Preferred Practice Guidelines for the Identification and Treatment of Substance Use Disorders

Transcription

1 Preferred Practice Guidelines fr the Identificatin and Treatment f Substance Use Disrders These Guidelines were based in part n the fllwing: Treatment f Patients with Substance Use Disrders frm the American Psychiatric Assciatin (APA), May The APA guideline Treatment f Patients with Substance Use Disrders was amended by the fllwing Guideline Watch frm the American Psychiatric Assciatin (APA), April The practice guidelines included in this dcument are nt intended t be required treatment prtcls. Physicians and ther health prfessinals must rely n their wn expertise in evaluating and treating patients. Practice guidelines are nt a substitute fr the best prfessinal judgment f physicians and ther health prfessinals. Behaviral health guidelines may include cmmentary develped by the Cmpany s behaviral health cmmittees. Further, while authritative surces are cnsulted in the develpment f these guidelines, the practice guideline may differ in sme respects frm the surces cited. With respect t the issue f cverage, each patient shuld review his/her Plicy r Certificate and Schedule f Benefits fr details cncerning benefits, prcedures and exclusins prir t receiving treatment. The practice guidelines d nt supersede the Plicy r Certificate and Schedule f Benefits. Anthem Blue Crss and Blue Shield is the trade name f Anthem Insurance Cmpanies, Inc. Independent licensee f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. WEB-AIN

2 Identificatin and Treatment f Substance Use Disrders (SUD) Ratinale: Substance use disrders are highly prevalent illnesses. Alchl misuse is strngly assciated with health prblems, disability, death, accident, injury, scial disruptin, and vilence. 1 Each year, drug and alchl abuse cntributes t the death f mre than 120,000 Americans. Drugs and alchl cst U.S. taxpayers nearly $276 billin annually in preventable health care csts, extra law enfrcement, aut crashes, crime and lst prductivity. 2 The U.S. Preventive Services Task Frce (USPSTF) recmmends screening and behaviral cunseling interventins t reduce alchl misuse by adults, including pregnant wmen in primary care settings. 3 Data specific t adlescents are limited, but there is grwing evidence that successful early interventin and treatment carries significant benefit fr the individual and sciety. 4 Identificatin and interventin by the physician is especially imprtant, because even a brief physician interventin has been shwn t be helpful in stimulating patients t examine and decrease their substance use. Early physician diagnsis and interventin reduces subsequent direct and indirect csts, mtr vehicle accidents, emergency department visits, mrbidity, and mrtality. Identificatin: Screening fr Substance Use Disrders (SUD) can take place as part f a cmplete histry, r even in the mre restrictive setting f a brief ffice visit. All health care prviders shuld have a high index f suspicin regarding SUD in thse patients wh present with the fllwing: Labratry findings suggestive f SUD, such as elevated MCV r therwise unexplained abnrmalities f liver functin (e.g. GGT > 50 U/L, AST >40 U/L, ALT > 35, r AST/ALT > 1). Requests fr prescriptin f specific cntrlled substances by name, requests fr early refills, and lst supplies f cntrlled substances. Otherwise unexplained changes in behavir. Stigmata f needle injectin. Patients with psychiatric disrders wh fail t respnd t standard treatments fr the disrders being treated. Particular attentin shuld be paid t the fllwing grups f patients: Patients with c-existing significant psychiatric disrder (e.g. depressive disrders, biplar disrder, anxiety disrders including pst traumatic stress disrder, persnality disrders, ADHD, cnduct disrder, schizphrenia and thers). Patients with medical disrders likely t be cmprmised r cmplicated by substance abuse r dependence (e.g. hepatic disease, diabetes, bstructive sleep apnea, heart disease and hypertensin). Patients fr which substance abuse has resulted in legal prblems r cnsequences. Adlescents with marked changes in behavir r academic perfrmance.

