Your patient, Karen, tells you she uses cocaine occasionally. for Reed, smokes marijuana most days. Timothy, drinks a little at night. How can you tell the difference between recreational substance use and a substance use disorder? How can you tell if your patient uses substances at all? The best way is to ask your patient, don't wait for them to self-disclose. One of the most sided reasons why providers don't ask about substance use is because they are afraid of what they might uncover and aren't sure what to do with the answers. In this course, we will equip you with various clinical skills to address substance use and screening is a key foundational skill. In this lesson, you will learn how to screen your patients in order to determine their risk for a substance use disorder. For alcohol in particular, you will learn how to distinguish between moderate, binge, and heavy drinking, and understand the associated risk of each drinking pattern. Universal screening for substance use is critical to understanding your patient's mental and physical health. In most cases, it will open the pathway to prevention. Equipping patients with knowledge on how to prevent any future problems with substance use. In other cases, that will be the initial step on the pathway to substance use treatment. A quick caveat before we get into screening questions and guidelines is to please remember no one guideline fits all situations. An individual's context matters. For instance, are they on multiple medications? Are they pregnant? Are they under age? Or do they operate machinery like an airplane or a bus? All of these factors affect the calculus along with your advice and recommended next steps. But let's get started. Screening shouldn't take a long time. If you know the right question to ask, it can literally take a few seconds. For tobacco use, simply asked, do you sometimes smoke cigarettes or use other tobacco products? For alcohol, if your patient is a man, ask how many times in the past year have you had five or more alcohol containing drinks on one occasion? For women, ask how many times in the past year have you had four or more alcohol containing drinks on one occasion? For other drugs, you should simply ask, how many times in the past year have you used a drug or a prescription medication that was not prescribed to you? Or took a prescription medication in order to feel relaxed or to feel high? I often like to give examples of specific drugs running through the major classes. For example, marijuana, opioid, sedating medications, stimulants, etc. If the patient does not smoke or use tobacco, drink above the per occasion limit, or use drugs or non prescribed medications, then the screen is negative. You're done with a substance use screening and you can move on to other health assessments. But if you get a positive screen for tobacco, alcohol, or other drugs, we now have a decision tree. It does not mean your patient has an alcohol or drug use disorder, but it does mean you should get a little curious and ask additional questions. After a positive screen, what more would you want to know? A great place to start is to determine the frequency and quantity of use in order to understand how much and often the patient uses tobacco, drinks alcohol, or uses drugs. Let's take alcohol as our example, since it's the most common and well-researched substance. To understand your patients pattern of alcohol use, you will ask the following. In the past month, on average, how many days each week do you drink? On days that you drink, on average, how many drinks do you have? Keeping track of average standard drinks per occasion and per week is critical to understanding your patients drinking pattern. You might be wondering what's considered a drink? This is a crucial question and you can learn more about standard drinks in a separate lesson. Once you know how much and how often your patient drinks, you can classify their drinking using various definitions. Looking back to the one item screener for alcohol, the threshold for a positive screen is five or more drinks per occasion for men and four or more drinks per occasion for women. This amount is the definition of a binge drinking episode according to the National Institute on Alcohol Abuse and Alcoholism, NIAAA. Binge-drinking brings a person's blood alcohol concentration to 0.08 grams per decaliter or higher. This is where significant physical impairment and risk for harm is observed. If you're in the US, you probably recognize 0.08 as the legal limit of alcohol. Beyond binge drinking, there is also heavy drinking, which is often above this level, and moderate drinking, which is below this level. The 2015-2020 US Dietary Guidelines for Americans has defined moderate drinking levels is up to two drinks per day for men and up to one drink per day for women. Consuming alcohol in moderation will reduce your patient's risk of alcohol-related harms. That being said, no amount of alcohol is considered low-risk or safe for people younger than age 21, pregnant women, people with certain medical conditions, or those on certain medications. The next definition is heavy drinking, which the NIAAA defines as 15 drinks or more per week for men and eight drinks or more per week for women. The Center for Disease Control also defines heavy drinking this way, although some other institutions differ. Let's pause for a few questions to check your knowledge on the difference between moderate drinking, binge drinking, or heavy drinking. How did that go? We realized this might be a lot to remember, but we will link out to various tools for reference, and of course, it will get easier with repeated practice. What does all this mean? Well, once you understand your patients drinking patterns, you can determine where they fall in terms of risk categories. Patients can be grouped into different risk categories. The first category is the no risk category. This includes people that abstain from alcohol altogether, and therefore, no risk for developing an alcohol use disorder. The next category is the low risk category. This includes those that have a moderate drinking pattern. Again, this is up to two drinks for men and up to one drink for women on a daily basis. This group has less than a one percent chance of having an alcohol use disorder. If your patient drinks above the moderate drinking level, that falls in the at-risk category. Those that meet a binge drinking pattern or a heavy drinking pattern have roughly a 20 percent chance of having an alcohol use disorder. Again, binge drinking looks at per occasion patterns, five or more drinks for men and four or more drinks for women. Heavy drinking factors in weekly patterns. So 15 drinks or more per week for men and eight drinks or more per week for women. Those who report both binge and heavy drinking are high risk. In this category, about one in every two people will have alcohol use disorder. Let me state this clearly. While a patient drinking at this level does not mean he or she has an alcohol use disorder, it does mean that a person has about a 50 percent chance of having an alcohol use disorder. The top of the pyramid represents those that have a diagnosed alcohol use disorder. Again, having a substance use disorder is not based on amount of drinking, but rather on 11 diagnostic criteria. At any point in the screening process, you may be met with skepticism or resistance. A patient might want to know why you are asking about their substance use. In this case, you assure them that those questions are vital to understanding their health and providing them the best care possible. Simply put, substance use negatively impacts your patient's overall health. For smoking, with a positive screen, you can move straight to giving advice since there is no amount of smoking that is low risk, the harms from tobacco are clear and extensive. After getting permission to provide advice, tell your patient that quitting smoking is the best thing they can do for their health, and that you can help them quit. For alcohol, the more drinks on any day and the more heavy drinking over time, the greater the risk. Binge drinking and heavy drinking increases the risk of harmful consequences, including alcohol use disorder. Additionally, heavy drinking puts us at a greater risk of liver disease, heart disease, depression, stroke, and stomach bleeding, as well as cancers of the oral cavity, esophagus, larynx, pharynx, liver, colon, and rectum. Drinking can also interfere with managing conditions such as diabetes, high blood pressure, pain, and sleep disorders. These are just a few of the negative consequences of heavy alcohol use and binge drinking. For drugs, there is no level that is considered moderate use. We just don't know enough to make recommendations. More questions are needed to assess risk and make a diagnosis. The goal of screening is to understand who is at risk and what to do depending on that risk. If your patient is no or low risk, you will want to focus on prevention and educating your patients on the benefits of keeping their use at low risk. Those above low risk should be asked diagnostic questions to determine if they meet criteria for substance use disorder. Those that do not meet criteria should be given a brief intervention with the goal to reduce current use or abstain altogether. Those that do meet enough diagnostic criteria should be referred to treatment. You will learn more about how to do this brief intervention, how to diagnose, and how to revert to treatment in upcoming lessons.
