__________________________________________________ Responsible Prescribing of Controlled Substances
SCREENING Regular screenings in primary care and other healthcare settings enables earlier identification of mental health and substance use disorders, which translates into earlier care. Screenings should be provided to people of all ages, even the young and the elderly. The National Institute on Drug Abuse has identified the following evidence-based screening tools and assessment resource materials as potentially useful for this process [74]: • Screening to Brief Intervention (S2BI) • Brief Screener for Alcohol, Tobacco, and other Drugs (BSTAD) • Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) • Opioid Risk Tool • CRAFFT • Drug Abuse Screen Test (DAST-10 or DAST-20: Adolescent version) • Screening, Brief Intervention, and Referral to Treatment (SBIRT) Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) The TAPS Tool consists of a combined screening component followed by a brief assessment for those who screen positive [75]. If a patient responds positively (i.e., any response other than “never”) to ever using tobacco, alcohol, illicit drugs, and/ or non-medical use of prescription drugs, a series of brief substance-specific assessment questions are asked to arrive at a risk level for that substance. Screening, Brief Intervention, and Referral to Treatment (SBIRT) SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alco- hol and illicit drugs. It is an early intervention approach that targets those with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or specialized treatment [76]. The first component of the SBIRT process is screening, which provides a quick and simple method of identifying patients who use substances at at-risk levels, as well as those who are already experiencing substance use-related issues. The typi- cal screening process involves the use of a brief one-to-three question prescreen. If a person screens positive on one of these screening instruments, they would then be given a lon- ger alcohol or drug use screening. The screens usually assess patient self-reported information about substance use, and any healthcare professional can easily score the results [76].
The next step is brief intervention. In primary care settings, brief interventions last from 5 minutes of brief advice to 15 to 30 minutes of brief counseling. Brief interventions are not intended to treat people with serious substance dependence, but rather to treat problematic or risky substance use. Skill- fully conducted, brief interventions are essential to successful SBIRT implementation. The two most common behavioral therapies used in SBIRT programs are brief versions of cogni- tive behavioral therapy and motivational interviewing, or some combination of the two [76]. Referral to treatment is a critical yet often overlooked com- ponent of the SBIRT process. It involves establishing a clear method of follow-up with patients that have been that have been identified as having a possible dependency on a substance or in need of specialized treatment. The referral to treatment process consists of assisting a patient with accessing specialized treatment, selecting treatment facilities, and helping navigate any barriers such as treatment cost or lack of transportation that could hinder treatment in a specialty setting [76]. TREATMENT Management of opioid dependence entails different methods to achieve different goals, depending on the health situa- tion and treatment history of the patient. These treatment approaches include [1; 2; 70]: • Crisis intervention: Directed at immediate survival by reversing the potentially lethal effects of overdose with an opioid antagonist. • Harm reduction: Intended to reduce morbidity and mortality associated with use of dirty needles and overdose. • Detoxification/withdrawal: Aims to remove the opioid of abuse from the patient’s body, either through gradual taper and substitution of a long-acting opioid or through ultra-rapid opioid detoxification. • Maintenance treatment or opioid (agonist) replacement therapy: Also known as medication- assisted treatment, this therapy is aimed at reduction/ elimination of illicit opioid use and lifestyle stabilization. Maintenance follows detoxification/ withdrawal, whereby the patient is tapered from short-acting opioids and introduced to a long-acting opioid agonist, such as methadone or buprenorphine. Patients remain on agonist therapy short-term, long- term, or indefinitely depending on individual needs. • Abstinence-oriented therapy: Treatment directed at cure. The patient is tapered off of short-acting opioids during the detoxification/withdrawal process and may be placed on an opioid antagonist with the goal of minimizing relapse.
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