Title : Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 11 Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . .2 What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . .3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .4 The Simple Screening Instrument for Alcohol and Drug Abuse . . . . . . . . . . . . . . . .7 The Simple Screening Instrument for Infectious Diseases . . . . . . . . . . . . . . . . . . .15 Implementation . . . . . . . . . . . . . . . . . . . . . .22 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . .26 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based entirely on information contained in TIP 11, published in 1994. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 11 Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ----------------------------------------------- 2 Simple Screening Instruments for Outreach WHY A QUICK GUIDE? The purpose of a Quick Guide is to provide busy clinicians with succinct, easily accessible information. This Quick Guide is based on Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases, number 11 in the Treatment Improvement Protocol (TIP) Series, published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. It will help alcohol and drug abuse treatment providers assess patients and clients presenting with prob lems related to alcohol and drug abuse and com municable diseases. The Quick Guide is divided into sections to help readers quickly locate relevant material. Terms related to this Quick Guide appear in a glossary on page 26. For in-depth information on the topics in this Quick Guide, readers should refer to TIP 11. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP Series was launched in 1991. The goal of these publications is to disseminate consensus- based, field-tested guidelines on current topics to substance abuse treatment providers. TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ! Discusses the twin epidemics of substance abuse and infectious diseases involving multiple disciplines, systems, and agencies ! Presents two screening instruments—one for alcohol and drug abuse and one for infectious diseases—that can be administered rapidly and scored and interpreted relatively easily by a wide range of providers ! Describes the development of these instru ments, and offers guidelines for training staff in the use of these instruments ! Discusses legal and ethical concerns, especially confidentiality. To order a copy of TIP 11 and other related products, see the inside back cover of this Quick Guide. ----------------------------------------------- 4 Simple Screening Instruments for Outreach INTRODUCTION Substance abuse and infectious diseases are 2 of the 10 leading causes of illness and death in the United States. People with alcohol and drug abuse problems account for a significant proportion of the increasing number of people with ! Sexually transmitted diseases (STDs) ! Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) ! Urinary tract infections (especially women) ! Tuberculosis (TB) ! Hepatitis B and hepatitis C. If left untreated, substance abuse disorders may have adverse consequences on the successful treat ment of infectious diseases and on the prevention of disease transmission. Alcohol and drug abuse ! Often results in behaviors that increase the risk for contracting HIV and other infectious diseases ! Adversely affects an individual’s ability to com plete prescribed therapy. Alcohol and drug abuse treatment personnel, outreach workers, and other healthcare personnel ----------------------------------------------- Introduction 5 ! Need to be able to recognize risk factors for infectious diseases in the individuals with whom they come into contact ! Need to be alert to signs of possible alcohol and drug problems in their clientele. The screening instruments discussed herein were designed for use by alcohol and drug abuse treat ment and infectious disease workers to screen for disorders with which they may have only limited familiarity. The Screening Process ! Is defined as a range of evaluation procedures and techniques ! Does not enable treatment personnel to make a clinical diagnosis ! Indicates whether a probability exists that the condition sought is present ! Is a preliminary assessment to determine whether key features of a targeted problem are present in an individual. A comprehensive assessment is a thorough evaluation to establish the presence or absence of a disorder or disease. Once screening results are known, one of the following three conclusions can be drawn: ----------------------------------------------- 6 Simple Screening Instruments for Outreach ! The individual is likely to benefit from referral for a comprehensive assessment. ! Further assessment is unwarranted. ! Screening should be repeated at a later time. The Instrument Development Process A CSAT-sponsored consensus panel developed the screening instruments for alcohol and drug abuse and infectious diseases. The benefits of these instruments are ! The instruments are suitable for use with both adolescents and adults. ! The alcohol and drug screening instrument addresses all substances of abuse. ! The instruments are designed for rapid adminis tration (in 15 minutes or less) and are easy to read, administer, score, and interpret. ! The user-friendly instruments were designed for a diverse group of alcohol and drug abuse and infectious disease outreach workers, parapro fessionals, and professionals. The instruments use the self-report method. Results are based on the respondent’s answers rather than solely