3 Patients with a family histry f substance abuse. Patients with nictine dependence. Screening: The American Medical Assciatin has recmmended that primary care physicians shuld establish rutine alchl screening prcedures fr all patients, including children and adlescents as apprpriate and that primary care physicians shuld learn hw t cnduct brief interventin cunseling and mtivatinal interviewing. 5 The USPSTF has recmmended screening f all adults, 3 and the American Academy f Pediatrics (AAP) Cmmittees n Child Health Financing and Substance Abuse 4 has recmmended screening f adlescents fr substance abuse. Other physicians, especially psychiatrists and physicians treating traumatic injuries, als have the pprtunity t identify patients with substance abuse and t intervene in a way that decreases the likelihd f later sequellae. Substance Abuse and Dependence Instruments: There are a number f screening instruments available t prviders. Instruments suitable fr primary care settings have been emphasized, but these instruments can be helpful in any clinical setting. The easiest and quickest is the Tw-Item Cnjint Screen. The Tw-Item Cnjint Screen (TICS) has been used in primary care t identify patients with current alchl r ther drug prblems. At least ne psitive respnse t the TICS In the last year detected current substance use disrders with nearly 80% sensitivity and specificity. 6 The tw questins are: 1. Have yu ever drunk r used drugs mre than yu meant t? 2. Have yu felt yu wanted r needed t cut dwn n yur drinking r drug use in the last year? The Drug Abuse/Dependence Screener (Appendix A) is a three-item screen with excellent preliminary validity in cmmunity ppulatins. The mst cmmnly used instrument in primary care settings fr alchl abuse and dependence is the CAGE Questinnaire. This cnsists f fur questins reflected in the acrnym CAGE. Endrsement f tw r mre items is cnsidered t be a psitive screen fr alchl abuse r dependence. The wrding can easily be adapted t cver ther substances. Have yu ever felt yu shuld Cut dwn n yur drinking? Have peple Annyed yu by criticizing yur drinking? Have yu ever felt bad r Guilty abut yur drinking? Have yu ever had a drink first thing in the mrning t steady yur nerves r t get rid f a hangver (Eye pener)?

4 The Alchl Use Disrders Identificatin Test (AUDIT) has als been used extensively in the primary care setting. Scres f eight (8) r mre fr men (up t age 60) r fur (4) r mre fr wmen, adlescents, and men ver the age f 60 are cnsidered psitive screens. The Drug Abuse Screening Test (DAST) is a 28-item (r abbreviated 10-item versin) instrument t identify adverse cnsequences f substance abuse, but it has nt been well studied in primary care settings. Substance Withdrawal Severity Instruments: The fllwing instruments may prve useful t prviders in assessing the severity f substance withdrawal. Alchl: The Clinical Institute Withdrawal Assessment - Alchl, revised (CIWA-Ar) 7 is a well-validated instrument supprted by ASAM guidelines. 8,9 High scres (10 r higher) n this instrument have been shwn t be predictive f withdrawal seizures and withdrawal delirium. 9 Opiids: Clinical Opiate Withdrawal Scale (COWS) is a relatively new instrument meant t be helpful during the initial evaluatin. It shuld help the practitiner assess the severity f withdrawal. Older instruments useful fr this purpse include the Subjective Opiate Withdrawal Scale (SOWS) and the Clinical Institute Narctic Assessment Scale fr Withdrawal Symptms (CINA). 10 It is essential t keep in mind that withdrawal frm alchl and sedative-hypntics carries the risk f serius medical cmplicatins, including delirium and withdrawal seizures. These are ptentially fatal cmplicatins. NOTE: Delirium tremens and withdrawal seizures shuld be treated as medical emergencies in an acute medical hspital. These culd have significant life threatening issues and/r serius cmplicatins. Specialist Referral Criteria: Althugh sme patients with substance abuse can be successfully treated within a primary care setting, it is essential that the prvider cnsider the type, cmplexity and severity f the symptmlgy, as well their wn cmfrt level, when determining if a referral t a specialist is required. Clinical cnsultatin r referral t ne f the fllwing specialists shuld be cnsidered in these situatins: Psychiatrists: Patients with significant cmrbid psychiatric issues such as anxiety, depressin, biplar disrder and PTSD. Addictin Medicine Physicians (Including physicians certified by the American Sciety f Addictin Medicine [ASAM] in Addictin Medicine, physicians certified by the American Bard f Psychiatry an Neurlgy in Addictin Psychiatry, and ther physicians with special training and expertise in Addictin Medicine): Patients wh are likely t require medically-supervised withdrawal in a specialized, mnitred setting t prevent cmplicatins. These include:

