information: 301–827–4570 • To submit a report about Adverse Drug Reaction: Medwatch: 1–800–FDA–1088 Provides information on prescription and over-the-counter medications, consumer drug information, and reports and publications. 9 NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM NIH . . . Turning Discovery Into Health NIH Publication No. 13–5329 Published 2003 Revised 2014 Guideline for Tobacco Cessation and Secondhand Smoke Exposure Evidence indicates that patients are more likely to quit tobacco when clinicians intervene. • Integrate interventions for tobacco cessation and secondhand smoke exposure reduction into every interaction with the patient by using the 5As approach. • Utilize a combination of behavioral change counseling (including the Colorado QuitLine) and pharmacotherapy treatments for the highest rates of abstinence success. • Inform about the health risks of secondhand smoke exposure - especially children; encourage the establishment of smoke-free environments. Tobacco dependence (current or former) is a chronic relapsing disease that requires a systematic approach and may require repeated clinician interventions for multiple patient quit attempts. ASK ASK • ASK every patient at each encounter about tobacco use and document status. »» If patient recently quit using tobacco, reassess abstinence status, address possible relapse, and congratulate success. • ASK the patient if they are exposed to secondhand smoke, or if the person who cares for their children smokes. ADVISE ARRANGE ADVISE ASSIST ASSESS If you have limited time: ASK ADVISE REFER • ADVISE every tobacco user to quit smoking with a clear, strong and personalized health message about the benefits of quitting. • Discuss the health risks of secondhand smoke exposure on household members, especially children, and ADVISE them to always smoke outside and to create smoke-free home and car environments. ASSESS • ASSESS the willingness to make a quit attempt within the next 30 days: »» If willing, proceed to the next step: “ASSIST” »» If not willing, use strategies of empathy, listening reflectively and open ended questions to enhance patient’s motivation to quit: »» Address the appropriate 5 Rs with encouragement and support self-reliance in a non-confrontational manner: ›› Relevance - search for patient’s personal important reason(s) to quit ›› Risk - ask patient to identify what are the harms to continued tobacco use ›› Rewards - have patient talk about benefits of quitting ›› Roadblocks - have patient discuss barriers and fears to quitting ›› Repetition - review the relevant 5 Rs at each visit ASSIST • ASSIST by referring the patient to the Colorado QuitLine at 1-800-QUIT-NOW (1-800-784-8669) and/or • Provide positive practical behavioral coaching as part of a quit plan: »» Practical problem solving and coping skills training ›› Discuss cessation tips: set a quit date, create smoke-free environments, avoid high risk situations, and identify triggers ›› Provide tailored self-help materials for cessation and reducing secondhand smoke exposure ›› Establish a system of self-rewarding success (e.g.: money saved, improved sense of taste) »» Social support: ›› Use encouragement, communicate caring and concern, assist with establishing support of friends and family • Offer tailored pharmacotherapy treatments (see reverse side). • AGREEMENT: collaboratively set specific quit goals and address barriers (e.g.: weight gain, fear of failure). ARRANGE 1-800-QUIT-NOW 1-800-784-8669 Additional Resources: • ARRANGE a follow-up contact within the first week after the quit date or QuitLine referral and a second follow-up contact within the first month. • Ongoing monitoring for relapse; if relapse occurs, reassure this is normal and use lapse as a learning experience, identify triggers and plan next quit attempt. • Congratulate successes! Reference: • CCGC Website: www.coloradoguidelines.org/tobacco • Free office toolkits and materials: www.cohealthresources.com • Colorado QuitLine: 1-800-QUIT-NOW (1-800-784-8669) or www.myquitpath.org • Provider Website: www.cohealthproviders.com • Surgeon General’s Website: www.surgeongeneral.gov/tobacco/ For important updates, special clinical considerations, additional information and copies of the guideline, email CCGC at [email protected] OR call (720) 297-1681 OR (866) 401-2092. This guideline is designed to assist clinicians in the management of patients with tobacco use and/or secondhand smoke exposure. This guideline is not intended to replace a clinician’s judgment or establish a protocol for all patients with a particular condition. www.coloradoguidelines.org/tobacco Funded with proceeds from the 2004 state tobacco excise tax Pharmacotherapy Treatments: Tobacco Cessation Medication Classification and Dosages Category Drugs Recommended Dosage Tobacco use should be approached as a chronic relapsing disease. Pharmacotherapy should be offered for all patients attempting to quit smoking except when contraindicated. The average smoker has multiple attempts to quit before successful abstinence. Combination therapy options: Nicotine patch + other NRT or Nicotine patch + Bupropion SR Current evidence is insufficient and risk/benefits should be discussed with these patients: light smokers, adolescents, smokeless tobacco users, and pregnant patients. Recommended Duration Relative Cost Index: 1ppd = $$ (av $150/mo) NRT (nicotine replacement therapy) Nicotine Patch/transdermal (NicoDerm CQ, Habitrol, Nicotrol) > 10 cigs/day: use 21 mg/24 hrs for 6-8 wks, then 14 mg/24 hrs for 2-4 weeks, then 7mg/24 hrs for 2-4 weeks Up to 10 weeks < 10 cigs/day: use 15 mg/16 hrs for 6 weeks Nicotine Gum (Nicorette) 1-24 cigs/day: 2 mg gum (every 1- 2 hrs up to 24 pieces/day) 25+ cigs/day: 4 mg gum (every 1- 2 hrs up to 24 pieces/day) Up to 12 weeks Contraindications/Precautions Consult package insert for full list of precautions, contraindications, use in pediatrics, and drug interactions Adverse Side Effects/Treatment Tips These are general categories; individual patient reactions may vary Pregnancy (weigh risk vs. benefit) • • • • • OTC $ Available from QuitLine with program enrollment Contraindicated: • Recent (</= 2 weeks) myocardial infarction, • severe arrhythmias, • unstable angina Precautions: • TMJ disease • Local skin reaction • Insomnia, abnormal or change in dreams • Headache • GI nausea, gas, dyspepsia, constipation Cat D OTC $$$ Contraindicated: • Recent (</= 2 weeks) myocardial infarction, • severe arrhythmias, • unstable angina • Jaw pain, mouth or throat soreness, throat nasal and mouth irritation • Insomnia, abnormal or change in dreams • GI nausea, gas, dyspepsia, constipation Cat C Contraindicated: • Recent (</= 2 weeks) myocardial infarction, • severe arrhythmias, • unstable angina • Jaw pain, mouth or throat soreness, throat nasal and mouth irritation • Headache • GI nausea, gas, dyspepsia, constipation Cat D Cat D No food or drink 15 minutes before use “Chew and Park” technique Nicotine Lozenge (Commit) 2 mg for those who smoke their first cigarette more than 30 min after waking 4 mg for those who smoke their first cigarette within 30 min of waking Up to 12 weeks: wks 1- 6: 1 loz/ 1-2 hrs wks 7-9: 1 loz/ 2-4 hrs wk 10-12: 1 loz/ 4-8 hrs OTC $$$ No food or drink 15 min before use Nicotine Oral Inhaler (Nicotrol Inhaler) 6-16 cartridges/day; puff each cartidge for up to 20 minutes Each cartridge 4 mg 10 puffs inhaler=1 puff cigarette Medications prescription $$$ Contraindicated: • Recent (</= 2 weeks) myocardial infarction, • severe arrhythmias, • unstable angina • Jaw pain, mouth or throat soreness, throat nasal and mouth irritation • Headache Nicotine Nasal Spray (Nicotrol NS) 8-40 sprays/day: 1 dose = 1 spray/ nostril 1-2 doses/ hr (maximum 5 doses/hr or < 40 doses/day) Up to 3 - 6 months prescription $$ Contraindicated: • Recent (</= 2 weeks) myocardial infarction, • severe arrhythmias, • unstable angina Precautions: • Severe reactive airway disease • Underlying chronic nasal disorders (rhinitis, nasal polyps, sinusitis) • Jaw pain, mouth or throat soreness, throat nasal and mouth irritation • GI nausea, gas, dyspepsia, constipation Bupropion SR (Zyban) 150 mg/day for 3 days, then 150 mg/day BID from day 4 to end of treatment (begin treatment 1-2 weeks pre-quit) Up to 12 weeks Maintenance up to 6 months prescription $$ Contraindicated: • Patients with seizure disorders, bulimia or anorexia nervosa (eating disorders) • Patients with bipolar and schizophrenia, MAO use within previous 14 days • Simultaneous abrupt discontinuation of alcohol or sedatives • Suicide risk (Black box warning): increased in children, adolescents, and young adults • Insomnia, abnormal or change in dreams • Headache 0.5 mg/day on days 1-3, 0.5 mg BID on days 4-7, then 1 mg BID from day 8 to end of treatment (begin treatment 7 days pre-quit date) 12 weeks treatment: may consider additional 12 weeks to enhance cessation prescription $ Warning/precaution: • Renal impairment, dialysis, psychiatric condition • Serious psychiatric illness: monitor frequently for depressed mood, agitation, changes in behavior, suicidal ideation and suicide • Monitor neuropsychiatric symptoms • Use caution driving or operating machinery until you know how quitting smoking and/or using CHANTIX may affect you. • Insomnia, abnormal, strange or vivid dreams • Headache • GI nausea, gas, dyspepsia, constipation Varenicline (Chantix) Reference: 6-16 cartridges/day; puff each cartidge for up to 20 minutes Each cartridge 4 mg Treating Tobacco Use and Dependence; US Department of Health and Human Services Public Health Service, 2008 For important updates, special clinical considerations, and effectiveness information, visit www.coloradoguidelines.org/tobacco 3rd revision: 5/2009 2nd revision: 2/2007 1st revision: 11/2004 Original: 9/2002 Cat D Cat C Cat C Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. SECTION 1: Screening and Monitoring Instruments The PHQ2/9 can be effectively used to screen for depression with adolescents, adults, and seniors. The additional screens offer greater sensitivity for select populations and psychiatric conditions. PHQ-2/9 (Patient Health Questionnaire) PHQ-2: The first two questions of the PHQ-9 are recommended as the first step to screen for current depression. It can be administered orally or self-administered on a written form. It may be scored as a “yes/no” questionnaire or using a Likert scale to assess symptom frequency. Scoring the PHQ-2: A positive score is: 1. “Yes” to either question; or 2. A score >3 using the Likert scale (which is aligned with the PHQ-9 scoring criteria): Over the past two weeks, how often have you been bothered by any of the following problems? 2. Feeling down, depressed, or hopeless. 1. Little interest or pleasure in doing things. 0 = Not at all 0 = Not at all 1 = Several days 1 = Several days 2 = More than half the days 2 = More than half the days 3 = Nearly every day 3 = Nearly every day Total point score:_______________ A patient with a positive PHQ-2 should complete the full PHQ-9. PHQ-9: This 9-item questionnaire to assess symptoms of depression during the past two weeks scores each of the 9 DSM-IV criteria and is derived from the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic tool. The PHQ-9 is available in more than 80 languages and no permissions or cost are required to use it. Download at: http://www.phqscreeners.com The PHQ-9 can also be downloaded at: http://www.healthteamworks.org/guidelines/depression.html Recommended use: • To assess symptoms and functional impairment and make a tentative diagnosis of depression • To assess severity of depressive symptoms and assist with treatment planning • To monitor treatment effectiveness • May be self-administered on a written form or administered orally by a member of the healthcare practice team Scoring the PHQ-9: • Instructions are included on the PHQ-9 form. • It is simple to score by hand and can be embedded in an EHR. • Question #9 (about self harm) should always be reviewed before the patient leaves the clinic. page 1 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. Suicide Risk Assessment The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) was adapted from the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors and developed with funding from SAMHSA. Available free at: http://www.stopasuicide.org/downloads/Sites/Docs/SAFE-T_One_Page_Final.pdf Edinburgh Postnatal Depression Scale The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a validated screening tool to identify patients at risk for perinatal depression. It is available in multiple languages. To download the scale in English: http://www.aap.org/practicingsafety/toolkit_resources/module2/epds.pdf Spanish version: http://steppingup.washington.edu/keys/documents/EPDSSpan.pdf Geriatric Depression Scale This questionnaire was developed as a basic screening measure for depression in older adults. It is in the public domain and available in multiple languages. Download at: http://www.stanford.edu/~yesavage/GDS.html Cornell Scale for Depression in Dementia Depression and dementia frequently co-occur. This screening tool assesses signs and symptoms, and utilizes a comprehensive interviewing and observational approach that derives information from the patient and the informant. To download the scale and a guide to administration and scoring: http://healthteamworks-media.precis5.com/depression-in-dementia-cornell-scale Assessment of Bipolar Disorder Patients with bipolar disorder are more likely to seek care for their depressive states than for their manic or hypomanic states. Differentiating between unipolar depression and bipolar depression is important because starting antidepressant medication in a person who has bipolar depression can be destabilizing (it may contribute to increased anxiety /hypermania) and because failure to detect the bipolar depression means that the person is less likely to receive the appropriate treatment for that condition. The initial assessment of depression should include questions about a history of bipolar depression/mania. The MDQ is a screening tool for bipolar disorder. Note that there is a cost associated with using the MDQ. For additional information and to order copies go to: www.jblearning.com. To view the MDQ go to: http://www.dbsalliance.org/pdfs/MDQ.pdf page 2 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. Assessment of Generalized Anxiety Disorder (GAD) The GAD-7 is from the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool containing modules on 12 different mental health disorders. It can be downloaded and used at no cost from: http://www.phqscreeners.com/ Screening Brief Intervention Referral to Treatment (SBIRT) Guideline This guideline summarizes screening and appropriate intervention for risky/unhealthy use of alcohol, tobacco, and illicit or prescription drugs. Developed by HealthTeamWorks and available at: http://www.healthteamworks.org/guidelines/sbirt.html Post Traumatic Stress Disorder Screening The Primary Care PTSD Screen (PC-PTSD) is a 4-question screening tool designed for use in primary care and other settings and is also currently used to screen veterans for PTSD at the VA. The introductory (first) question cues the respondent to traumatic events that they may have experienced. In most cases, the screen should be considered “positive” if a patient answers “yes” to any of the three items. Individuals with a positive screen should be assessed with a structured assessment such as the Posttraumatic Stress Disorder Checklist for Civilians (PCL-C). PC-PTSD: http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp PCL-C in English (includes scoring info.): http://www.pdhealth.mil/guidelines/downloads/PCL_Primer.pdf PCL-C in Spanish: http://healthteamworks-media.precis5.com/pcl-spanish PTSD CheckList – Civilian Version (PCL-C) The PCL is a standardized self-report rating scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD. Two versions of the PCL exist: 1) PCL-M is specific to PTSD caused by military experiences and 2) PCL-C is applied generally to any traumatic event. The PCL can be easily modified to fit specific time frames or events. For example, instead of asking about “the past month,” questions may ask about “the past week” or be modified to focus on events specific to a deployment. How is the PCL completed? • The PCL is self-administered • Respondents indicate how much they have been bothered by a symptom over the past month using a 5-point (1–5) scale, circling their responses. Responses range from 1 Not at All – 5 Extremely How is the PCL Scored? 