on direct observation or other findings of the test administrator. The self-report method can be a valid strategy for screening, but its limitations should be considered. ----------------------------------------------- The Simple Screening Instrument for Alcohol and Drug Abuse 7 Because of the social stigma of both alcohol and drug abuse and infectious diseases, subjects may be reluctant to directly admit to either. Screeners must ! Word questions carefully. ! Be sensitive and patient in administering the instruments. ! Be aware that people being screened may deny or minimize their problems. (For more information, see TIP 11, pages 1–7.) THE SIMPLE SCREENING INSTRUMENT FOR ALCOHOL AND DRUG ABUSE Routine screening for alcohol and drug abuse identifies the possibility that a client has alcohol- and drug-related problems. It may lead to a com prehensive assessment that will help engage the client in treatment. The screening instrument for alcohol and drug abuse identifies the following five primary content domains: ! Alcohol and Drug Consumption: Refers to an individual’s pattern of frequency, length, and amount of use. Frequent, long-term use is the common marker of alcohol and drug abuse, but periodic binges over shorter periods also may characterize an addiction problem. ----------------------------------------------- 8 Simple Screening Instruments for Outreach ! Preoccupation and Loss of Control: Preoccupation refers to devoting inordinate amounts of time to matters pertaining to alco hol and drug use; loss of control is typified by uncontrollable alcohol and drug consumption or uncontrollable behavior during use. ! Adverse Consequences: Refer to negative effects in the physical, psychological, and social domains of an individual’s life. " Physical Consequences: Blackouts, injury or trauma, withdrawal symptoms, STDs " Psychological Consequences: Depression, anxiety, mood changes, delusions, paranoia, psychosis " Social Consequences: Involvement in violent encounters (arguments or fights); loss of employment, intimate relationships, and friends; legal problems (arrests for driving while impaired or for possession or sale of illicit drugs). ! Problem Recognition: Refers to the individual’s acknowledgment of the link between his or her use of alcohol and drugs and the problems that result. Some individuals report negative consequences during a screening assessment but may not consciously recognize their problem because of denial, lack of insight, or mistrust of the interviewer. ----------------------------------------------- The Simple Screening Instrument for Alcohol and Drug Abuse 9 ! Tolerance and Withdrawal: Refer to physiological problems resulting from prolonged alcohol and drug use. Tolerance is the need for increasing amounts of a substance to obtain a high. The withdrawal syndrome may include symptoms of depression, agitation, and lethargy. Anxiety, insomnia, panic attacks, abdominal pain, increased heart rate, and perspiration also may occur. Administration of the Alcohol and Drug Screening Instrument The alcohol and drug screening instrument (exhibit 11–1) can be administered in a long version and a short version (the questions for the short version are in bold type). Interpretation of Results An individual with an alcohol or drug problem may receive a score of 4 or more on the long version of the screening instrument. For many individuals a score of less than 4 means they do not have an alcohol or drug problem. However, a low score may also indicate that the person is in denial or is not responding truthfully. (For more information, see TIP 11, pages 9–18. A screening instrument that can be used as a self- administered questionnaire appears in TIP 11, pages 14 and 15, and is available as KAP Key 11–1.) ----------------------------------------------- 10 Simple Screening Instruments for Outreach Exhibit 11–1 Simple Screening Instrument for Substance Abuse (Administered by Interviewer) Introductory Statement Made by Interviewer I’m going to ask you a few questions about your use of alcohol and drugs during the last 6 months. Your answers will be kept private. Based on your answers to these questions, I may advise you to get a more complete assessment. This would be voluntary. During the last 6 months 1. Have you used alcohol (such as wine, beer, or hard liquor) or drugs (such as pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)? !"Yes !"No If no, stop or skip to question 14. 2. Have you felt that you use too much alcohol or too many drugs? !"Yes !"No 3. Have you tried to cut down on or quit drinking or using drugs? !"Yes !"No 4. Have you gone to anyone for help because of your drinking or drug use (such as ----------------------------------------------- The Simple Screening Instrument for Alcohol and Drug Abuse 11 Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program)? !"Yes !"No 5. Have you had any of the following? !"Blackouts or other periods of memory loss !"Injury to your head after drinking or using drugs !"Convulsions or delirium tremens (DTs) !"Hepatitis or other liver problems !"Feelings of being sick, shaky, or depressed when you stopped drinking or using drugs !"Feelings of “coke bugs,” or a crawling feeling under the skin, after you stopped using drugs !"Injury after drinking or using drugs !"The desire to use needles to shoot drugs. 