5 A histry f withdrawal seizures, delirium tremens, substance-related hallucinatins, r substance-related acute psychtic symptms. Sedative-hypntic withdrawal with cmrbid withdrawal frm alchl, piids r stimulants. Alchl withdrawal with a CIWA-Ar scre f 10 r higher, r the equivalent n a cmparable standardized scring system. Mderately severe t severe piid withdrawal (e.g. a COWS scre f 25 r higher r the equivalent n a cmparable standardized scring system. Cmrbid severe medical r psychiatric disrders likely t decmpensate in the curse f withdrawal. Physicians with special training and DEA licensure fr piid maintenance therapy (OMT): Patients wh are dependent n piids and likely t require piid maintenance therapy (OMT) r piid substitutin and tapering, including the use f buprenrphine. It shuld be nted that this treatment can usually be prvided in an ffice-based, primary care setting. Primary care physicians whse practice includes patients dependent n prescribed r illicit piids are strngly encuraged t seek this CME training, which is available thrugh the American Sciety f Addictin Medicine (ASAM) at r the American Academy f Addictin Psychiatry at Addictin Medicine Physicians AND OBGYN: Any patient wh is pregnant and substance dependent. Substance Abuse Specialists such as Certified Alchl and Drug Cunselrs (CADAC) and licensed r certified mental health practitiners with special expertise in substance abuse: Patients wh are likely t need psychscial interventin beynd the skill, time, r cmfrt level f the PCP. Patients wh are likely t need a structured prgram f substance abuse rehabilitatin treatment. Other specialties: All patients with SUD wh have experienced recent significant trauma r wh have evidence f any rgan cmprmise, shuld receive the same level f specialty cnsultatin and treatment that wuld be prvided fr a patient withut SUD. Behaviral Health Treatment Crdinatin: The AMA recmmends that primary care clinics shuld establish clse wrking relatinships with alchl treatment specialists, cunselrs, and self-help grups in their cmmunities, and, whenever feasible, specialized alchl and drug treatment prgrams shuld be integrated int the rutine clinical practice f medicine. 5 We strngly supprt effrts directed at the crdinatin f care between all prfessinals invlved in prviding treatment t a member. Cmmunicatin between the varius disciplines is essential in rder t avid cnflicting treatment plans,