1) Add up all items for a total severity score, or 2) Treat response categories 3–5 (Moderately or above) as symptomatic and responses 1–2 (below Moderately) as non-symptomatic, then use the following DSM criteria for a diagnosis: - Symptomatic response to at least 1 “B” item (Questions 1–5), page 3 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. - Symptomatic response to at least 3 “C” items (Questions 6–12), and - Symptomatic response to at least 2 “D” items (Questions 13–17) Are Results Valid and Reliable? Two studies of both Vietnam and Persian Gulf theater veterans show that the PCL is both valid and reliable Adverse Childhood Experiences The Adverse Childhood Experiences (ACE) Study is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. It is analyzing the relationship between multiple categories of childhood trauma and health and behavioral outcomes later in life. To read about the study: http://www. acestudy.org/ What’s an ACE? Growing up experiencing any of the following conditions in the household prior to age 18: 1. Recurrent physical abuse 2. Recurrent emotional abuse 3. Contact sexual abuse 4. An alcohol and/or drug abuser in the household 5. An incarcerated household member 6. Someone who is chronically depressed, mentally ill, institutionalized, or suicidal 7. Mother is treated violently 8. One or no parents The ACE Study used a simple scoring method to determine the extent of each study participant’s exposure to childhood trauma. Exposure to one category (not incident) of ACE, qualifies as one point. When the points are added up, the ACE Score is achieved. The ACE study found that persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease (1998; American Journal of Preventive Medicine). To access the ACE score calculator: http://healthteamworks-media.precis5.com/ace-score-calculator Resources for Adolescent Depression Screening and Assessment Recommended screening tools: 1. Guidelines for Adolescent Depression in Primary Care (GLAD-PC) http://www.thereachinstitute.org/files/documents/GLAD-PCToolkit.pdf page 4 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. 2. Teen Screen National Center for Mental Health Checkups For information about the Center: http://www.teenscreen.org For screening tools and a pocket guide with information on reimbursement and tips for making mental health referrals: http://www.teenscreen.org/programs/primary-care SECTION 2: Demographic and Psychosocial Considerations in Depression Care Psychosocial stressors • Serious adverse events – especially involving loss of a major relationship or role may trigger a major depressive disorder (particularly true for initial episodes of depression). • Lower socioeconomic status, living alone, unemployment, urbanization, and violent trauma may increase the risk of major depression. Gender • Depression disproportionately affects women. »» Consider the role of hormonal fluctuations in depressive symptoms in premenopausal women. »» Consider the potential for oral contraceptive interactions with antidepressants. »» The perimenopausal transition is a high risk period for new onset major depressive disorder. »» Consider SSRI or SSNI to decrease somatic symptoms in perimenopausal women. • Gender-specific antidepressant risks: »» Priapism in men treated with trazodone »» Anticholinergic side effects in benign prostatic hypertrophy »» Specific effects on libido in both genders »» Ejaculatory dysfunction associated with antidepressants »» TCA dosage may need to be higher in women who take oral contraceptives Bereavement Bereavement can trigger major depression but normal grief should not be confused with depression. • Acute grief usually resolves after a period of about 6 months. • Complicated grief may warrant treatment with psychotherapy and/or medication. Comorbid medical considerations • Consider medical and medication causes of depressive symptoms. • Treated or untreated hypertension may affect the choice of antidepressant. • Depression increases the risk of cardiovascular disease. • Patients with depression have a higher mortality rate after myocardial infarction. • The risk of depression increases in the weeks and months following a stroke. • Major depressive disorder occurs in 40-50% of patients with Parkinson’s disease. • Major depressive disorder increases the risk of unprovoked seizures in patients with epilepsy. • Major depressive disorder may be more common in patients with obesity (especially women). Consider the potential for weight gain with certain antidepressants. Address how depressive symptoms affect efforts to page 5 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. follow a healthy diet and exercise plan. • Depression may lead to poor treatment plan adherence in patients with diabetes. • Sleep apnea may contribute to depressive symptoms, especially in patients who are obese, report excessive daytime sleepiness, or who have treatment-resistant depression. • Rates of depression are increased in patients with HIV infection. • Pain syndromes frequently co-occur with depression; more than half of depressed individuals report some type of pain. • Depression commonly co-occurs with dementia; mood symptoms may precede cognitive symptoms. • Depression is associated with worse functional outcomes in hip fracture recovery. Older Age • Older adults may report more vegetative signs and cognitive disturbance and less subjective dysphoria. • Older adults may be more sensitive to antidepressant medication side effects. • Generally start with a lower dose of antidepressant medication. • Consider renal and hepatic function when prescribing antidepressant medications. • Suicide risk is higher in older adults with major depression. Elderly white men have the highest rates of completed suicides. Pregnancy/Postpartum During the pregnancy and postpartum periods 10-15% of women will experience a major depressive disorder. • 50% of pregnancies in the U.S. are unplanned. • Untreated postpartum depression places both the mother and infant at risk and is associated with significant long-term effects on child development and behavior. • Planning depression treatment during the perinatal period requires an individualized risk/benefit discussion. • Depression focused psychotherapy such as Interpersonal Therapy (IPT) or Cognitive Behavioral Therapy (CBT) is recommended for treatment of depression during pregnancy; however medication should not be avoided if symptoms are intolerable. • The American Academy of Pediatrics’ (AAP’s) Committee on the Psychosocial Aspects of Child and Family Development recommends that pediatric providers should integrate screening for postpartum depression into well-child visits. • The MedEd Postpartum Depression (PPD) website offers information on all aspects of perinatal depression care, including patient/family education materials: http://www.mededppd.org/default2.asp • Medication choices for pregnancy/postpartum: http://healthteamworks-media.precis5.com/depressionpregnancy-med-chart Cultural considerations • Consider language barriers and the importance of accurate, sensitive interpreter services. • Culture may influence expression of depression symptoms – particularly somatic and psychomotor symptoms. • In some cultures depression symptoms may be more likely to be attributed to physical illnesses. • Ask the patient, “How do you understand what you are experiencing?” • There is greater stigma associated with a depression diagnosis and with receiving services from a psychiatrist page 6 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. and/or mental health professional in some cultures. Additional information on treatment considerations and recommendations: American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Major Depressive Disorder (available on the HealthTeamWorks website: http://healthteamworks-media.precis5.com/apa-depression-guideline-2010) SECTION 3: Prepare your practice for effective depression care Primary care and mental health are inseparable. Recognizing depression or other mental health conditions must begin with symptom identification and diagnosis. Screening is one important way to identify possible depression; however, screening alone does not lead to positive clinical outcomes. The United States Preventive Services Task Force (USPSTF) recommends screening for depression in primary care when there are staff assisted mechanisms in place for accurate diagnosis, treatment and follow-up (B Grade recommendation). Implement staff assisted mechanisms for diagnosis, treatment and follow-up: 1. Assemble a practice team. Include one or more clinicians and practice support staff. 2. Develop an operational plan. • Determine who will receive screening: All patients? All new patients? All patients in for a health maintenance visit? Select populations? Only when depression suspected? • Determine how to administer and document the PHQ-2/9: Self-administered on a written form? Orally administered? Using an electronic tool or EHR? • Determine where to administer the PHQ-2/9: Waiting room? Exam room? • Determine who will help coordinate depression care and how that will happen: See next section for more information 3. Design a workflow for depression diagnosis, treatment and follow-up. Assign specific responsibilities to different members of the practice team, such as: • Administer screening and assessment questionnaires to patients, including scoring the PHQ-9 and entering the information into an EHR. • Compile patient education resources. • Maintain adequate supplies of PHQ- 2/9 forms, depression tracking logs, and patient education materials. • Maintain accurate information about options for referral to specialists, mental health services and community support services. • Compile information about health plan depression care coverage. • Provide education about depression, healthy lifestyle and depression treatment to patients and family members. • Assist with scheduling and communication about appointments with the primary care clinician, psychiatrist, and/or behavioral health providers. • Carry out structured protocols to monitor depressive symptoms (with the PHQ-9), adherence to treatment and referrals, and medication side effects. This may be done by telephone in some cases. Establish a clear process for documentation and communication with the providers. • Consider using a registry or EHR registry functionality to track patients who have a diagnosis of depression. page 7 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. 4. Establish relationships with mental health providers. Establish relationships with mental health providers in your medical neighborhood to promote collaboration and communication. Suggestions: • Invite mental health providers to visit the primary care practice to introduce themselves and their specific expertise. • Identify referral options for specific patient demographics, such as older adults, postpartum patients, or patients with specific language and cultural needs. • Establish referral and communication protocols that address confidentiality, sharing of information, and bidirectional communication. Note that mental health providers will need to address state and federal confidentiality and privacy requirements. Sample workflow coming soon (check HealthTeamWorks website). SECTION 4: Mental health services and benefits information Assess benefits information: Health plans often specify “in network” mental health providers and parameters of the services that will be covered (such as number of visits, emergency care, and inpatient services). • Compile and maintain a list of available and most accessible mental/behavioral health therapists and psychiatrists in your region. • Include information about language, insurance options, and accessibility for patients with disabilities, and providers that work with adolescents. Resources: • To identify the Community Mental Health Center in a catchment area and identify resources for behavioral health and psychiatric services: go to the Colorado Behavioral Healthcare Council’s website: www.cbhc.org. Click on “About Us” and drop down to “Community Mental Health Centers List”. An individual who has private health insurance has the option of pursuing treatment with anyone credentialed with that insurance company. Patients should contact their insurance company to identify a provider in their geographical area (this will frequently include the local mental health centers). • An individual who has Behavioral Health Medicaid must go through the organization that manages Medicaid (the BHO) for their catchment area. That information is available at: www.cbhc.org. Click “About Us”. • An individual who is uninsured must go to community agencies that accept uninsured patients. A list of these resources is frequently available through the mental health agency in your catchment area. • Additional resources may be accessed through the community hospitals in your area. page 8 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. SECTION 5: Helping individuals change behaviors The way we interact with individuals about behavior change has a significant impact on whether each person will actually be motivated to take steps that will improve their health and well being. Empathy is at the core of effective conversations about behavior change. A motivational interviewing approach collaborates with an individual to help them connect to their own intrinsic motivation and best reasons to change. Ambivalence about change is completely normal. And change is not a linear process, but most often a set of steps and setbacks before actual change is accomplished. In conversations about change, it is important to “roll” with any resistance that comes up. The idea is to let the patient argue for change, not you! First, the provider demonstrates genuine curiosity about an individual’s values, priorities, strengths, fears, and past successes and challenges. Then, the provider helps the person develop goals and a plan that is congruent with their readiness, abilities, assets, resources and priorities. Specific techniques and examples: Ask permission to give feedback and advice. Examples: »» “Would it be alright if I gave you some feedback/education about how alcohol could be related to the depression?” »» “Could we talk about diet, exercise and sleep as part of your treatment plan for depression?” Open-ended questions. Examples: »» “What do you already know about depression?” »» “What concerns do you have about the treatment options we’ve discussed?” Affirmations (of core values and strengths). Examples: »» “Your health is very important to you.” »» “You really care about being responsible and available to your family.” Reflections (of verbal and nonverbal statements about health, behaviors, and feelings). Examples: »» “You feel worried about what your family will think about a diagnosis of depression.” »» “You feel that taking a medication for depression is a sign of weakness.” »» “It just feels overwhelming to have to do so many things to take care of your health.” page 9 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. Ruler questions Examples: »» “On a scale from 0-10, how important is it to you to begin to get some exercise every day as a way to help treat the depression?” »» Followed by: “So, why a 4 and not a lower number?” This is to get the individual talking about their desire, ability, reasons, or need to