6. Has drinking or drug use caused problems between you and your family or friends? !"Yes !"No (continued on next page) ----------------------------------------------- 12 Simple Screening Instruments for Outreach 7. Has your drinking or drug use caused problems at school or work? !"Yes !"No 8. Have you been arrested or had other legal problems (such as being charged with bouncing checks, driving while intoxicated, theft, or drug possession)? !"Yes !"No 9. Have you lost your temper or gotten into argu ments or fights while drinking or using drugs? !"Yes !"No 10. Do you need to drink or use drugs more and more to get the effect you want? !"Yes !"No 11. Do you spend a lot of time thinking about or trying to get alcohol or drugs? !"Yes !"No 12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? !"Yes !"No ----------------------------------------------- The Simple Screening Instrument for Alcohol and Drug Abuse 13 13. Do you feel bad or guilty about your drinking or drug use? !"Yes !"No Now I have some questions that are not limited to the last 6 months. 14. Have you ever had a drinking or drug problem? !"Yes !"No 15. Has any family member ever had a drinking or drug problem? !"Yes !"No 16. Do you feel that you have a drinking or drug problem now? !"Yes !"No Thank you for answering these questions. Do you have any questions for me? Is there something I can do to help you? Observation Checklist The following signs and symptoms may indicate a substance abuse problem in the individual being screened: !"Needle (track) marks (continued on next page) ----------------------------------------------- 14 Simple Screening Instruments for Outreach !"Skin abscesses, cigarette burns, or nicotine stains !"Tremors (shaking and twitching of hands and eyelids) !"Unclear speech: slurred, incoherent, or too rapid !"Unsteady gait: staggering or off balance !"Dilated (enlarged) or constricted (pinpoint) pupils !"Scratching !"Swollen hands or feet !"Smell of alcohol or marijuana on breath !"In possession of drug paraphernalia such as pipes, papers, needles, or roach clips !"“Nodding out” (dozing or falling asleep) !"Agitation !"Inability to focus !"Burns on the inside of the lips (from freebasing cocaine). Scoring For short version (boldface questions), any yes answers by the respondent merit followup questioning. ----------------------------------------------- The Simple Screening Instrument for Infectious Diseases 15 Items 1 and 15 are not scored. For the remaining questions, score 1 for yes and 0 for no. __2 __6 __10 __14 __3 __7 __11 __16 __4 __8 __12 __5 __9 __13 __Total score Preliminary Interpretation of Results Score Degree of Risk for Alcohol and Drug Abuse 0 or 1 None to low 2 or 3 Minimal !4 Moderate to high; possible need for further assessment THE SIMPLE SCREENING INSTRUMENT FOR INFECTIOUS DISEASES Identifying diseases in the alcohol- and drug- abusing populations through routine screening can lead to detection of treatable conditions and allow for the initiation of treatment. ----------------------------------------------- 16 Simple Screening Instruments for Outreach The infectious diseases screening instrument ! Focuses on infectious diseases that are significant public health problems because they pose the risk of transmission to others ! Evaluates aspects of an individual’s lifestyle and behavior that may place him or her at risk for infectious diseases ! Identifies the symptoms of an active TB infection. When individuals have both substance abuse problems and infectious diseases, symptoms of infectious diseases often are not apparent. For this reason, it is usually not effective to screen by merely noting the presence of symptoms. Administration of the Infectious Disease Screening Instrument The infectious disease screening instrument (exhibit 11–2) appears in interview form. It is for use by outreach workers who may have time constraints. (See TIP 11, pages 23–26, for an annotated version of the instrument that provides more background information and suggested introductions.) ----------------------------------------------- The Simple Screening Instrument for Infectious Diseases 17 Timing of the Administration The point at which the screening instrument is administered varies according to circumstances and settings. ! It can be administered following the decision to accept an individual into an alcohol and drug abuse treatment program. ! If referral resources for infectious disease treatment are immediately available, the instru ment can be administered to those awaiting the opening of a treatment program slot. Scoring and Interpretation A “yes” response indicates an increased risk for an infectious disease. Each question is followed by a letter or letters in parentheses that indicate the type of referral to be made when an increased risk is identified. Staff should limit the number of agencies to which referral is made. For example, STD and HIV/AIDS testing may be available at STD clinics, prenatal care sites, or comprehensive health centers. (For more information on the infectious diseases screening instrument, see TIP 11, pages 19–28; for more information about legal issues surround ing the referral process, see TIP 11, pages 39–49.) ----------------------------------------------- 18 Simple Screening Instruments for Outreach Exhibit 11–2 Simple Screening Instrument for Infectious Diseases (Administered by Interviewer) Introductory Statement Made by Interviewer I’m going to ask you a few questions about your health and lifestyle. I want you to know that my agency will not give this information to anyone without your permission. Based on your answers, I may advise you to get a physical exam or further tests. This would be voluntary—it would be your choice whether to have the exam. If you do get an exam and are found to have certain diseases, they must be reported to the health department. 