• Screen all new patients and reevaluate established patients periodically. Data show that physicians very often overlook substance use disorders. In one primary care study, physicians reported a prevalence of substance abuse disorders of less than 1% of their patients despite an estimated substance abuse prevalence of 2%-9%.(3)
  
  
• Place particular attention on high risk patients with co-morbid medical or psychiatric disorders, including those with chronic pain, gastrointestinal complaints (abdominal pain), systemic infections including Hepatitis B and C, HIV/AIDS, other STD’s, bacterial endocarditis, pulmonary disease, obesity, cardiovascular and cerebral vascular disease, trauma including motor vehicle accidents, gunshot wounds, and psychiatric symptoms including depression, anxiety, and insomnia.(13) (see http://www.drugabuse.gov/consequences)
  
  
• The assessment and management of chronic pain presents complex challenges to the clinician.(14,15) Some patients will come to physicians having been treated with narcotics, and feel they cannot function without them. It is important to remember that pain is a subjective sensation that is very real for the patient. Many factors influence the processing of pain signals and the sensation of pain, including past life experiences, personality traits, fear and anxiety, the meaning of the pain, depression, “secondary gains,” etc., in addition to any pathology that may be present. The factors that contribute to a patient’s perception of pain may need to be evaluated over several visits, sometimes with the help of a pain professional or psychiatrist. All patients with chronic narcotic use for painful conditions should be evaluated for substance use and abuse disorders.
  
  
• If any of the known medical, psychiatric, familial, social, school or employment, and legal “red flags” are present (See next section on “Red Flags.”), a more detailed evaluation is needed to ascertain the presence of a substance use disorder and the patient’s readiness to accept treatment.
  
  
• When screening for substance use disorders, include questions about both alcohol and drug use, which are frequently linked. Many patients use more than one substance of abuse. Each should be explored. Ask specifically about tobacco (cigarettes, cigars, smokeless tobacco), alcohol (beer, wine, liquor), marijuana, cocaine/crack, methamphetamines, other stimulants, opioids (heroin and prescription pain medications), PCP, inhalants, and other prescription "pills." (8,14,15,16)
  http://www.nida.nih.gov/DrugPages/DrugsofAbuse.html
  For example, the NIDA Modified Alcohol, Smoking, and Substance Involvement Screening Test (NMASSIST) provides screening questions covering all drugs of abuse (specifically separating out prescription drugs from similar street drugs). http://www.drugabuse.gov/nidamed/screening
  

Please click the video-button on the left to play Dr. Parran's Comment on screening.

• Studies show that “subtle” screening is not better than direct questioning. (16) Specific screening strategies include simple structured questionnaires, such as the CAGE-AID, adapted from the widely used CAGE questions for alcohol dependence. (17,18,23,24 )
  

With adult patients, start with a question about use: “Do you use, or have you ever experimented with alcohol or other substances?” If “yes”, or if the answer is equivocal, follow with: Have you ever felt a need to Cut Down on or Control your use of alcohol or other drugs? Have friends/family made comments to you about your use of alcohol or other drugs … have those comments ever Annoyed you? Have you ever felt bashful, embarrassed or Guilty about things you have said/done when using alcohol or other drugs that you would not have said/done otherwise? Do you ever use Eye-openers (drinking or using in the morning to “get going” or settle your nerves)?

Please click the video-button on the left to play Dr. Parran's Comment on patients' positive responses to these questions.

• If any answer is positive, initiate a “Brief Intervention” (below), but before doing so, ask follow up questions, because the patient’s responses to them will help you structure the particulars of your brief intervention conversation.
  

• Define patterns of use for each substance including the quantity, duration of use, frequency of use during that time, route of administration, effect of use, strategies used to acquire substances and cost. Explore periods of abstinence and triggers to use substances along with associated physical symptoms. (18)
  

One helpful strategy is to ask the patient about his/her perspectives and observations about their use and consequences. Helpful questions include the following: Do you ever think you use too much? Have you ever tried to cut down on your use? Have you needed to use more to get the same effect? Has use created any problems, e.g. medical, educational, job?