change. »» “On a scale from 0-10, how confident do you feel that you will be able to take the next steps and begin to get some exercise every day as a way to help manage the depression?” »» Followed by: “What would help you to feel more confident about taking the next step and starting to exercise?” This is in order to identify concrete ways to help the individual set goals and make a plan. SECTION 6: Brief supportive counseling in primary care Brief supportive counseling interactions, lasting only a few minutes, can be carried out by different members of a practice team (including lay health workers). In the interaction the practitioner explores the context and stressors related to an individual’s current problem(s), the physical and emotional effects, and then helps the individual solve problems and adopt healthy self-care practices. Problem Focused Counseling Guideline Define the problem and/or its potential to be improved. Identify associated beliefs and concerns about: • self • the situation • Problems and/or concerns appear to be realistic. • Problems have potential to be improved. Problem Solving Strategies: • Establish a realistic goal • Identify and evaluate possible simple small steps to attaining goal • Explore barriers to implementing these steps • Discuss ways to overcome possible barriers • Select a plan and implement it • Review progress and celebrate success no matter how small Beliefs and/or concerns may be modifiable & maladaptive (e.g. “I am at fault or a failure”) General Coping Strategies: • Provide reflection (“I can see this is upsetting you”), empathy (“I can appreciate how difficult this must be for you”), legitimation (“It is normal to feel this way”) • Encourage patients to focus on and participate in activities that are: pleasurable, relaxing, and/or rewarding (e.g. hobbies, exercise, taking a bath, vacation, etc.) • Encourage patients to spend more time with family and friends who can support them • Discuss importance of adequate sleep and good nutrition Cognitive Strategies: • Discuss why the patient feels this way • Evaluate the evidence for the negative thought • Identify alternative explanations that are realistic and believable • Determine the type of information the patient needs to modify the thought • Encourage patient to survey others regarding the validity of their thought or to evaluate the costs and benefits of maintaining the thought • Encourage patient to identify and focus on their more positive qualities • Monitor changes in beliefs and impact on moods Reference: Brody DS, Thompson TL, Larson DB, et al Strategies for Counseling Depressed Patients by Primary Care Physicians. J or General In Med 1994; 9:569-575. page 10 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. SECTION 7: Co-occurring Psychiatric and Dependence Disorders Tobacco dependence • Patients with a history of major depressive disorder may be at risk for recurrence when they attempt tobacco cessation. • Use the PHQ-9 to monitor depressive symptoms throughout the process of tobacco cessation. • Develop a tobacco cessation plan that also addresses depressive symptoms. • Buproprion and nortriptyline increase tobacco cessation by about two-fold. • Provide education about the temporary risk of depression relapse, the importance of tobacco cessation, and available support services and treatments. • Multiple methods are more effective than single methods for tobacco cessation (e.g. QuitLine services + medication). Substance abuse • Frequently co-occurs with depression • It may be difficult to distinguish substance-induced depressive disorder from major depressive disorder. • Use the HealthTeamWorks Screening Brief Intervention Referral to Treatment (SBIRT) Guideline: http:// www.healthteamworks.org/guidelines/sbirt.html to assess the use of alcohol, illicit and prescription drugs. • Current recommendation: Treat both disorders simultaneously and actively (SAMHSA). • These patients are more likely to require inpatient treatment. • There is a greater risk of suicide in these patients. • These patients are less likely to adhere to treatment. • Substance abuse treatment options in CO: www.LinkingCare.org (CO Division of Behavioral Health web portal) Anxiety disorders • The most commonly co-occurring disorders in patients with major depression (may co-occur in ~60% of patients with depression) • Treatment: »» Both anxiety and depression may respond to antidepressant medication. »» TCAs and SSRIs may initially worsen rather than alleviate anxiety. Introduce medication at a low dose and advise the patient about possible initial increased anxiety symptoms. »» Adjunctive medication (e.g., benzodiazepines) may be necessary. »» Psychotherapies- in particular CBT and IPT may be useful (see psychotherapy section for more information). Dysthymic disorder • A chronic mood disorder with symptoms that fall below the threshold for major depressive disorder • May co-occur with major depression (“double depression”) • Treatment: Similar as for major depression; may respond best to medication + therapy page 11 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. Dementia • All patients with dementia should be screened for depression (if cognitive status allows). • Carefully monitor pharmacotherapy in patients with dementia. • Antidepressants are likely to be efficacious even though they are unlikely to improve cognition. • Antidepressants with the least anticholinergic effects are recommended. • ECT may be helpful for some patients with co-occurring depression and dementia. • For current criteria and guidelines for Alzheimer’s Disease diagnosis: http://www.alzheimersanddementia.org/ content/ncg Eating disorders • Eating disorders are common in patients with major depression. • SSRIs are the best studied medications for the treatment of eating disorders. Fluoxetine has the most evidence for the treatment of bulimia nervosa. • Antidepressants may be less effective in patients who are severely underweight or malnourished. For additional information on treatment considerations and recommendations see the American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Major Depressive Disorder available on the HealthTeamWorks website: http://healthteamworks-media.precis5.com/apa-depression-guideline-2010. SECTION 8: Complementary and Alternative Medicine (CAM) “CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” (NIH National Center for Complementary and Alternative Medicine). Complementary therapies refer to those that are not considered mainstream but are consistent with Western biomedical concepts. Alternative therapies are more philosophically separate from traditional Western medical practice. Integrative medicine incorporates standard Western medicine and CAM to use all therapies that are considered appropriate for an individual’s needs. • Currently at least 40% of adult Americans use at least one CAM treatment annually and major depressive disorder was the most common diagnosis associated with CAM use in one study. • Clinicians should routinely ask patients about CAM treatments they may be using to treat depressive symptoms since patients may not disclose use of nonconventional treatments. • Consider that in some patients use of CAM modalities that may not be efficacious may delay initiation of other efficacious depression treatment(s). A resource for checking the quality of supplements is the Natural Medicines Comprehensive Database: http://naturaldatabase.com. Use of this database requires a subscription. The PDR publishes a guide on herbs and supplements. Direct patients to select supplements with the GMP and/or USP stamps to insure quality. page 12 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. 5-HTP and tryptophan Evidence is lacking on the effectiveness of tryptophan for depression. It was banned by the FDA in 1989 due to an outbreak of Eosinophilia-Myalgia Syndrome (EMS). Some studies suggest that 5-HTP may be an effective treatment for depression (perhaps comparable to prescription antidepressants); other studies have not found a benefit. It can have serious adverse effects just like prescription antidepressants. There is also concern regarding possible contaminants. Potential dangers may outweigh any possible benefits. Acupuncture Acupuncture is part of traditional Chinese medicine. There is significant variation in acupuncture techniques. • Evidence for the efficacy of acupuncture as a primary treatment for depression is inconclusive. • This is a challenging modality to study adequately in randomized control trials. Exercise Exercise is well established for its contribution to overall health. • Aerobic and nonaerobic exercise have positive effects on mood in men and women across a wide age range. • Exercise may help prevent depressive symptoms during the antepartum or postpartum period. • Exercise may also help prevent relapse and recurrence of depression. Folate Folate has been studied as a predictor of antidepressant medication response and as an adjunctive treatment. • Higher folate levels at treatment baseline appear to be associated with better response to antidepressants. • Folate is a low-risk intervention with general health benefits, including protection against neural tube defects in early pregnancy. • There is no evidence about the efficacy of folate as a monotherapy for antepartum or postpartum depression, or for depression during the menopausal transition. Light therapy Bright light therapy is an evidence-based, effective, and well tolerated treatment for seasonal affective disorder. • The mechanism is unclear but appears to involve the serotonergic neurotransmitter system. • In general, this may be a reasonable treatment option for nonseasonal depression. • Light therapy may hasten the response to antidepressant medication. • Greater intensity of light is associated with efficacy. • Monitor for mania and hypomania during initiation of light therapy. • More research is needed in order to determine the efficacy of this method for nonseasonal depressive conditions specific to women (PMS, antepartum and postpartum depression, postmenopausal transition page 13 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. depressive symptoms). • The preferred apparatus is a commercially produced fluorescent box with a light intensity of 10,000 lux. »» To use: sit in front of the downward tilted box situated 12-14 inches from the eyes. »» The starting dose is 10,000 lux for 30 minutes in the morning. Mindfulness and other mind-body therapies • Mindfulness-based cognitive therapy may decrease symptoms of depression and anxiety and shows promise for preventing depression relapse and recurrence. • Other mind-body therapies that show promise in the treatment or depression and anxiety and may play promote overall health include meditation, Qigong, Tai Chi, yoga, and biofeedback and neurofeedback. Omega-3 fatty acids Generally recommended as an adjunctive therapy since the health benefits, especially for cardiovascular health, are established, and individuals with psychiatric disorders may be at greater risk for obesity and metabolic problems than the general population. • Adjunctive EPA, or the combination of EPA and DHA (what is found in most commercial brands) appears most useful for depressive disorders. • Dosages from 1-9 grams have been studied and the evidence supports lower doses. • Omega-3 fatty acid supplementation is a reasonable augmentation strategy in depression treatment. • Evidence is sparse concerning Omega-3 fatty acids for PMS, antepartum and postpartum depression, or depressive symptoms during the menopausal transition. S-adenosyl methionine (SAMe) SAMe is a naturally occurring molecule. Cerebrospinal fluid levels of SAMe are lower in individuals with severe major depressive disorder compared with control subjects. • Some data support the efficacy and tolerability of SAMe in patients with major depressive disorder. • More research is needed to determine the comparative efficacy of SAMe to standard antidepressants. • Available preparations are not regulated by the FDA and formulations may vary widely. • SAMe may be effective for treatment of depressive symptoms during the menopausal transition. • Safety and efficacy of SAMe for antepartum depression or in women who are breastfeeding has not been adequately studied. St. John’s Wort St. John’s Wort is a plant that is widely used to treat depressive symptoms. • There is conflicting evidence for the effectiveness of St. John’s Wort. »» The available evidence suggests that it may be superior to placebo in major depression, similarly effective as standard antidepressants, and have fewer side effects than standard antidepressants. page 14 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. »» Overall, studies show greater support for benefits in mild-moderate depressive disorder and less consistent findings in patients with more severe symptoms. • Drug-drug interactions are an important consideration. The efficacy of some medications may be decreased by St. John’s Wort, including antiretroviral medications, immunosuppressants, antineoplastic agents, anticoagulants, oral contraceptives, and hormone replacement therapy. • St John’s Wort is excreted in breastmilk at levels comparable with other antidepressants. SECTION 9: Evidence-based mental health therapies for depression Interpersonal psychotherapy (IPT) Problem-solving therapy (PST) Focus Resolving everyday How relationships problems that and interpersonal may contribute events affect to depression. the onset or Brief, structured maintenance of treatment. depression. Usually Combines elements short term. of CBT and IPT. How thoughts and beliefs influence depression and a person’s behaviors. Usually short term. Process Cognitive/ behavioral therapies (CBT) Recognize and Recognize and change distorted change patterns of social functioning beliefs and dysfunctional that cause problems. Explore thinking to be more adaptive and issues that may healthy; change contribute to behaviors and depression: grief, solve problems that role transitions, interpersonal may contribute to depression. deficits or conflicts. Improve ability of an individual to understand and cope with stressful life experiences, and resolve problems constructively. Couples/Family therapy Psychodynamic therapy How relationships On the etiology with family/ of psychological significant others vulnerability can be a resource that may lead to help resolve to depression depression. stemming from Family/significant development and others included in conflict throughout therapy. the life cycle. Address conflicts Identify difficulties and conflicts that related to may contribute guilt, shame, interpersonal to depression and find ways to relationships, management resolve w/ effective communication. of anxiety, Improve and repressed or socially relationships to support depression unacceptable treatment. impulses. SECTION 10: Recommended patient education books and online resources Important components of depression care: • To help patients and their families understand and accept a diagnosis of depression. • To activate patients to seek help, adhere to treatment recommendations, and practice healthy behaviors that can promote recovery. page 15 Depression in Adults: Diagnosis & Treatment Guideline Supplement References and supporting documents used to develop the guideline and supplement are available at: http://www.healthteamworks.org/guidelines/depression.html. Web sites: 1. The MacArthur Initiative Depression Tool Kit: http://www.depression-primarycare.org 2. Medicine Plus Depression Tutorial: http://www.nlm.nih.gov/medlineplus/tutorials/depression/htm/index.htm 3. Depression Awareness Recognition and Treatment Program of the National Institute of Mental Health: http://www.nimh.nih.gov/publicat/index.cfm 4. National Foundation for Depressive Illness: http://www.depression.org 5. Mental Health America: http://www.mentalhealthamerica.net/ 6. E-Couch: http://ecouch.anu.edu.au/welcome 7. MoodGym: Free online self help program; teaches cognitive behavior therapy skills: http://www.moodgym.anu.edu.au/welcome 8. National Mental Health Alliance: http://www.nami.org Self-help manuals and books: Cognitive and behavior oriented self-help books have been shown to significantly improve symptoms of depression for up to 2 years. Recommended resources: 1. Burns DD: Feeling Good The New Mood Therapy. Avon Books 1999. Updated version; teaches a cognitive therapy approach to combating depression. Includes techniques to identify and combat faulty thinking, self assessment techniques, self help forms and charts and a section on medication. 