1. Have you seen a doctor or other healthcare provider in the last 3 months? (A; see Key) !"Yes !"No 2. a. Do you live on the street or in a shelter? (C, F) !"Yes !"No b. Have you ever been in jail? (C, F) !"Yes !"No 3. Have you ever been told you tested positive for HIV (the virus that causes AIDS)? (G) !"Yes !"No ----------------------------------------------- The Simple Screening Instrument for Infectious Diseases 19 4. Women: Have you missed your last two periods? (D, E, F) !"Yes !"No 5. Have you ever had a positive TB skin test? I mean a test where you got a shot in your forearm and a few days later a hard bump like a blister appeared. (C) !"Yes !"No 6. Have you ever been told you have TB? Has anybody you know or have lived with been diagnosed with TB in the last year? (C) !"Yes !"No 7. a. Within the last 30 days, have you had any of the following symptoms lasting for more than 2 weeks? (B, C, F) !"Fever !"Drenching night sweats that were so bad you had to change your clothes or the sheets on the bed !"Attacks of coughing up blood !"Shortness of breath !"Lumps or swollen glands in the neck or armpits (continued on next page) ----------------------------------------------- 20 Simple Screening Instruments for Outreach !"Weight loss without trying !"Diarrhea (“runs”) lasting more than a week. b. Do you live with someone who has any of the following symptoms? (C) !"Attacks of coughing up blood !"Drenching night sweats. 8. Do you use needles to shoot drugs? (F) !"Yes !"No 9. Do you use coke or crack? (D, F) !"Yes !"No 10. In the last 6 months, have you had VD (vene- real disease) or an STD (sexually transmitted disease) like syphilis, the clap (gonorrhea), chlamydia, NGU (nongonococcal urethritis), or trichomoniasis (trich)? (D, F) !"Yes !"No 11. Have you, or anyone you’ve had sex with, had any of the following symptoms within the last 30 days? (D, F) !"Sore or ulcer on the penis/vagina (“down there”) ----------------------------------------------- The Simple Screening Instrument for Infectious Diseases 21 !"Rash, spots, or other skin problems, especially on your palms or the soles of your feet !"Women: A vaginal discharge that is different from what you usually have !"Women: Pain when you have vaginal sex !"Men: Discharge from the penis. 12. Have you had sex with more than two people —at different times—in the last 6 months? I mean any type of vaginal, rectal, or oral contact, such as you “went down” on your partner or he or she “went down” on you, with or without a condom? (D, F) !"Yes !"No 13. Have you used your rectum for sex? (Use regionally appropriate terminology to indicate penile penetration, as opposed to other types of sexual contact.) (F) !"Yes !"No 14. In the last 6 months, have you had sex with someone in return for anything like money, alcohol or drugs, a place to stay, or just to survive? (D, F) !"Yes !"No (continued on next page) ----------------------------------------------- 22 Simple Screening Instruments for Outreach 15. Have you ever been forced to have sex against your will? (A) !"Yes !"No Key A = Needs supporting data B = General medical evaluation C = TB screening D = STD assessment E = Prenatal care F = HIV/AIDS counseling, testing, referral, and partner notification. (Assessment for hepatitis B and hepatitis C is also warranted.) G = HIV/AIDS care/early intervention IMPLEMENTATION The goal of the screening process is to determine the need for a more comprehensive assessment; screening is not used to diagnose a problem. Remember ! The screening process itself is never diagnostic. ! An individual with a positive screening test must have a clinical assessment for diagnosis before treatment. ----------------------------------------------- Implementation 23 ! Individuals with a high score on a screening test may, on more comprehensive assessment, be found not to have a disorder. Conversely, a low score on a screening test does not rule out the possibility that a disorder is present. Training Issues for Clinical Supervisors Although many substance abuse treatment providers already possess the skills necessary to administer screening instruments, they may need special training to use the instruments that accompany this Quick Guide. Special training is necessary because ! Substance abuse treatment workers may have scant knowledge of infectious disease issues. ! Infectious disease workers may have little understanding of alcohol and drug abuse and dependence. The training program should incorporate the following elements: ! A review of interpersonal skills, including basic communication and interviewing techniques ! Guidelines on how to deal with a range of client reactions ! Approaches for administering the instruments in a casual, friendly, nonthreatening, and ----------------------------------------------- 24 Simple Screening Instruments for Outreach nonjudgmental manner in terms of verbal and body language ! Methods for helping interviewers become familiar and comfortable with using local termi nology to describe an illness or behavior ! Methods for familiarizing interviewers with the regional and cultural characteristics of the population to be screened. Curriculum Content Staff members who will be screening clients need a basic understanding of the instruments’ limitations and purpose. Training should emphasize that ! The purpose of screening is to identify persons at risk for substance abuse problems and infectious diseases. ! Diagnosis and treatment can be undertaken only after in-depth clinical