6 eliminate duplicated effrts and decrease the risk f medicatin errrs. This type f dialgue is especially imprtant between the primary care prvider, psychiatrist, addictin medicine physician, substance abuse prvider and/r ther behaviral health specialist when treatment is being prvided fr a behaviral health issue, including substance use disrders. Tward that end, we recmmend that all practitiners take an active rle in crdinating behaviral health treatment by requesting an authrizatin t release infrmatin t the patient s primary care prvider, ensuring that cmmunicatin ccurs and then dcumenting the results. Primary care prviders are encuraged t cmmunicate the ratinale and any relevant medical infrmatin when a member is referred t a psychiatrist, substance abuse prvider r therapist. Likewise, psychiatrists, addictin medicine physicians and ther behaviral health dpecialists are encuraged t establish an nging dialgue with their patient s primary care prviders. References: 1. Tenth special reprt t the U.S. Cngress n alchl and health frm the Secretary f Health and Human Services. U.S. Department f Health and Human Services. Washingtn, DC: Natinal Institutes f Health, Natinal Institute n Alchl Abuse and Alchlism (NIAAA). NIH Publicatin N ; June HHS Fact Sheet, December U. S. Department f Health and Human Services. 3. Screening and behaviral cunseling interventins in primary care t reduce alchl misuse: recmmendatin statement. U.S. Preventive Services Task Frce. Ann Intern Med Apr 6;140(7): Imprving substance abuse preventin, assessment, and treatment financing fr children and adlescents. American Academy f Pediatrics. Cmmittee n Child Health Financing and Cmmittee n Substance Abuse. Pediatrics Oct;108(4): Screening and Brief Interventins Fr Alchl Prblems. American Medical Assciatin Plicy H ; Dec Brwn DL, et al. A Tw-Item Cnjint Screen fr Alchl and Other Drug Prblems J Am Bard Fam Pract 14(2):95-106, Sullivan JT, Sykra K, Schneiderman J, Naranj CA, Sellers EM. Assessment f alchl withdrawal: the revised clinical institute withdrawal assessment fr alchl scale (CIWA- Ar). British Jurnal f Addictin. 1989;84: Patient placement criteria fr the treatment f substance-related disrders: ASAM PPC-2R. American Sciety f Addictin Medicine. 2nd Ed Revised. Chevy Chase, Md.: American Sciety f Addictin Medicine, Pharmaclgical management f alchl withdrawal. A meta-analysis and evidence-based practice guideline. American Sciety f Addictin Medicine Wrking Grup n Pharmaclgical Management f Alchl Withdrawal. May-Smith MF. JAMA Jul 9;278(2): Center fr Substance Abuse Treatment. Clinical guidelines fr the use f buprenrphine in the treatment f piid addictin. Rckville (MD): Substance Abuse and Mental Health Services Administratin; p. (Treatment imprvement prtcl; n. TIP 40). SUBSTANCE ABUSE SCREENING MATERIALS AND RESOURCES

7 CAGE Questinnaire, AUDIT, are available at The AUDIT is available as an nline questinnaire at The Clinical Institute Withdrawal Assessment - Alchl, revised (CIWA-Ar), with supprting dcumentatin, is available at: Articles discussing the Tw-Item Cnjint Screen (TICS) and CAGE Questinnaire can be fund at ( Medscape site requires free registratin ) nd The COWS, SOWS, and CINA can all be fund in PDF frmat starting n page number 110 in Appendix B f Clinical Guidelines fr the Use f Buprenrphine in the Treatment f Opiid Addictin n the Substance Abuse and Mental Health Services Administratin site at Substance Abuse Screening Inventry SAMHSA/CSAT Treatment Imprvement Prtcls

8 Appendix A Here is a list f drugs: Drug Abuse/Dependence Screener Marijuana, hashish, pt, grass Amphetamines, stimulants, uppers, speed Barbiturates, sedatives, dwners, sleeping pills, Secnal, Quaaludes Tranquilizers, Valium, Librium Ccaine, cke, crack Herin Opiates, cdeine, Demerl, mrphine, methadne, Darvn, pium Psychedelics, LSD, Mescaline, peyte, psilcybin, DMT, PCP 1. Have yu ever used ne f these drugs n yur wn mre than 5 times in yur life? By "n yur wn", I mean t get high r withut a prescriptin r mre than was prescribed. Yes = 1; N = 0 (skip questins 2 and 3) 2. Did yu ever find yu needed larger amunts f these drugs t get an effect r that yu culd n lnger get high n the amunt yu used t use? Yes = 1; N = 0 3. Did yu ever have emtinal r psychlgical prblems frm using drugs - such as feeling crazy r paranid r depressed r uninterested in things? Yes = 1; N = 0 Cnsider screen psitive fr lifetime drug abuse/dependence if item 1 = Yes and either item 2 r 3 = Yes References: Rst, K., Burnam, A., & Smith, G. R. (1993). Develpment f screeners fr depressive disrders and substance disrder histry. Medical Care, 31, Schrling, J. B., & Buchsbaum, D. G. (1997). Screening fr alchl and drug abuse. Medical Clinics f Nrth America, 81,