2. Hayes SC: Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. New Harbinger 2005. A five-step plan for coping with painful emotions such as anxiety and depression. Patients learn to engage with painful thoughts and feelings through step-by-step acceptance and mindfulness. 3. McKay M, Fanning P and David M: Thoughts and Feelings: Taking Control of Your Moods and Your Life: A Workbook of Cognitive Behavioral Techniques. New Harbinger 2007. Offers a simple and easy to understand discussion on how to use the principles of cognitive behavioral therapies to control anxiety and depression and enhance self-esteem. 4. Lewinsohn P: Control Your Depression (revised). Simon and Schuster 2010. A classic text that helps patients identify specific areas related to their depression. Provides instruction on self control strategies, relaxation techniques, social skills training, and modification of self-defeating thinking patterns. 5. Katon W, Ludman E, Simon G: The Depression Helpbook. Bull Publishing Co. 2008. Explains what causes depression, how to recognize it, and how to make decisions about treatment. Integrates pharmacologic and psychotherapeutic approaches; emphasizes self-care strategies to help develop confidence in one’s ability to manage depression. page 16 Depression in Adults: Diagnosis & Treatment Guideline ~14% of adults have a major depressive episode in their lifetime ~30% of adults with major depression do not receive treatment This guideline is intended for ages ≥18 years. For adolescents and pre-adolescents, use GLAD PC or Teen Screen Mental Health Check-ups. Prepare your practice: put systems in place for accurate diagnosis, treatment, and follow-up. Tip 1: Implement staff assisted patient self-management and care coordination (possible by phone). Tip 2: Compile info on psychiatry and mental health consultation and referral options. 1. Screening and Assessment 1. Screening and Assessment Consider Depression: High Risk Conditions and Cues • Chronic conditions (CVD, Diabetes, cognitive impairment) • Chronic pain • Geriatric patient Screening: Screen if systems are in place for adequate diagnosis/ treatment/follow-up/referral. Use PHQ-2*. “In the past 2 weeks… 1. Have you had little interest or pleasure in doing things? 2. Have you felt down, depressed or hopeless?” If “yes” on either question, complete full PHQ-9*. 2. Diagnosis (first episode or recurrence?) DSM IV Criteria Symptom 1. Depressed mood 2. Marked Diminished Interest/Pleasure 3. Significant wt loss/gain, appetite decrease/increase 4. Insomnia/hypersomnia 5. Psychomotor Agitation/Retardation 6. Fatigue/loss of energy 7. Feelings of worthlessness or inappropriate guilt 8. Diminished concentration or indecisiveness 9. Suicidal ideation: thoughts, plans, means, intent 10. Hopelessness Tip 3: Identify resources to address treatment barriers. Tip 4: Monitor symptoms with PHQ-9*. • Multiple somatic complaints • Postpartum • Tobacco Use • ETOH/Substance misuse/abuse • Chronic anxiety • History of Abuse/Trauma/PTSD • Combat veteran • Persistent anger/irritability • Recent loss Further Assessment: 1. Recent life events (Why now?) 2. History of depression/bipolar disorder or alcohol/substance misuse 3. Patient’s perception of problem: »» Beliefs and knowledge about depression »» Cultural considerations (language, stigma, influence on symptom presentation) 4. Consider medical and medication causes of depression 5. Family history: depression/bipolar disorder 6. Suicide risk (thoughts, plans, means, previous attempts, recent exposure). “Are you thinking of harming or killing yourself?”* 7. Assess risk of harming others 8. Screen for co-morbid psychiatric disorders: bipolar, anxiety, PTSD, panic disorder, tobacco†, substance misuse† 9. Complementary/Alternative Medicine or other treatments currently used* 2. Diagnosis (first episode or recurrence?) Major Depression 5 total for 2 wks duration: must include symptom #1 or 2 a a a a a a a a a Dysthymia 3 total for ≥2 yrs.: must include symptom #1 Severity Rating (Based on initial PHQ-9* score): PHQ-9 Score 5-9 a 10-14 a a 15-19 a a a ≥20 Provisional Diagnosis Minimal Symptoms Minor Depression Dysthymia Major Depression, mild Major Depression, moderately severe Major Depression, severe Treatment Recommendations Support, educate to call if worse; return in 1 month Evidence-based psychotherapy equally effective as anti-depressant Evidence-based psychotherapy and/or antidepressant Anti-depressant and psychotherapy (esp. if not improved on monotherapy) a Plan Treatment (see page 2 for treatment chart) 3. Plan Treatment (see page 2 for treatment 3. chart) Shared Decision Making: • Tailor treatment to individual patient • Provide education on diagnosis • Review treatment options (based on PHQ-9 score) • Discuss treatment barriers: family/work responsibilities, insurance, transportation • Negotiate treatment plan • Set timeline: response, side effects and treatment duration • Educate on importance of adherence • Develop safety plan for suicidal ideation Promote Health Behaviors: • Exercise • Social support • Faith/spiritual support • Healthy sleep pattern • Healthy diet • Alcohol only in moderation† • Cessation of tobacco and illicit drug use† • Engagement in positive activities • Stress management • Educational books and online resources Additional Considerations: • Current or planned pregnancy: psychotherapy preferred if symptoms tolerable* • Start with lower dose for anxiety or elderly* • Cultural factors that influence treatment choice* • SNRI or tricyclic for chronic pain • Level of functioning/activities of daily living • Discuss safety with the patient* • Need for emergency services • Psychiatry referral, including ECT evaluation • Complementary/Alternative Medicine* Consider Referral or Consult: • Suicidal patient • Bipolar disorder • Co-occurring substance abuse • Psychotic features • Multiple medications *See supplement for additional information. †Go to www.healthteamworks.org for guidelines on Tobacco & Alcohol/Substance Use. This guideline is designed to assist the primary care provider in the diagnosis and treatment of depression. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. The Depression Guideline supplement, references, and additional copies of the guideline are available at www.healthteamworks.org or call (303) 446-7200. This guideline was supported through funds from The Colorado Health Foundation. Approved 1/3/2011. page 1 of 2 3. Plan Treatment Continued: Treatments for Depression Evidence-Based Psychotherapies* • Cognitive/behavioral therapy (CBT) • Interpersonal psychotherapy (IPT) • Problem-solving therapy (PST) • Psychodynamic therapy • Couples/Family therapy If receiving therapy alone: • Onset of effectiveness is more gradual • Discuss and share PHQ-9* with therapist Considerations for Medication Selection • Cost • Formulary • Responsiveness to prior treatment • Responsiveness in a first degree relative • Complementary/Alternative Medicine* Medication Chart Adverse Side Effects and Precautions‡ Paroxetine (Paxil CR) 12.5-25 mg QAM 25-62.5 mg Sertraline (Zoloft) 25-50 mg QAM 50-200 mg Venlafaxine (Effexor) 25 mg BID-TID Venlafaxine XR (Effexor-XR) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Bupropion (Wellbutrin) 37.5 mg QD 20 mg BID or 30 mg QD 50 mg QD 100 mg BID-TID Bupropion (Wellbutrin SR) 100 mg QAM to 100 mg BID 150-200 mg BID Bupropion (Wellbutrin XL) 150 mg Mirtazapine (Remeron or Remeron Sol-Tab) Trazodone Long-Acting (Oleptro) Amitriptyline (Elavil) 150-375 mg a 150-225 mg 60 mg 50 mg 300-450 mg a +++ + 0 ++ ++ +++ +++ +++ + + 0 0 ++ + +++ ++ +++ +++ + + 0 0 + +++ 0 ++ +++ + 0 +++ 0 +++ +++ + 0 + 0 ++ ++ 0 0 X 0 0 0 0 ++ ++ 0 0 X a + + 0 0 ++ ++ ++ + + 0 0 0 0 0 0 0 X a 0 0 ++ 0 0 0 X 300-450 mg a 0 0 ++ 0 0 0 X X 15 mg QHS 150 mg QHS 25-75 mg QHS 15-45 mg 150-375 mg 100-300 mg a + + +++ ++ +++ +++ 0 0 +++ + 0 0 + + + +++ +++ +++ X X X X + ++ a Clomipramine (Anafranil) 25-75 mg QHS 100-250 mg +++ + + ++ ++ +++ X X ++ a Desipramine (Norpramin) 25-75 mg QHS 100-300 mg a + 0 ++ + + +++ X X ++ a Doxepin (Adapin, Sinequan) 25-75 mg QHS 100-300 mg a +++ +++ 0 ++ ++ +++ X X ++ a Imipramine (Tofranil) 25-75 mg QHS 100-300 mg a +++ ++ + + ++ +++ X X ++ a Nortriptyline (Aventyl, Pamelor) 25-50 mg QHS 30-150 mg a ++ ++ + + ++ ++ X ++ Drug Daily Starting Dosage Usual Daily Adult Dosage a a a a a a a a Cardiac Arrhythmia Orthostatic Hypotension 0 Weight Gain 0 a Sexual Dysfunction a Activation 0 0 + 0 0 ++ Category SSRIs SNRIs Other Agents 0 0 0 0 0 High Potential for Lethal Overdose a Liver Disease a Precautions Eating Disorders 20-40 mg 10-20 mg 20-80 mg 90 mg 20-50 mg Sedation On the $4 plan? 10-20 mg QAM 10 mg QAM 10-20 mg QAM 90 Qwk 10-20 mg QAM Side Effects Anticholinergic Generic? Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluoxetime (Prozac weekly) Paroxetine (Paxil) 0 = very low, none X = generally contraindicated Withdrawal Syndrome Risk Relative Cost Pregnancy: Requires individualized risk/benefit discussion.* Tricyclics +++ = strong ++ = moderate + = mild Seizure Disorder FDA Black Box Warning: In short-term placebo controlled studies antidepressants increased the risk compared to placebo of suicidal thinking and suicidality in children, adolescents, and young adults; but not in adults beyond age 24; and there was a reduction in risk in adults age >65. Monitor all patients closely for clinical worsening, suicidality, or unusual changes in behavior. ++ X X +++ X +++ X X ++ + + X + X + ++ a ‡References: Applied Therapeutics: the clinical use of drugs. Edited by Mary Anne Koda-Kimble, et al. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, c2009. 9th edition. International consensus statement on major depressive disorder. Nutt DJ, et al. J Clin Psychiatry. 2010; 71 Suppl E1:308. Drug facts and comparisons. St. Louis: Facts and Comparisons, c1981-2010. Circulation. 2009 September 22; 120(12): 1123-1132. Expert opinion. 4. Monitor and Adjust Treatment. Monitor Side Effects. Goal of treatment is complete remission. First follow-up contact at 1-2 weeks, then every 4-8 weeks (consider telephone contact in some cases). Perform ongoing suicide risk assessment; risk may increase during early treatment phase. If starting dose was low, consider up-titration at initial check-in. Acute Phase (months 1-4) Response PHQ-9* Score after 4-6 weeks Treatment Plan Responsive Drop ≥5 points from baseline No treatment change needed. Follow-up again after an additional 4 weeks. Partially responsive Drop 2-4 points from baseline Often warrants increase in dose. Possibly no change needed. Drop 1 point or no change or increase • Consider starting anti-depressant if receiving therapy alone • Increase dose • Switch meds • Augmentation (Lithium, thyroid, stimulant, 2nd gen anti-psychotic, 2nd anti-depressant) Non-responsive • Review psychological counseling options and preferences • Informal or formal psychiatric consulation (ECT an option in some cases) Continuation Phase (months 4-9) Maintenance Phase for Recurrent Depression (month 9 and on) Tapering Anti-Depressant Medication • Begins after symptom resolution • Continue medications full strength • Contact every 2-3 months (telephone appropriate in some cases) • Monitor for signs of relapse • Generally, use same anti-depressant dose as in Acute Phase • For patient with history of 3+ episodes of Major Depression or chronic Major Depression • Also consider for patient w/ additional risk factors for recurrence (family history, early age onset, ongoing psychological stressors, co-occurring disorders) • May need to maintain for one to several years • Use PHQ-9* for ongoing monitoring • • • • Goal: Prevent Relapse *See supplement for additional information Taper over several weeks Educate about side effects and relapse Flu-like symptoms common With SSRI and SNRI may also experience anxiety/agitation, sweats, paresthesias • Diphenhydramine may help with anticholinergic withdrawal symptoms Supplemental Guidance on Marijuana Page 1 of 2 Information to guide work with adolescents and adults. Why Screen for Marijuana Recommendations for Screening and Brief Intervention • Marijuana is the third most commonly used substance after tobacco and alcohol in the U.S., Australia and Europe. • Marijuana use is associated with health and mental health problems. • Adolescents are particularly at risk for developing problems related to use. • Marijuana users who begin during adolescence have a 1 in 6 chance of developing dependence. • Current research does not provide safe limits of use; there is insufficient research on potential medical benefits of marijuana. • Screen adults and adolescents aged 12 and older. • Recommended screening question: “In the past year, how many times have you used marijuana?” Positive score = > 1 time • Assess for possible cannabis use disorder • Offer a personalized brief intervention for marijuana use. In Colorado: - 2001: medical cannabis use was permitted - 2013: recreational cannabis (1 oz. or less) was legal to possess and consume in private residencies for individuals ages 21 and older. Per the Colorado constitution, medical marijuana may be recommended for: • Cancer • Glaucoma • HIV or AIDS positive OR .. The patient has a chronic or debilitating disease or medical condition that produces one or more of the following and which, in the physician’s professional opinion, may be alleviated by the medical use of marijuana. • • • • • Cachexia Persistent muscle spasms Seizures Severe nausea Severe pain Click here for updated CDPHE information or follow: http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDP HE-CHEIS%2FCBONLayout&cid=1251593017076&pagename=CBONW rapper Strains 1. Cannabis indica • Larger amounts of Cannabidiol • Known for relaxation, commonly used to relieve inflammation, and glaucoma. 2. Cannabis sativa • Larger amounts of Tetrahydrocannabinol (THC) • Known to be more energizing; can reduce headaches, pain and nausea and stimulate appetite. • Sativa has higher tendency to induce anxiety or paranoia 3. Cannabidiol by itself, lacks noticeable psychoactive effects General Effects of Marijuana • Temporarily increases heart rate and blood pressure; increases risk of cardiac arrest and stroke. • May interact with prescription medications (especially barbiturates, CNS depressants, theophylline, warfarin and fluoxetine). • Avoid marijuana if scheduled for surgery in the next two weeks (may cause excessive sedation when combined with parioperative medications). • Diminished motor coordination • Distorted perception (sights, sounds, time, touch) Pregnancy-Postpartum Key Points Adolescent Key Points • Problems with learning and memory • Increased risk of psychosis • Risk of long-term neurocognitive deficits and reduced IQ • Chronic use of marijuana increases the risk of: • Impaired cognitive functioning, memory, and decision-making • Depression and anxiety • Weakened immune system • Infertility • Cannabinoid Hyperemesis Syndrome • Chronic use of smoked marijuana increases the risk of: • Oral cancer • Chronic bronchitis • Frequent upper respiratory infections • Pneumonia • • • • THC crosses the placenta and is a form of exposure. THC is present in breast milk and a form of exposure. Marijuana use may increase the risk of miscarriage. Prenatal exposure is associated with long-term motor, mental health and neurobehavioral problems (including problems with learning and attention). • Prenatal or exposure while breast-feeding may cause irritability and poor sleep in the infant. Safety Concerns • Impaired driving. Marijuana is associated with a 2-3-fold increase in motor vehicle crashes (lower risk than alcohol). • Second-hand smoke exposure. • Accidental ingestion by young children and pets (edibles and smoked). This guideline is designed to assist clinicians with Marijuana supplemental information to implement for management. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For copies of the supplement, go to www.healthteamworks.org or call (303) 446-7200. This guideline was supported with funds from SBIRT Colorado. FINAL January 7, 2014 Supplemental Guidance on Marijuana Page 2 of 2 Information to guide work with adolescents and adults. Discussion with Parents Key factors to prevent use: • Parental involvement and monitoring • Engagement in school • Healthy, strong neighborhood attachments Important things parents need to know: • Use of marijuana can be especially harmful to adolescents because the brain is still developing. • Be nonjudgmental and offer opportunities for the young person to disclose use. • Communicate a “no-use” expectation. • Share stories of drug incidents and people in recovery. Brief Intervention Key Points • Raise the subject (ask permission to discuss marijuana). • Explore underlying reasons for using marijuana (stress, anxiety, depression, physical symptoms). Explore lifestyle and other alternatives to marijuana for management of symptoms. • Use reflective listening to try to understand a person’s beliefs about marijuana and reasons for using it. • Offer feedback (with permission) on short and long term health effects of marijuana tailored to the person’s age, health and life circumstances. • Advise to cut back, or consider abstaining - especially if experiencing negative health consequences or at higher risk such as adolescents or pregnant and breastfeeding woman. • Negotiate and advise a plan to decrease or stop use. Focus on reducing harm to self and others. • Offer assistance and referral if needed. • Follow-up to monitor progress. Suggestions For Addressing Common Myths About Marijuana Marijuana is all natural • Marijuana may also contain harmful contaminants. Many natural substances are known to harm human health. Marijuana is not addictive • Marijuana can be addictive. • Overall ~9% of users will become addicted; Of those who start young ~17% will become addicted; 25-50% of daily users will become addicted. No one has ever died from a marijuana overdose • In Colorado emergency room visits are increasing related to marijuana induced delirium, cyclic vomiting and overdoses. Potency has increased dramatically over the years. Edibles may especially deliver very high doses. There are no reliable controls over strength and dosing. It’s legal. So why quit, or how could it be a problem? • Other legal substances such as tobacco, alcohol, and prescription narcotics cause significant harm. Marijuana is associated with serious, long-term negative health effects. Marijuana is safer than tobacco or alcohol • Similar to alcohol or tobacco, chronic use of marijuana may harm health and other areas of a person’s life. Marijuana may especially be harmful in adolescents, and pregnant and breastfeeding women. Marijuana is an effective treatment for serious medical conditions (cancer, epilepsy, diabetes, depression, etc.) • Serious medical conditions should be managed by a qualified health professional. Self-treatment or augmenting conventional treatments with marijuana could cause harm. Marijuana is safer than smoking tobacco during pregnancy • Tobacco and marijuana can harm the developing fetus in different ways. The effects of marijuana on fetal development may be long-term and include problems with learning and behavior. Marijuana helps with stress and anxiety • It is important to identify underlying causes of stress and anxiety. Explore alternatives to marijuana. Heavier users of marijuana may experience improved mental clarity and motivation when they stop using. Cannabis Use Disorder Indicated by a problematic pattern of marijuana use leading to clinically significant impairment or distress manifested by at least two of the criteria for a substance use disorder. For example: 1) recurrent use resulting in a failure to fulfill major role obligations at work, school, or home; 2) continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by marijuana 3) tolerance; or 4) withdrawal. See the HealthTeamWorks SBIRT guideline webpage for information about DSM-5 diagnostic criteria for Substance Use Disorder at http://www.healthteamworks.org/guidelines/sbirt.html To identify treatment and recovery support services in Colorado, please visit www.LinkingCare.org For More Information: National Institute on Drug Abuse – For Adults: drugabuse.gov/drugs-abuse/ – For Teens: teen.drugabuse.gov/drug-facts/marijuana For Additional Resources, Go To: www.healthteamworks. org/guidelines/ sbirt.html This guideline is designed to assist clinicians with Marijuana supplemental information to implement for management. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For copies of the supplement, go to www.healthteamworks.org or call (303) 446-7200. This guideline was supported with funds from SBIRT Colorado. FINAL January 7, 2014 Guideline for Alcohol and Substance Use Screening, Brief Intervention, Referral to Treatment (SBIRT) page 1 of 2 Why screen for alcohol and drug use? Brief motivational conversations with patients can promote significant, lasting reduction in risky use of alcohol and other drugs. Nearly 30% of adult Americans engage in unhealthy use of alcohol and/or other drugs, yet very few are identified or participate in a conversation that could prevent injury, disease or more severe use disorders.* E ST P 1 Brief Screening Frequency: »» Tobacco: Every visit. »» Alcohol and Drugs: At least yearly; consider screening at every visit.† Consider more frequent screening for women who are pregnant or who are contemplating pregnancy; adolescents; and those with high levels of psychosocial stressors. Youth (ages 11-17 years) See CRAFFT Toolkit for youth information, talking points, tools and more at http://healthteamworks-media.precis5.com/sbirt-crafft-toolkit Adults (18+ years old) Substance Questions Positive Screen Alcohol: Assess frequency and quantity 1. How many drinks do you have per week? 1. All women or men >65 years: More than 7. Men ≤65 years old: More than 14. ----------------------------- OR ---------------------------2. In the past 3 months. Drugs‡ In the past year, have you used or experimented with an illegal drug or a prescription drug for nonmedical reasons? Yes Tobacco Do you currently smoke or use any form of tobacco? Yes ---------------------------------------------------------------------------------------------2. When was the last time you had 4 or more (for men >65 years and all women) or 5 or more (for men ≤65 years) drinks in one day? For all patients, consider: E ST P 2 Reinforce healthy behaviors. See “For all patients, consider:” A standard drink is: • Any alcohol use is a positive screen for patients under 21 yrs. or pregnant women.§ • Potential for alcohol-exposed pregnancy in women of childbearing age; assess for effective contraception use.§ + Negative Screen • Alcohol/medication interactions. • Chronic disease/alcohol precautions. • Role of substance use in depression and other mental health conditions.¶ • Medical marijuana use. Positive on alcohol and/or drug brief screen: proceed to Step 2. Tobacco use only: see page 2 for Tobacco Advise and Refer. Further Screening Patients with a positive brief screen should receive further screening/assessment using a validated screening tool. Scoring instructions are on each tool. Screening tools in English and Spanish available at www.healthteamworks.org/guidelines/sbirt.html Screening tools: • AUDIT (adult alcohol use) http://healthteamworks-media.precis5.com/sbirt-audit • DAST-10© (adult drug use) http://healthteamworks-media.precis5.com/sbirt-dast-10 • ASSIST (adult poly-substance use) http://healthteamworks-media.precis5.com/sbirt-assist • CRAFFT (adolescent alcohol and drug use) http://healthteamworks-media.precis5.com/sbirt-crafft Low risk: Provide positive reinforcement Moderate risk: Provide brief intervention Moderate-high risk: Provide referral to brief therapy High risk: Refer to treatment STEP 3 (page 2) * “Helping Patients Who Drink Too Much: A Clinician’s Guide,” U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Updated 2005. www.niaaa.nih.gov/guide † See Clinical Preventive Health Recommendations for the General and Targeted Populations Guideline at: www.healthteamworks.org/guidelines/prevention.html. ‡ See Prescription Drug Misuse supplement at www.healthteamworks.org/guidelines/sbirt.html. § See Fetal Alcohol Spectrum Disorder (FASD) supplement, Preconception and Interconception Care Guideline, and Contraception Guideline at www.healthteamworks.org. ¶ See Depression in Adults: Diagnosis and Treatment Guideline at: www.healthteamworks.org/guidelines/depression.html. This guideline is designed to assist clinicians with alcohol and substance use screening and management. It is not intended to replace a clinician’s judgment or establish a protocol for all patients. For national recommendations, references and additional copies of the guideline, go to www.healthteamworks.org or call (303) 446-7200. This guideline was supported with funds from SBIRT Colorado. Approved September 2011. E ST P 3 Brief Intervention - Brief Therapy - Referral to Treatment For more information, demonstration videos, an online training module and the CRAFFT Toolkit with adolescent talking points, go to www.healthteamworks.org. A Brief Intervention is a short motivational conversation to educate and promote health behavior change. Important: Recognize a person’s readiness to change and respond accordingly. Use OARS: Open-ended questions Affirmations Reflections Summaries Brief Intervention (Brief Negotiated Interview model\\): This model may also be used to address other substance use. 1. Raise the subject. »» “Would you mind if we talked for a few minutes about your alcohol use?” ›› Ask permission. ›› Avoid arguing or confrontation. 2. Provide feedback. »» “We know that drinking above certain levels can cause problems such as...” ›› Review reported substance use amounts and patterns. ›› Provide information about substance use and health. ›› Advise to cut down or abstain. ›› Compare the person’s alcohol use to general adult population (see drinking pyramid below). »» “What do you think about this information?” ›› Elicit patient’s response. 3. Enhance motivation. »» “What do you like about your current level of drinking? What do you not like about your current level of drinking?” »» “On a scale from 0-10, how important is it for you to decrease your drinking?” »» »» »» “What makes you a 5 and not a lower number?” “On a scale from 0-10, how ready are you to decrease your drinking?” “What would make you more ready to make a change?” ›› Assess readiness to change. ›› Discuss pros and cons. ›› Explore ambivalence. 4. Negotiate and advise. »» “What’s the next step?” »» “What are the barriers you anticipate in meeting this goal? How do you plan to overcome these barriers?” »» “On a scale from 0-10, how confident are you that you will be able to make this change?” »» “What might help you feel more confident?” ›› Negotiate goal. ›› Provide advice and information. ›› Summarize next steps and thank the patient. 012345678910 Importance — Readiness — Confidence U.S. Adult Alcohol Use Estimate Potential consequences of risky drinking: multiple health, work and family issues Alcohol dependent Referral to Treatment Risky drinkers Brief Intervention 5% 25% Tobacco Advise and Refer: Ask permission, then advise every tobacco user to quit with a personalized health message. Colorado QuitLine and Other Programs Refer individuals age 15+ to the Colorado QuitLine (1-800-QUIT-NOW [1-800-784-8669] or www.coquitline.org): • Personally tailored quit program Abstainers or low-risk drinkers Positive reinforcement • Five scheduled, telephone-based coaching sessions 70% • May include free nicotine replacement therapy (age 18+ and medically eligible) Information on programs for specific populations and ages: www.myquitpath.com Order free tools and materials: www.cohealthresources.com Pharmacotherapy options: HealthTeamWorks Tobacco Cessation and Secondhand Smoke Exposure Guideline at www.healthteamworks.org/guidelines/tobacco.html E ST P 3 Referral to treatment Spectrum: Screening Brief Intervention Brief Therapy Specialty Treatment continued: Brief Therapy: For moderate to high risk use of alcohol or drugs Substance Use Disorder Treatment: For high risk alcohol or drug use • Motivational discussion; focused on empowerment and goal setting • Includes assessment, education, problem-solving, coping strategies, supportive social environment • Typically 4-6 sessions, each one approached as though it could be the last • Proactive process to facilitate access to specialty care • Focus on motivating a person to follow-up on referral for further assessment and possible treatment • Appropriate level of care may include inpatient, outpatient, residential • Pharmacotherapy options: www.healthteamworks.org/guidelines/sbirt.html Referral information in Colorado: http://linkingcare.org SBIRT is reimbursable if: Documentation: Key points • A validated screening tool is used • It is properly documented • Time requirement is met • SBIRT should be documented like any other healthcare service. • These records may require special permission for release. Consult your organization’s privacy policy. • Documented use of a validated screening tool (e.g., AUDIT, DAST, CRAFFT, ASSIST) required for reimbursement. See www.healthteamworks.org for up-to-date information. \\ The Yale Brief Negotiated Interview Manual. D’Onofrio, et al. New Haven, CT: Yale University School of Medicine. 2005. SBIRT Guideline Supplement: Prescription Drug Abuse Prevention page 1 of 2 Those who use prescription drugs inappropriately may have underlying issues that need to be addressed. Clinicians should screen, identify, monitor and work with patients at risk to prevent potential harms caused by misuse or abuse of prescription drugs. Management of chronic pain and other conditions treated with medications that have the potential to be abused requires balancing the need for appropriate treatment with prevention of abuse. This information is intended to assist clinicians in preventing and monitoring for prescription drug misuse and abuse. Definitions: Adapted from Katz NP, Adams EH, Chilcoat H, Colucci RD, Comer SD, Goliber P, et al. (2007). Challenges in the Development of Prescription Opioid Abuse-deterrent Formulations. Clin J Pain. 23(8):648-660. Prescription drug misuse is “use of a medication (for a medical purpose) other than as directed or as indicated.” Prescription drug abuse is “the intentional self-administration of a medication for a non-medical purpose.” Why address prescription drug abuse? (go to www.healthteamworks.org for a full reference list) Prescription drug abuse is the nation’s fastest growing drug problem (ONDCP). Poisoning is the leading cause of injury death for adults 35-54 yrs., mainly from prescription drugs (CDC). Prescription drugs are no safer than illicit drugs, and often easier to obtain. 1/3 of people age 12+ who used drugs for the first time in 2009 used a prescription drug non-medically (SAMHSA). 70% of people who abused prescription pain relievers got them from friends and family, 5% from drug dealers or internet (SAMHSA). Prescription drugs are the second most abused category of illicit drugs after marijuana (University of Michigan). In 2009, almost 3 times as many Coloradoans died from abusing prescription drugs (445) as from drunk driving crashes (158) (CDPHE). Screening questions Many patients will answer truthfully if practices emphasize and ensure the information is handled confidentially. 