assessment. ! Culturally competent trainers and interviewers are crucial to the effectiveness of the screening process. Developing an understanding of the language, cul ture, and ethnicity of the populations to be served should be an integral part of the training process. To this end, agencies also should develop policies and procedures that promote the recruitment and retention of culturally competent personnel. ----------------------------------------------- Implementation 25 (See TIP 11, appendix C, pages 57–63, for perspectives from treatment professionals on issues of cultural sensitivity.) Before administering the instrument, interviewers should talk with clients about the purposes of screening and how the results will be used. Clients may be more forthcoming if they under stand these points before the screening begins. (Other interviewing techniques, including safety issues, are discussed in TIP 11, pages 33 and 34.) Workers will need training in scoring and inter preting screening results. Training also must incorporate mechanisms for referral actions and for tracking referred clients to ensure that recommended services were rendered. (TIP 11, appendix B, pages 53–55, presents a sample curriculum for instructing outreach workers in STD prevention. For more information on training and implementation, see TIP 11, pages 29–37.) ----------------------------------------------- 26 Simple Screening Instruments for Outreach GLOSSARY Blackouts: Periods of amnesia typically associated with high-dose use of sedative-hypnotics, such as alcohol and the benzodiazepines, that occur while a person is conscious. The nature of the memory impairment is such that the person has no recollection of his or her actions during these episodes. Chlamydia: An STD seen in both sexes but often asymptomatic in women. It can cause infertility, pelvic inflammatory disease (PID), and complica tions during pregnancy. Coke bugs: Tactile hallucinations that cause a person to feel as if insects are crawling on or beneath the skin, often stemming from chronic or high-dose abuse of stimulant drugs. Convulsions: Twitching or jerking motions of the limbs that often accompany seizures resulting from uncontrolled electrical brain activity. Substance abuse-associated seizures are linked to high-dose use of stimulant classes of drugs and withdrawal from sedative-hypnotics. ----------------------------------------------- Glossary 27 Delirium tremens (DTs): A confused state accompanied by trembling and vivid hallucinations that seem quite real to the person experiencing them. DTs can occur in chronic alcoholics follow ing withdrawal or sudden abstinence from alcohol. Other symptoms of DTs include restlessness, agitation, sleeplessness, tachycardia, and convulsions. Diarrhea lasting more than 1 week: For the purpose of these screening instruments, this means watery diarrhea, without any formed stool, occurring more than three times a day for a week or more. Gonorrhea (“the clap”): An STD that may cause a discharge from the penis in men and may cause vaginal discharge, pain, infertility, and PID in women. Hepatitis: An inflammation of the liver, of chronic or limited duration, accompanied by cell damage and risk of death. The disease has various causes: viral infection, exposure to poisons or chemicals, or chronic alcohol abuse. Nongonococcal urethritis (NGU): A sexually trans mitted infection whose symptoms are similar to those of gonorrhea but that can be differentiated only by laboratory tests. NGU is most commonly caused by the organism that causes chlamydia. ----------------------------------------------- 28 Simple Screening Instruments for Outreach Positive HIV test: A blood test that is positive for antibodies to HIV, the virus that causes AIDS. Positive TB skin test: A positive result on a test for TB in which an injection is made into the skin of the forearm; more accurately called a Tine or PPD test. A positive result is marked by a hard, red swelling at the injection site after 3 days. A PPD test must be interpreted by a nurse or doctor. Sexually transmitted disease (STD): A disease that is spread through sexual contact. Syphilis: An STD that causes a characteristic ulcer or lesion on the genitals. Untreated it can spread to other parts of the body and cause a symmetri cal rash on the palms of the hands and the soles of the feet. In advanced stages, syphilis can cause major health problems, including central nervous system disorders and death. Tuberculosis (TB): A highly infectious disease that spreads through airborne droplets to people who have had close contact with an infected person. TB is most commonly found in the lungs but also appears in other parts of the body. Symptoms include fever, night sweats, and weight loss. TB more commonly occurs in HIV-infected people and some substance abuse treatment patients. ----------------------------------------------- Ordering Information TIP 11 Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases TIP 11-Related Products KAP Keys for Clinicians Based on TIP 11 Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT’s Web site at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: TIP 6, Screening for Infectious Diseases Among Substance Abusers (1993, Reprinted 1995) BKD131 TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (1993) BKD138 TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (1994, Reprinted 1999) BKD134 TIP 16, Alcohol and Other Drug Screening of Hospitalized Trauma Patients (1995) BKD164 See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3559 Printed 2001