IN THIS ISSUE
SUBSTANCE USE DISORDERS
Exposure to stress and trauma may increase the risk of substance use disorders. Primary care providers can play an important role in creating a treatment plan and supporting the patient in locating the appropriate specialty addiction treatment, support service, or network. These referral services can help patients recover, maintain remission, and reduce the risk of relapse (31,32). For patients with existing substance use disorders, exposure to stress can increase cravings and therefore the likelihood of a relapse (33).
Screening. While most patients seen in primary care settings who are exposed to disaster-related stress will not engage in high-risk drinking, stress can increase alcohol use, especially in people who drank unsafe amounts of alcohol before the disaster (34). Prescreen all patients by asking, "Do you sometimes drink alcoholic beverages?" If the answer is yes, use the single-question screen, "How many times in the past year have you had X or more drinks in a day?" where X is 5 for men and 4 for women (35). If the answer is 1 or more, assess the level of risk with the AUDIT for adults (36) or CRAFFT for adolescents (see Resources—City Health Information: Brief Intervention for Excessive Drinking for screening tools) (37). Following screening, you can also use current American Psychiatric Association diagnostic criteria or other assessment tools to determine presence of a substance use disorder (Resources).
Intervention and referral. Use the brief intervention technique to help patients reduce unhealthy drinking (38):
The AUDIT score can be used also to determine the level of intervention needed. Patients at low risk (AUDIT score 0-7) require educational messages about safe alcohol use, which means no more than an average of 1 drink per day for women and 2 drinks per day for men. For patients with an AUDIT score between 8 and 19, offer a brief intervention, that is, simple, personalized advice in addition to education. An AUDIT score of 20 or higher is associated with a greater likelihood of having an alcohol use disorder requiring specialized treatment, which may include supervised detoxification. Offer patients with alcohol use disorders a referral to specialty care for further evaluation and treatment (Resources—Referrals). For adolescents with a positive score on the CRAFFT, consult the 2011 American Academy of Pediatrics statement, "Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians" (Resources).
Pharmacotherapy. Medication can help patients with alcohol use disorders decrease their alcohol use—and may be prescribed as part of specialty or primary care. Naltrexone, acamprosate, and disulfiram are approved for the treatment of alcohol use disorders.
Screening. Ask all patients the screening question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons (39)?" If the patient answers 1 or more, use a standardized tool such as the NIDA-ASSIST (Resources—City Health Information: Improving the Health of People Who Use Drugs) for further assessment, or consult the American Psychiatric Association diagnostic criteria for substance use disorders (Resources).
Intervention and referral. Brief interventions may reduce substance use and improve the health of primary care patients who use illicit drugs (40-42). Offer patients referral to drug-treatment and harm-reduction programs when necessary (Resources—Referrals). Patients using opioids are at risk for overdose; refer to an overdose prevention program for the patient to receive training in layperson-administered naloxone (Resources—Overdose Prevention). PCPs can also prescribe sterile syringes under the New York State Expanded Syringe Access Program. Address primary care needs of drug-using patients, including appropriate screening for infectious diseases and counseling safer sex.
Pharmacotherapy. Buprenorphine and methadone in combination with counseling are effective in reducing illicit opioid use, decreasing craving, and improving social function in patients with opioid dependence (43) (Resources—City Health Information: Buprenorphine). For information on obtaining a waiver that allows you to prescribe buprenorphine, visit the Substance Abuse and Mental Health Services Administration website (Resources—SAMHSA: Buprenorphine).
See Resources—City Health Information: Improving the Health of People Who Use Drugs for information on addressing the needs of these patients.