1. In the past year, have you used or experimented with an illegal drug or a prescription drug for non-medical reasons? Yes = (+) screen 2. Have you taken any prescription drugs not prescribed to you or for a purpose for which they were not prescribed? Yes = (+) screen ic P a i n D Su M is u ression past trauma, family history of dependence, etc.? Is patient self-medicating for another issue? Chronic pain, depression and substance misuse commonly co-occur. Careful screening will help clinicians provide the most appropriate care. on ep Screen for depression using PHQ-2/PHQ-9*, especially in patients presenting with chronic pain. Does patient have history of abuse of tobacco/alcohol/other drugs or current abuse of a substance? Does patient have substance abuse/dependence risk factors such as untreated mental health issues, se Ch r Behavioral health considerations b s ta n ce Pain management as prevention of abuse: Opioids are not the only drug for pain Duration of pain Acute: Examples: new fracture, surgical incision Consider opioids, NSAIDs, acetaminophen. Chronic: Examples: frequent headache syndromes, peripheral neuropathy, arthritic joint Consider certain anti-depressants, anti-convulsants, NSAIDS, acetaminophen. Somatic: Pain originates from damaged body component, signaling pain appropriately. Typical descriptors: sharp, pressure, gnawing Character of pain Neuropathic: Pain originates from damaged neural pathway, signaling pain inappropriately. Typical descriptors: shooting, electric shock, pins and needles, tingling If neuropathic pain, consider anti-depressants and anti-convulsants. Consider referring to a Pain Management Specialist when: Clinical presentation does not fit the response. The quantity of drugs a patient consumes is rapidly increasing. Pain is not improving despite current dose or increased dose. Alternate modalities to manage pain: Meditation Physical Therapy Yoga Massage Reiki Biofeedback Relaxation Tai Chi Antidepressant Anticonvulsant *See Depression in Adults: Diagnosis and Treatment Guideline at: www.healthteamworks.org/guidelines/depression.html. This supplement is designed to assist clinicians with prevention of prescription drug misuse and abuse. It is not intended to replace a clinician’s judgment or establish a protocol for all patients with a particular condition. For references, important updates and copies of the supplement go to www.healthteamworks.org or call (303) 446-7200 or 1-866-401-2092. Funding for this supplement was provided by SAMHSA. Completed September 2011. Sedative hypnotics abuse Alcohol risk Benzodiazepines have a synergistic effect with opioids and alcohol. »» Benzodiazepines with opioids or alcohol put patient at increased risk for Alcohol + opioids or benzodiazepines have a synergistic effect. Consider a patient’s alcohol use when prescribing opioids. Reinforce the Often used with alcohol to increase the synergistic effect. Only approved for short-term use in insomnia. Contraindicated to use these drugs with COPD or sleep apnea. There is no known safe amount of alcohol while taking sedatives or CNS depression or respiratory depression. importance of not using simultaneously (especially with benzodiazepines). opioids. Stimulant abuse Abused primarily for recreation and academic enhancements. Before prescribing, consider gathering references from parents and teachers to discourage drug-seeking. Look at past records and be willing to say “no.” Talk with children about not revealing their prescription use to their friends. Give an appropriate diagnosis, amount of medicine, and instructions for medications. Note: some practices (i.e. student health centers) require testing-based diagnosis of ADD/ADHD before prescribing. Steps to reduce risks For Your Practice Screen: Screener and Opioid Assessment for Patients with Pain, Opioid Risk Tool, Pain Medication Questionnaire (see below for links). Check: Colorado Prescription Drug Monitoring Program (PDMP) at www.coloradopdmp.org to ensure patient is not receiving similar medications from other sources, for evidence of prescriptions you did not write, or stolen prescription pads on your profile. Watch for potential signs of misuse: multiple use on PDMP, calling after hours, ER/urgent care visits, manipulative/demanding, lost/stolen prescriptions. Monitor use: when patient calls in for refills, do a phone screen to review side effects, interactions and to monitor the use of the drug. Use contracts: consider having patient sign a Pain Medication Contract. See example at www.healthteamworks.org. Safeguard Rx access: Keep pads in your pocket or locked up and do not share passwords with others. Use scripts that can’t be photocopied. For Your Patients Address patient concerns: (i.e., pain). Trust your clinical judgment: don’t completely rely on pain scale. Avoid opioid drugs: educate yourself about responsible opioid prescribing and alternative therapies for pain. Warn patients: many medications have the potential for creating dependence and other harmful side effects such as constipation, central apnea, hormonal imbalance, dependence, and withdrawal. Screen: for sleep apnea, pregnancy and breast feeding which can place patient/child at an increased risk for death if combined with opioid use. Plan: for a step-down process. Safeguarding of medications: tips for patients and caregivers Sharing your prescriptions with others is against the law. Don’t openly discuss your medications with others. Keep medications in a safe, locked place (not in medicine/kitchen cabinets). Treat prescription drugs as you would cash or credit cards. Many medications have a high street value and are often stolen from homes or vehicles. Some over-the-counter medications (i.e., pseudoephedrine, dextromethorphan) have the potential for abuse and should be secured. Proper medication disposal Approximately 20% of all prescription medications are unused. Proper disposal is key to decreasing abuse. O Controlled Controlled medications can only be given to a uniformed law enforcement officer for safe disposal. According to the FDA, some controlled substances should be flushed. For a list: www.fda.gov. Be aware of community pharmaceutical take back programs sponsored by law enforcement. o flush! Kt Non-Controlled Be aware of community pharmaceutical take back programs. Take unused, unneeded prescription drugs out of original containers, mix with an undesirable substance (e.g., used coffee grounds or kitty litter), put in nondescript containers or sealed bags and throw them in the trash. Colorado Medication Disposal Pilot Project: www.cdphe.state.co.us/hm/medtakeback/index.htm Resources for prescribers Food and Drug Administration: www.fda.gov Opioid Risk Tool (ORT): www.opioidrisk.com/node/884 Screener & Opioid Assessment for Patients with Pain (SOAPP): www.painedu.org/soap.asp Pain Medication Questionnaire: www.opioidrisk.com/node/943 Colorado PDMP: www.coloradopdmp.org Books Avoiding Opioid Abuse While Managing Pain by Lynn R. Webster, MD, and Beth Dove Responsible Opioid Prescribing by Scott M. Fishman, MD Referral to Treatment Division of Behavioral Health: http://linkingcare.org See HealthTeamWorks SBIRT Guideline Referral to Treatment section Alcohol and your health Research-based information from the National Institutes of Health U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES NIH...Turning Discovery Into Health® “Sometimes we do things out of habit and we don’t really stop to think about it. This made me think about my choices.” “It emphasized that drinking is not bad in and of itself—it’s how much you’re doing it and how it’s affecting your life.” “I thought the strategies for cutting down were really good. It gives you tools to help yourself.” These are comments from social drinkers who reviewed Rethinking Drinking in focus testing. We welcome your comments as well. Send an email to [email protected] or call 301–443–3860. For an online version of this booklet with interactive features and additional resources, visit RethinkingDrinking.niaaa.nih.gov RETHINKING DRINKING Do you think you may drink too much at times? Do you think “everyone” drinks a lot? See below for results from a nationwide survey of 43,000 adults by the National Institutes of Health on alcohol use and its consequences. Alcohol use by adults in the United States* 7 in 10 adults always drink at low-risk levels or do not drink at all 37% always drink at low-risk levels *Although the minimum legal drinking age in the U.S. is 21, this survey included people aged 18 or older. For anyone who drinks, Rethinking Drinking offers valuable, research-based information. The first part, How much is too much?, answers these questions and more: • What’s “low-risk” drinking versus “at-risk” or “heavy” drinking? • Why is being able to “hold your liquor” a concern? • What are signs that drinking is causing harm? Thinking about a change? 35% don’t drink at all 28% drink at heavy or at-risk levels 3 in 10 adults drink at levels that put them at risk for alcoholism, liver disease, and other problems How much is too much? Do you enjoy a drink now and then? Many of us do, often when socializing with friends and family. Drinking can be beneficial or harmful, depending on your age and health status, the situation, and, of course, how much you drink. Many heavy drinkers do not have alcohol-related problems yet and can reduce their risk of harm by cutting back. For the nearly 18 million Americans who have alcoholism or related problems, however, it’s safest to quit. The second part of this booklet, Thinking about a change?, offers tips, tools, and resources for people who choose to cut down or quit. Success is likely for those who persist in their efforts. Even for those with alcoholism, studies show that most do recover, often without professional treatment. What do you think about taking a look at your drinking habits and how they may affect your health? Rethinking Drinking can help you get started. 1 HOW MUCH IS TOO MUCH? What counts as a drink? Many people are surprised to learn what counts as a drink. In the United States, a “standard” drink is any drink that contains about 0.6 fluid ounces or 14 grams of “pure” alcohol. Although the drinks pictured below are different sizes, each contains approximately the same amount of alcohol and counts as a single drink. 12 fl oz of regular beer = 8–9 fl oz of malt liquor (shown in a 12 oz glass) about 5% alcohol = about 7% alcohol 5 fl oz of table wine about 12% alcohol = 1.5 fl oz shot of 80-proof spirits (“hard liquor”— whiskey, gin, rum, vodka, tequila, etc.) about 40% alcohol The percent of “pure” alcohol, expressed here as alcohol by volume (alc/vol), varies by beverage. How many drinks are in common containers? Below is the approximate number of standard drinks in different sized containers of regular beer malt liquor table wine 80-proof spirits or “hard liquor” 12 fl oz = 1 12 fl oz = 1½ 750 ml (a regular a shot (1.5 oz glass/50 ml bottle) = 1 16 fl oz = 1 16 fl oz = 2 wine bottle)= 5 a mixed drink or cocktail = 1 or more 22 fl oz = 2½ 200 ml (a “half pint”) = 4½ 22 fl oz = 2 40 fl oz = 3 40 fl oz = 4½ 375 ml (a “pint” or “half bottle”)= 8½ 750 ml (a “fifth”) = 17 The examples shown on this page serve as a starting point for comparison. For different types of beer, wine, or malt liquor, the alcohol content can vary greatly. Some differences are smaller than you might expect, however. Many light beers, for example, have almost as much alcohol as regular beer—about 85% as much, or 4.2% versus 5.0% alcohol by volume (alc/vol), on average. Although the standard drink sizes are helpful for following health guidelines, they may not reflect customary serving sizes. A mixed drink, for example, can contain one, two, or more standard drinks, depending on the type of spirits and the recipe. 2 RethinkingDrinking.niaaa.nih.gov What’s your drinking pattern? 1.On any day in the past year, have you ever had •For MEN: more than 4 drinks? yes no •For WOMEN: more than 3 drinks? yes no 2. Think about your typical week: (a) • On average, how many days a week do you drink alcohol? • On a typical drinking day, how many drinks do you have? X How much is too much? Using the drink sizes on page 2, answer the questions below: (b) (multiply a x b) weekly average = Sometimes even a little is too much Even moderate levels of drinking (up to 2 drinks per day for men or 1 for women) can be too much in some circumstances. It’s safest to avoid alcohol if you are • • • • planning to drive a vehicle or operate machinery taking medications that interact with alcohol managing a medical condition that can be made worse by drinking pregnant or trying to become pregnant Can you “hold your liquor”? If so, you may be at greater risk. For some people, it takes quite a few drinks to get a buzz or feel relaxed. Often they are unaware that being able to “hold your liquor” isn’t protection from alcohol problems, but instead a reason for caution. They tend to drink more, socialize with people who drink a lot, and develop a tolerance to alcohol. As a result, they have an increased risk for developing alcoholism. The higher alcohol levels can also cause liver, heart, and brain damage that can go unnoticed until it’s too late. And all drinkers need to be aware that even moderate amounts of alcohol can significantly impair driving performance, even when they don’t feel a buzz from drinking. 3 What’s “low-risk” drinking? A major nationwide survey of 43,000 U.S. adults by the National Institutes of Health shows that only about 2 in 100 people who drink within both the “single-day” and weekly limits below have alcoholism or alcohol abuse. How do these “low-risk” levels compare with your drinking pattern from page 3? MEN WOMEN No more than No more than Low-risk drinking limits 3 1 2 10 9 8 6 7 6 17 1 4 5 5 1 13 14 24 11 12 22 23 20 21 9 30 31 18 19 2 27 28 25 26 On any single DAY 4 drinks on any day ** AND ** ** AND ** No more than Per WEEK 3 drinks on any day 14 drinks per week No more than 7 drinks per week To stay low risk, keep within BOTH the single-day AND weekly limits. “Low risk” is not “no risk.” Even within these limits, drinkers can have problems if they drink too quickly, have health problems, or are older (both men and women over 65 are generally advised to have no more than 3 drinks on any day and 7 per week). Based on your health and how alcohol affects you, you may need to drink less or not at all. What’s “heavy” or “at-risk” drinking? For healthy adults in general, drinking more than the single-day or weekly amounts shown above is considered “at-risk” or “heavy” drinking. About 1 in 4 people who drink this much already has alcoholism or alcohol abuse, and the rest are at greater risk for developing these and other problems. It makes a difference both how much you drink on any day and how often you have a “heavy drinking day”—that is, more than 4 drinks in a day for men or more than 3 drinks for women. The more drinks in a day and the more heavy drinking days over time, the greater the chances for problems (see “What’s the harm?” on the next page). Why are women’s low-risk limits different from men’s? Research shows that women start to have alcohol-related problems at lower drinking levels than men do. One reason is that, on average, women weigh less than men. In addition, alcohol disperses in body water, and pound for pound, women have less water in their bodies than men do. So after a man and woman of the same weight drink the same amount of alcohol, the woman’s blood alcohol concentration will tend to be higher, putting her at greater risk for harm. 4 How much do U.S. adults drink? The majority—7 out of 10—either abstain or always drink within low-risk limits. Which group are you in? 9% 19 % drink more than both the single-day limits and the weekly limits Highest risk drink more than either the single-day Increased risk limits or the weekly limits 37 % always drink within low-risk limits 35 % never drink alcohol Low risk How much is too much? Drinking patterns in U.S. adults — What’s the harm? Not all drinking is harmful. You may have heard that regular light to moderate drinking (from ½ drink a day up to 1 drink a day for women and 2 for men) can even be good for the heart. With at-risk or heavy drinking, however, any potential benefits are outweighed by greater risks. Injuries. Drinking too much increases your chances of being injured or even killed. Alcohol is a factor, for example, in about 60% of fatal burn injuries, drownings, and homicides; 50% of severe trauma injuries and sexual assaults; and 40% of fatal motor vehicle crashes, suicides, and fatal falls. Health problems. Heavy drinkers have a greater risk of liver disease, heart disease, sleep disorders, depression, stroke, bleeding from the stomach, sexually transmitted infections from unsafe sex, and several types of cancer. They may also have problems managing diabetes, high blood pressure, and other conditions. Birth defects. Drinking during pregnancy can cause brain damage and other serious problems in the baby. Because it is not yet known whether any amount of alcohol is safe for a developing baby, women who are pregnant or may become pregnant should not drink. Alcohol use disorders. Generally known as alcoholism and alcohol abuse, alcohol use disorders are medical conditions that doctors can diagnose when a patient’s drinking causes distress or harm. In the United States, about 18 million people have an alcohol use disorder. See the next page for symptoms. 