Have that talk with your patients.

Screening for substance abuse, including alcohol, illegal drugs, and prescription medications, should be a regular part of health care. According to national data, nearly one-fourth of patients seeking routine hospital care have an active addiction. Many people go untreated for substance use disorders due to a lack of screening and diagnosis. Make the discussion about drugs and alcohol a part of routine office visits. You could help identify an addiction problem early — which could help get your patient into treatment early.

The potential for drug and alcohol abuse is everywhere — in our homes, our schools, our workplaces, and our communities. Talk with your patients. They’ll listen to you.

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How you speak with your patients matters:

  • Ask nonjudgmental, open-ended questions.
  • Start out simply: “Is it ok if I ask you some questions about drugs and alcohol?”
  • Tell patients it’s a standard part of health screening and that everyone is asked the same questions.
  • Quantify the drug or alcohol use and how it can impair judgment.
  • Be empathetic and inquisitive.
  • Be alert for signs of addiction and be prepared to refer your patient if you suspect an addiction issue. For a list of treatment resources, visit our resources section.

Signs a patient may be addicted:

  • Altered sleep habits
  • Small or pinpoint pupils
  • Dramatic weight changes
  • Frequent nosebleeds
  • Frequent colds or illness
  • Itchy skin or unexplained cuts or scabs
  • Leg cramps
  • Poor hygiene
  • Sense of desperation
  • Changes in personality or friends
  • School or work performance problems
  • Out of or in need of money
  • Nodding off or constant sleep problems
  • Paranoia
  • Secrecy

Help your patients avoid becoming addicted to opioids.

Legally prescribed opioids are a proven pipeline to prescription- and illegal-drug addiction. Nearly 80 percent of heroin users indicate they started with prescription opioids.

Medical providers are encouraged to avoid prescribing opioids as the first-line treatment for chronic pain (excluding active cancer, palliative, or end-of-life care).

Opioids can be a powerful tool if prescribed and used carefully, but should never be the first line of defense to treat chronic pain. And, the benefits of long-term opioid therapy for chronic pain are not well-supported by evidence.

Treatment of Pain and Informed-Consent Language

New Department of State regulations for the safe prescribing of opioid analgesics were published in the January 1, 2017 issue of the Delaware Register of Regulations and took effect April 1, 2017. The new regulations specify that when informed consent and a treatment agreement is required in relation to prescribing these medications.

The treatment agreement information and example informed consent form are intended to be samples only. Use of this information is not intended to fulfill a practitioner’s legal duty to obtain full and complete informed consent. Medical providers are encouraged to customize the forms and work with legal counsel prior to using the forms in their medical practice.

Consider recommending alternatives to opioids, including:

  • physical therapy
  • exercise and strength training
  • cognitive behavioral therapy
  • relaxation techniques

And use alternative mediations for pain, such as:

  • non-opioid medications
  • acetaminophen
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • tricyclic antidepressants (TCAs) acetaminophen
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • tricyclic antidepressants (TCAs)

Prescribers should evaluate patients for Substance Use Disorder (SUD) risk during regular clinical visits, but especially as part of prescribing opioids.

Use the Prescription Drug Monitoring Program and be aware of the new prescribing rules by the Division of Professional Regulation.

When a patient has a chronic pain problem, set a recovery goal and develop and tailor a treatment plan. If prescribing opioids, use only those that are short-acting with the lowest dose on product labeling, and match the prescription duration to the next visit.

CDC Opioid Prescription Checklist

Information to share with your patients

Opioid Therapy Chart Download (748K)

For providers

Opioid Therapy Chart Download (373K)

Addiction Screening Tools

Asking your patients a few simple questions may help identify a substance abuse problem. Popular, proven, and easy-to-use tools that address drugs and alcohol are the CAGE and CAGE-AID Questions.


CAGE and CAGE-AID Questions

  • In the last three months, have you felt you should cut down or stop drinking or using drugs?
  • In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?
  • In the last three months, have you felt guilty or bad about how much you drink or use drugs?
  • In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?

If you identify or suspect a problem, consider the 5 A’s of Intervention (Ask, Advise, Assess, Assist, and Arrange).

Ask
Ask: Screen for a potential issue.
Advise
Advise: Provide medical advice about the patient’s substance use.
Assess
Assess: Determine how willing the patient is to changing behavior.
Assist
Assist: Help the patient make a change through setting concrete goals and follow up plan.
Arrange
Arrange: refer the patient for further assessment and treatment, if appropriate, and set up follow up appointments.

Screening, Brief Intervention, and Referral for Treatment

For detailed information, training, and strategies on screening and referral, consider using Screening, Brief Intervention, and Referral to Treatment (SBIRT), is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The SBIRT model was inspired by an Institute of Medicine recommendation that called for community-based screening for health risk behaviors, including substance use.

OB/GYN Resources

Remind Patients

not to use alcohol or illegal drugs during pregnancy, and take prescription medications exactly as prescribed.

Most people know that using illegal drugs, including marijuana and heroin, is not safe for the fetus during pregnancy, but many do not know that alcohol is just as, or even more dangerou. Remind your patients that drinking alcohol and using illegal drugs while pregnant harms their baby, and that prescription drugs should be taken exactly as prescribed.

For information and referrals for pregnant women needing treatment in partnership with medical services, call:

  • New Castle County: 800-652-2929
  • Kent and Sussex counties: 800-354-6785
  • Resources

General Screening Tools and Recommendations

The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for alcohol and opioids, and that providers ask pregnant women about their marijuana use. If they are using, you should urge them to stop because of the risk of permanent damage to the baby.

There are several validated screening tools for pregnant women, including DAST and MAST (Kemper 1993), and CRAFFT (Chang 2011) for pregnant adolescents. Another tool to consider is 4P’s Plus (Chasnoff 1999).

Alcohol Dangers and Screening Tools

Alcohol is the number one cause of preventable birth defects in this country. Drinking alcohol during pregnancy greatly increases the chances that the fetus will develop a fetal alcohol spectrum disorder (FASD). According to the Centers for Disease Control and Prevention, up to one in 20 school children have FSAD.

Signs and symptoms of the various FASDs range from mild to severe, and include a combination of physical, emotional, behavioral, and learning problems. Prenatal alcohol exposure is a frequent cause of structural or functional effects on the brain, heart, bones and spine, kidneys, vision, and hearing. It's also associated with a higher incidence of attention-deficit/hyperactivity disorder and specific learning disabilities, such as difficulties with mathematics and language, information processing, memory, and problem solving.

The American College of Obstetricians and Gynecologists recommends the T-ACE screening tool, specifically developed for use with pregnant women.


Ask patients four questions:

  • (T) Tolerance: How many drinks does it take to make you high?
  • (A) Have people annoyed you by criticizing your drinking?
  • (C) Have you ever felt you ought to cut down on your drinking?
  • (E) eye opener: Have you ever had a drink the first thing in the morning to steady your nerves or get rid of a hangover?

Any drinking during pregnancy requires education and intervention. Inform patients that any alcohol during pregnancy can harm their fetus, and offer resources to address drinking.

Additional Resources

For further health provider resources on fetal alcohol and counseling patients, visit CDC.gov .

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