5 What are symptoms of an alcohol use disorder? See if you recognize any of these symptoms in yourself. In the past year, have you had times when you ended up drinking more, or longer, than you intended? more than once wanted to cut down or stop drinking, or tried to, but couldn’t? more than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? spent a lot of time drinking? Or being sick or getting over other aftereffects? continued to drink even though it was causing trouble with your family or friends? found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems? given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? more than once gotten arrested, been held at a police station, or had other legal problems because of your drinking? found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there? If you don’t have symptoms, then staying within the low-risk drinking limits on page 4 will reduce your chances of having problems in the future. If you do have any symptoms, then alcohol may already be a cause for concern. The more symptoms you have, the more urgent the need for change. A health professional can look at the number, pattern, and severity of symptoms to see whether an alcohol use disorder is present and help you decide the best course of action. Thinking about a change? The next section may help. Note: These questions are based on symptoms for alcohol use disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) of Mental Disorders, Fourth Edition. The DSM is the most commonly used system in the United States for diagnosing mental health disorders. 6 THINKING ABOUT A CHANGE? THINKING ABOUT A CHANGE? It’s up to you It’s up to you as to whether and when to change your drinking. Other people may be able to help, but in the end it’s your decision. Weighing your pros and cons can help. Pros: What are some reasons why you might want to make a change? to improve my health to lose weight or get fit to improve my relationships to save money to avoid hangovers to avoid more serious problems to do better at work or school to meet my own personal standards Cons: What are some possible reasons why you might not want to change? Compare your pros and cons. Put extra check marks by the most important one(s). Is there a difference between where you are and where you want to be? Ready . . . or not? Are you ready to change your drinking? If so, see the next sections for support. But don’t be surprised if you continue to have mixed feelings. You may need to re-make your decision several times before becoming comfortable with it. If you’re not ready to change yet, consider these suggestions in the meantime: • Keep track of how often and how much you’re drinking. • Notice how drinking affects you. • Make or re-make a list of pros and cons about changing. • Deal with other priorities that may be in the way of changing. • Ask for support from your doctor, a friend, or someone else you trust. Don’t wait for a crisis or to “hit bottom.” When someone is drinking too much, making a change earlier is likely to be more successful and less destructive to individuals and their families. 8 RethinkingDrinking.niaaa.nih.gov To cut down or to quit . . . If you’re considering changing your drinking, you’ll need to decide whether to cut down or to quit. It’s a good idea to discuss different options with a doctor, a friend, or someone else you trust. Quitting is strongly advised if you • • • • • try cutting down but cannot stay within the limits you set have had an alcohol use disorder or now have symptoms (see page 6) have a physical or mental condition that is caused or worsened by drinking are taking a medication that interacts with alcohol are or may become pregnant If you do not have any of these conditions, talk with your doctor to determine whether you should cut down or quit based on factors such as • • • • family history of alcohol problems your age whether you’ve had drinking-related injuries symptoms such as sleep disorders and sexual dysfunction If you choose to cut down, see the low-risk drinking limits on page 4. Even when you have committed to change, you still may have mixed feelings at times. Making a written “change plan” will help you to solidify your goals, why you want to reach them, and how you plan to do it. A sample form is provided on page 14, or you can fill out one online at the Rethinking Drinking Web site. Reinforce your decision with reminders. Enlist technology to help. Change can be hard, so it helps to have concrete reminders of why and how you’ve decided to do it. Some standard options include carrying a change plan in your wallet or posting sticky notes at home. If you have a computer or mobile phone, consider these high-tech ideas: Thinking about a change? Planning for change • Fill out a “change plan” online at the Rethinking Drinking Web site, email it to your personal (non-work) account, and review it weekly. • Store your goals, reasons, or strategies in your mobile phone in short text messages or notepad entries that you can retrieve easily when an urge hits. • Set up automated mobile phone or email calendar alerts that deliver reminders when you choose, such as a few hours before you usually go out. • Create passwords that are motivating phrases in code, which you’ll type each time you log in, such as 1Day@aTime, 1stThings1st!, or 0Pain=0Gain. 9 Strategies for cutting down Small changes can make a big difference in reducing your chances of having alcoholrelated problems. Here are some strategies to try. Check off perhaps two or three to try in the next week or two, then add some others as needed. If you haven’t made progress after 2 to 3 months, consider quitting drinking altogether, seeking professional help, or both. Keep track. Keep track of how much you drink. Find a way that works for you, such as a 3x5” card in your wallet (see page 15 for samples), check marks on a kitchen calendar, or notes in a mobile phone notepad or personal digital assistant. Making note of each drink before you drink it may help you slow down when needed. Count and measure. Know the “standard” drink sizes so you can count your drinks accurately (see page 2). Measure drinks at home. Away from home, it can be hard to keep track, especially with mixed drinks. At times you may be getting more alcohol than you think. With wine, you may need to ask the host or server not to “top off” a partially filled glass. Set goals. Decide how many days a week you want to drink and how many drinks you’ll have on those days. It’s a good idea to have some days when you don’t drink. Drinkers with the lowest rates of alcohol use disorders stay within these limits (also shown on page 4): For men, no more than 4 drinks on any day and 14 per week; and for women, no more than 3 drinks on any day and 7 per week. Both men and women over age 65 generally are advised to have no more than 3 drinks on any day and 7 per week. Depending on your health status, your doctor may advise you to drink less or not at all. Pace and space. When you do drink, pace yourself. Sip slowly. Have no more than one standard drink with alcohol per hour. Have “drink spacers”—make every other drink a nonalcoholic one, such as water, soda, or juice. Include food. 10 Don’t drink on an empty stomach. Have some food so the alcohol will be absorbed into your system more slowly. Find alternatives. If drinking has occupied a lot of your time, then fill free time by developing new, healthy activities, hobbies, and relationships or renewing ones you’ve missed. If you have counted on alcohol to be more comfortable in social situations, manage moods, or cope with problems, then seek other, healthy ways to deal with those areas of your life. Avoid “triggers.” What triggers your urge to drink? If certain people or places make you drink even when you don’t want to, try to avoid them. If certain activities, times of day, or feelings trigger the urge, plan something else to do instead of drinking. If drinking at home is a problem, keep little or no alcohol there. Plan to handle urges. Know your “no.” You’re likely to be offered a drink at times when you don’t want one. Have a polite, convincing “no, thanks” ready. The faster you can say no to these offers, the less likely you are to give in. If you hesitate, it allows you time to think of excuses to go along. Thinking about a change? When you cannot avoid a trigger and an urge hits, consider these options: Remind yourself of your reasons for changing (it can help to carry them in writing or store them in an electronic message you can access easily). Or talk things through with someone you trust. Or get involved with a healthy, distracting activity, such as physical exercise or a hobby that doesn’t involve drinking. Or, instead of fighting the feeling, accept it and ride it out without giving in, knowing that it will soon crest like a wave and pass. Tools to help you manage urges to drink and build drink refusal skills are available on the Rethinking Drinking Web site. If you want to quit drinking— The four strategies on this page are especially helpful. But if you think you may be dependent on alcohol and decide to stop drinking completely, don’t go it alone. Sudden withdrawal from heavy drinking can be life threatening. Seek medical help to plan a safe recovery. 11 Support for quitting The suggestions in this section will be most useful for people who have become dependent on alcohol, and thus may find it difficult to quit without some help. Several proven treatment approaches are available. One size doesn’t fit all, however. It’s a good idea to do some homework on the Internet or at the library to find social and professional support options that appeal to you, as you are more likely to stick with them (see also Resources on the inside back cover). Chances are excellent that you’ll pull together an approach that works for you. Social support One potential challenge when people stop drinking is rebuilding a life without alcohol. It may be important to • • • • educate family and friends develop new interests and social groups find rewarding ways to spend your time that don’t involve alcohol ask for help from others When asking for support from friends or significant others, be specific. This could include • • • • • not offering you alcohol not using alcohol around you giving words of support and withholding criticism not asking you to take on new demands right now going to a group like Al-Anon Consider joining Alcoholics Anonymous or another mutual support group (see Resources). Recovering people who attend groups regularly do better than those who do not. Groups can vary widely, so shop around for one that’s comfortable. You’ll get more out of it if you become actively involved by having a sponsor and reaching out to other members for assistance. Feeling depressed or anxious? It’s common for people with alcohol problems to feel depressed or anxious. Mild symptoms may go away if you cut down or stop drinking. See a doctor or mental health professional if symptoms persist or get worse. If you’re having suicidal thoughts, call your health care provider or go to the nearest emergency room right away. Effective treatment is available to help you through this difficult time. 12 Professional support Advances in the treatment of alcoholism mean that patients now have more choices and health professionals have more tools to help. Medications to treat alcoholism. Newer medications can make it easier to quit drinking by offsetting changes in the brain caused by alcoholism. These options (naltrexone, topiramate, and acamprosate) don’t make you sick if you drink, as does an older medication (disulfiram). None of these medications are addictive, so it’s fine to combine them with support groups or alcohol counseling. A major clinical trial recently showed that patients can now receive effective alcohol treatment from their primary care doctors or mental health practitioners by combining the newer medications with a series of brief office visits for support. See Resources for more information. Specialized, intensive treatment programs. Some people will need more intensive programs. See Resources for a treatment locator. If you need a referral to a program, ask your doctor. Don’t give up. Thinking about a change? Alcohol counseling. “Talk therapy” also works well. There are several counseling approaches that are about equally effective—12 step, cognitive-behavioral, motivational enhancement, or a combination. Getting help in itself appears to be more important than the particular approach used, as long as it offers empathy, avoids heavy confrontation, strengthens motivation, and provides concrete ways to change drinking behavior. Changing habits such as smoking, overeating, or drinking too much can take a lot of effort, and you may not succeed with the first try. Setbacks are common, but you learn more each time. Each try brings you closer to your goal. Whatever course you choose, give it a fair trial. If one approach doesn’t work, try something else. And if a setback happens, get back on track as quickly as possible. In the long run, your chances for success are good. Research shows that most heavy drinkers, even those with alcoholism, either cut back significantly or quit. For tools to help you make and maintain a change, visit the Rethinking Drinking Web site. 13 Ready to begin? If so, start by filling out the change plan below or online at the Rethinking Drinking Web site, where you can print it out or email it to yourself. If you are cutting down as opposed to quitting, you can use the drinking tracker cards on the next two pages. Change plan Goal: I want to drink no more than ___ drink(s) on any day and no more than ___ drink(s) per week (see page 4 for low-risk limits) or I want to stop drinking Timing: I will start on this date: Reasons: My most important reasons to make these changes are: Strategies: I will use these strategies (see pages 10–11): People: The people who can help me are (names and how they can help): Signs of success: I will know my plan is working if: Possible roadblocks: Some things that might interfere and how I’ll handle them: 14 Drinking tracker cards If you want to cut back on your drinking, start by keeping track of every drink. Below are two sample forms you can cut out or photocopy and keep with you. Either one can help make you aware of patterns, a key step in planning for a change. The “4-week tracker” is a simple calendar form. If you mark down each drink before you have it, this can help you slow down if needed. The “drinking analyzer” can help you examine the causes and consequences of your drinking pattern. Try one form, or try both to see which is more helpful. These are also available on the Rethinking Drinking Web site. 4-week tracker GOAL: No more than ____ drinks on any day and ____ per week. Week starting Su M T W Th F Sa Total ___/___ Thinking about a change? ___/___ ___/___ ___/___ Drinking analyzer Date Situation (people, place) or Type of trigger (incident, feelings) drink(s) Amount Consequence (what happened?) 15 Drinking tracker cards (continued) These are the same cards as on the previous page. If you cut one out, you will have the drinking analyzer on one side and the 4-week tracker on the other side. Drinking analyzer Date Situation (people, place) or Type of trigger (incident, feelings) drink(s) Amount Consequence (what happened?) 4-week tracker GOAL: No more than ____ drinks on any day and ____ per week. Week starting ___/___ ___/___ ___/___ ___/___ 16 Su M T W Th F Sa Total Resources Professional help Mutual-help groups Your regular doctor. Primary care and Alcoholics Anonymous (AA) www.aa.org 212–870–3400 or check your local phone directory under “Alcoholism” mental health practitioners can provide effective alcoholism treatment by combining new medications with brief counseling visits. See “Helping Patients Who Drink Too Much” at www.niaaa.nih.gov/guide or call 301–443–3860. Specialists in alcoholism. For specialty addiction treatment options, contact your doctor, health insurance plan, local health department, or employee assistance program. Other resources include Medical and non-medical addiction specialists American Academy of Addiction Psychiatry www.aaap.org 401–524–3076 American Psychological Association 1–800–964–2000 (ask for your state’s referral number to find psychologists with addiction specialties) American Society of Addiction Medicine 301–656–3920 (ask for the phone number of your state’s chapter) NAADAC Substance Abuse Professionals www.naadac.org 1–800–548–0497 National Association of Social Workers www.helpstartshere.org (search for social workers with addiction specialties) Treatment facilities Substance Abuse Treatment Facility Locator www.findtreatment.samhsa.gov 1–800–662–HELP Moderation Management www.moderation.org 212–871–0974 Secular Organizations for Sobriety www.secularsobriety.org 323–666–4295 SMART Recovery www.smartrecovery.org 440–951–5357 Women for Sobriety www.womenforsobriety.org 215–536–8026 Groups for family and friends Al-Anon/Alateen www.al-anon.alateen.org 1–888–425–2666 for meetings Adult Children of Alcoholics www.adultchildren.org 310–534–1815 Information resources National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov 301–443–3860 National Institute on Drug Abuse www.nida.nih.gov 301–443–1124 National Institute of Mental Health www.nimh.nih.gov 1–866–615–6464 National Clearinghouse for Alcohol and Drug Information www.ncadi.samhsa.gov 1–800–729–6686 For additional resources, visit RethinkingDrinking.niaaa.nih.gov U AN VICES • U SER SA T OF HEA LT H A N DH M D E PA R TM NIH Publication No. 13-3770 Published 2010 EN SBIRT Basic AUDIT-C Protocol w/Scripting McPherson &Goplerud 2010 Open by saying: “How can I help you today?...proceed with Intake Introduce screening by saying: “We ask all our clients intake questions to help us better understand who you are and what your needs might be. As part of our holistic approach and as a preventive measure, we also ask some screening questions of all our members. Your answers will remain confidential”...proceed with screening [embed alcohol questions, e.g., start with depression, go to alcohol, drug use, then close with stress] Conduct AUDIT-C Hazardous Use Prescreen (3 questions) Q1: Frequency of drinking Q2: Quantity in a typical day Q3: Frequency of heavy use Record responses and add Q1+Q2+Q3, then Enter AUDIT-C score If client refuses at any point, indicate “Refused AUDIT-C” If AUDIT-C = <4 for men, <3 for women and adults over age 65 Follow NEGATIVE PRESCREEN Procedures: • AUDIT-C score feedback • Alcohol education • Normative feedback Brief Intervention RESPONSE • "From your responses, your drinking is in a healthy range, which means that you are at lower risk for many health and emotional concerns than those who drink at higher ranges. The U.S. recommended guidelines for low-risk drinking for women and adults over 65 is no more than 1 drink per day or 7 drinks per week, and for men no more than 2 drinks per day or 14 drinks per week. Most people, about 72% of adults in the U.S. never exceed these daily or weekly limits. Would you like me to send you some more information on healthy drinking patterns?" If yes, offer to email booklet and links • “Tips for Cutting Down on Drinking” booklet http://pubs.niaaa.nih.gov/publications/Tips/tips.p df • EAP website Document “BI provided” or “BI refused” Document “alcohol education materials provided” Close alcohol SBI: • “Thank you for taking a few minutes to talk with me.” STOP alcohol BI, continue EAP intake If AUDIT-C = 4+ for men, 3+ for women and adults over age 65 Follow POSITIVE PRESCREEN Procedures: • AUDIT-C score feedback • Alcohol Education • Normative Feedback • Simple Advice Brief Intervention RESPONSE AUDIT-C Score Feedback • "From your responses, your drinking may put you at higher risk for health and emotional concerns than those who drink at lower ranges. These questions have been given to thousands of people, so you can compare your drinking to others. Normal scores are 0-4 for men and 0-3 for women and anyone over age 65, which is low-risk drinking. Your score was [#]…on a scale of 0-12 which places you in the category for higher risk of harm.” Alcohol Education • “Unhealthy alcohol use can put you at risk for injury, accidents, and health problems such as diabetes, cancer, insomnia, high blood pressure, stroke, heart and gastrointestinal problem, depression and other conditions.” • “The U.S. recommended guidelines for low-risk drinking for women and adults over the age of 65 is no more than 1 drink per day (or 7 drinks per week) and for men no more than 2 drinks per day (or 14 drinks per week). Normative Feedback • “Most people, about 72% of adults in the U.S. never exceed these daily or weekly limits.” Simple Advice • “Reducing your alcohol consumption to safer drinking levels can decrease your risk.” Provide Alcohol Educational Materials • "Could I send you some information about healthy drinking?" If yes, offer to email booklets and links to websites: • • • • Rethinking Drinking booklet http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf Rethinking Drinking: Alcohol and Your Health website http://rethinkingdrinking.niaaa.nih.gov/; and “Tips for Cutting Down on Drinking” booklet http://pubs.niaaa.nih.gov/publications/Tips/tips.pdf EAP/BH website and other materials as appropriate: (e.g., Mixing Alcohol and Medication; Alcohol and Women; Young Teens and Drinking; Alcohol and Older Adults; Prevention for Children) Document “BI provided” or “BI refused”,“alcohol education materials provided” Close alcohol SBI: • “Thank you for taking a few minutes to talk with me.” STOP alcohol BI, continue EAP intake SBIRT MI-Informed AUDIT with 3 Risk Levels Protocol w/Scripting McPherson &Goplerud 2010 Open by saying: “How can I help you today?...proceed with Intake Introduce screening by saying: “We ask all our clients intake questions to help us better understand who you are and what your needs might be. As part of our holistic approach and as a preventive measure, we also ask some screening questions of all our members. Your answers will remain confidential”...proceed with screening [embed alcohol questions, e.g., start with depression, go to alcohol, drug use, then close with stress] Conduct AUDIT-C Hazardous Use Prescreen (3 questions) Q1: Frequency of drinking Q2: Quantity in a typical day Q3: Frequency of heavy use Record responses and add Q1+Q2+Q3, then Enter AUDIT-C score If client refuses at any point, indicate “Refused AUDIT-C” If AUDIT-C = <4 for men, <3 for women and adults over age 65 If AUDIT-C = 4+ for men, 3+ for women and adults over age 65 Follow POSITIVE PRESCREEN Procedures: • Complete remaining AUDIT items Q4 – Q10 • Record responses and add ALL AUDIT items (Q1-Q10), Enter total score • Identify Level of Risk (Low, Moderate, High) • If member refuses at any point, indicate “Member refused AUDIT” Follow NEGATIVE PRESCREEN Procedures: • AUDIT-C score feedback • Alcohol education • Normative feedback Brief Intervention RESPONSE • "From your responses, your drinking is in a • healthy range, which means that you are at lower risk for many health and emotional concerns than those who drink at higher ranges. The U.S. recommended guidelines for low-risk drinking for women and adults over 65 is no more than 1 drink per day or 7 drinks per week, and for men no more than 2 drinks per day or 14 drinks per week. Most people, about 72% of adults in the U.S. never exceed these daily or weekly limits. Would you like me to send you some more information on healthy drinking patterns?" If yes, offer to email booklet and links • “Tips for Cutting Down on Drinking” booklet http://pubs.niaaa.nih.gov/publications/Tips/tips.p df • EAP website Document “BI provided” or “BI refused” Document “alcohol education materials provided” Close alcohol SBI: • “Thank you for taking a few minutes to talk with me.” Risk Level Intervention AUDIT score* Level I Low Risk AUDIT score feedback Alcohol Education Normative Feedback [no follow-up] 0-7 Level II AUDIT score feedback Moderate Risk Alcohol Education Normative Feedback Simple Advice Referral to EAP Provider and/or other resources Schedule Follow-up Level III AUDIT score feedback High Risk Alcohol Education Normative Feedback Simple Advice Referral to Appropriate Level of Care (Specialist for Dx Eval, Tx, Alc DM, Community Resources) Schedule Follow-up STOP alcohol BI, continue EAP intake CONTINUE TO NEXT PAGE Level I See “Follow Negative Prescreen” Level II 8-19 Continue to “Brief Intervention Response” Level III 20-40 Continue to “Brief Intervention Response” Level II/Moderate (Score 8-19) Level III/High (Score 20-40) MI-Informed Brief Intervention for Risky Drinking RESPONSE …. Use your MI skills (OARS) to engage the member in conversation about alcohol use… 9 Open-ended Questions 9 Affirming Statements 9 Reflective Listening 9 Summarizing AUDIT Score Feedback…in a non-judgmental manner • "From your responses, your drinking puts you at higher risk for many health and emotional concerns than those who drink at lower ranges. These questions have been given to thousands of people, so you can compare your drinking to others. Your score was [#]…on a scale of 0-40 which places you in the category of [moderate or high] risk. Ask permission to continue discussion about alcohol: • “Would you mind if we spent just a few more minutes talking about your use of alcohol?” Explore member concerns, understand what they know: • “As I mentioned, your score was [#]…on a scale • • • of 0-40 which places you in the category of [Low, Moderate, or High] risk.” “What do you make of your score?” "What do you already know about how alcohol affects your health?" "What have you heard about what 'healthy' drinking is?" Alcohol Education • •“Unhealthy alcohol use can put you at risk for injury, •accidents, AUDIT-C feedback andscore health problems such as diabetes, •cancer, Normative feedback insomnia, high blood pressure, stroke, heart • Simple Advice and gastrointestinal problem, depression and other • Alcohol education conditions.” • “Would you be interested in knowing what the US guidelines are for low-risk drinking?” • “The U.S. recommended guidelines for low-risk drinking for women and adults over the age of 65 is no more than 1 drink per day (or 7 drinks per week) and for men no more than 2 drinks per day (or 14 drinks per week). AFFIRM, REFLECT BACK, SUMMARIZE (“Does that sound right to you?”) Explore Importance/Confidence (readiness to change): • “On a scale of 1-10, where 1 is ‘not at all important’ and 10 is ‘very important’, how important is it to you to … (e.g., change your drinking, cut back)?” • “Why did you give it that number and not a lower number?” • “What would it take to raise that number?” • “On a scale of 1-10, where 1 is ‘not at all confident’ and 10 is ‘very confident’, how confident are you that you could make this change successfully?” • “Why did you give it that number and not a lower number?” • “What would it take to raise that number?” AFFIRM, REFLECT BACK, SUMMARIZE (“Does that sound right to you?”) Explore Goals and Summarize: • “Where does this leave you? Do you want to quit, cut down, make no change? • “Would you like some suggestions on how to do this?” (e.g., cut back, abstain, limit to no more than 1 drink per day, alternate with healthier non-alcoholic beverage or replace with activity like walking). • What other changes do you want to make [e.g., not drink and drive, seek help]? • “What is your next step? How will you do that? Who will you ask to help you? What might get in the way? How will you deal with those challenges?” AFFIRM, REFLECT BACK, SUMMARIZE (“Does that sound about right?”) Provide Alcohol Educational Materials • "Could I send you some information about healthy drinking?" If yes, offer to email booklets and links to websites: • • Normative Feedback • Explore Ambivalence (Pros and Cons): • “What do you like about drinking?” • “What do you like less about drinking?” • “Okay, so on the one hand…..but on the other hand…” “Most people, about 72% of adults in the U.S. never exceed these daily or weekly limits.” Simple Advice • “Reducing your alcohol consumption to safer drinking levels can decrease your risk.” CONTINUE TO NEXT PAGE • • Rethinking Drinking booklet http://pubs.niaaa.nih.gov/publications/RethinkingDrinking /Rethinking_Drinking.pdf Rethinking Drinking: Alcohol and Your Health website http://rethinkingdrinking.niaaa.nih.gov/; and “Tips for Cutting Down on Drinking” booklet http://pubs.niaaa.nih.gov/publications/Tips/tips.pdf EAP/BH website and other materials as appropriate: (e.g., Mixing Alcohol and Medication; Alcohol and Women; Young Teens and Drining; Alcohol and Older Adults; Prevention for Children) Close Alcohol SBI on Good Terms SUMMARIZE member’s statements in favor of change, emphasize strengths, and agreed on next steps. Say “Thank You” • “Thank you for taking a few minutes to talk with me about your alcohol use. I appreciate your openness and sharing your experiences/thoughts with me today.” Document “BI provided” or “BI refused” Document “alcohol education materials provided” Ask Permission for Follow-up • "I would like to see how things are going for you over the next few months. Would you mind if I followed up with you? Is it okay to call your [cell phone]?" Document “Agreed to follow-up” or “Refused follow-up” Set Follow-up appointment Provide Referral [Note: More MI language can be crafted to facilitate connection to provider and/or engagement/retention] Moderate Risk Cases (as appropriate) Offer referral to provider for alcohol use – e.g., affiliate provider, community resource (AA) • • "Based on the information you provided, I would encourage you to consider bringing up your alcohol use with your counselor at your next appointment. What do you think about this? Do you have any thoughts or concerns?” High Risk Cases: Referral to Specialist for Diagnostic Assessment – e.g., addiction specialist, alcohol disease management, behavioral health provider or program, community resource (AA) • • "Based on the information you provided, I would encourage you to consider getting additional help for dealing with issues related to alcohol. I would like to refer you/put you in touch with a provider on your health plan. What do you think about this? Do you have any thoughts or concerns?” Document Referral STOP alcohol BI, continue EAP intake
