Do you screen patients for substance abuse? Too many slip through the cracks
Do you screen patients for substance abuse? Too many slip through the cracks
Study: Nurses often omit this intervention; 33% of patients need treatment
ED nurses at Yale-New Haven (CT) Medical Center suspected that a 61-year-old man complaining of dizziness, with a history of high blood pressure and noncompliance with medications, was unable to pay for his prescriptions.
However, the patient’s cardiologist was contacted and explained that the man was regularly given medication samples, but he still was not taking them. At that point, the patient was screened for substance abuse, and the real problem was discovered.
"It turns out that he is a big-time drinker and forgets to take his medications. No one had asked him about this previously," says Gail D’Onofrio, MD, MS, associate professor for the section of emergency medicine at Yale University School of Medicine, also in New Haven. In addition, alcohol was a possible cause of the man’s high blood pressure, she reports.
In another case, a well-groomed elderly man came to the ED because his wife insisted he was "not himself" since falling a few days earlier. To rule out a possible subdural hematoma, the patient was sent for a computed tomography scan, but the results were negative.
Finally, the man was asked about substance abuse, and he admitted drinking a bottle of wine each day, says D’Onofrio.
Recently, a 20-year-old college student came to the ED’s urgent care center with a sore throat. During a routine screening for substance abuse, he admitted drinking four days a week, six to 12 beers at a time.
What do all these patients have in common? They all came to the ED with problems unrelated to substance abuse, says D’Onofrio. "Many patients are at-risk or harmful drinkers that no one would have otherwise picked up," she says. "That is why ideally, this is universal screening."
A recent study reported that nearly one-third of ED patients in seven Tennessee hospitals were identified as having a substance abuse problem, but less than 10% of these individuals were receiving treatment.1
This is compelling evidence that many ED patients need substance abuse treatment and are not getting it, emphasizes Ian Rockett, PhD, MPH, professor and associate chair for the department of community medicine at West Virginia University in Morgantown and the study’s principal investigator.
As an ED nurse, you are in a unique position to make sure these patients get the help they need by identifying, intervening, and referring as appropriate, Rockett urges.
"The ED visit is a time when these individuals may be most receptive to efforts to address this problem," he adds.
In addition, routine screening can reduce follow-up ED visits by patients with substance abuse disorders, says Rockett. "These patients exacerbate the stresses experienced by staff in the typically busy ED," he explains.
To effectively screen ED patients for substance abuse, follow these steps:
• Screen all patients if possible.
At Yale — New Haven Medical Center’s ED, the nursing flowsheet contains screening questions for alcohol use, which are part of the initial history taken by the triage or staff nurse, says D’Onofrio.
"In an ideal world, we would try to complete this on everyone," she says.
For a basic, routine screening, use the following questions from the Bethesda, MD-based National Institute on Alcohol Abuse and Alcoholism, recommends D’Onofrio:
— Do you drink beer, wine, or distilled spirits? (If yes, go on.)
— On average, how many days per week do you drink alcohol?
— On a typical day when you drink, how many drinks do you have? (The low-risk amounts are less than seven weekly drinks for women or under 14 weekly drinks for men.)
— What’s the maximum number of drinks you had on a given occasion in the last month? (The low-risk amount is a daily maximum of three drinks for women or four for men.)
"If the patient is over the low-risk amounts or one already knows that there is a problem, we then go to the CAGE questions," says D’Onofrio.
The CAGE four-item alcohol screening questions are mnemonics of words: Cut Down, Annoyed, Guilty, and Eye-Opener. The questions are as follows:
— Have you ever thought you should cut down on your drinking?
— Have you ever felt annoyed by others’ criticism of your drinking?
— Have you ever felt guilty about your drinking?
— Do you have a morning eye opener?2
Although it is often difficult to find time to screen patients for substance abuse, you should ask every patient about smoking, drinking, and drug use, says Linda Whitt, RN, BSN, CEN, an ED nurse at Bon Secours DePaul Medical Center in Norfolk, VA.
"This is very important on many levels, because it helps to draw a complete picture," she says. "If the patient reports alcohol or drug use, it possibly prevents me from adding narcotics to their recipe."
"When I ask patients if they consider themselves alcoholics, I am often surprised at the yes’ answers," Whitt says.
Sometimes, patients volunteer that they are recovering addicts and don’t want narcotics administered, says Whitt. "This helps me plan their care and not sabotage their progress," she says.
Avoid giving aspirin or nonsteroidal anti-inflammatory drugs to alcoholic patients with gastrointestinal problems related to alcohol, since these patients are prone to coagulopathies and gastrointestinal bleeds, she advises. In addition, avoid acetaminophen products in patients with cirrhosis or liver disease, adds Whitt.
• Always screen high-risk patients.
Although, ideally, all patients are screened, you should always screen individuals at high risk for substance abuse, says D’Onofrio. "This would include anyone presenting with an injury, hypertension, gastrointestinal complaints, seizures, change in mental status, and 16- to 24-year-olds, who have the highest prevalence of drinking," she says.
• Use creative methods to screen.
"All kinds of creative strategies can be used to screen patients for substance abuse in the ED," says D’Onofrio. These include having patients fill out health questionnaires in the waiting room and computer-assisted entry, she notes.
• Use outside sources when possible.
Project ASSERT is a low-cost and innovative model for substance abuse screening that is used at several EDs in New Haven, CT, and Boston, notes Rockett. "In recognition that ED physicians and nurses already are at or beyond capacity, this model deploys social workers and other community outreach workers to conduct substance abuse screening and referral," he says.
If your ED doesn’t have these resources, it’s still important to develop a good working relationship with substance abuse treatment facilities in the area, Rockett advises.
• Don’t assume screening takes too much time.
Although many ED nurses are reluctant to screen because they already are too busy, this is a mistake, says D’Onofrio. "We ask every patient with an injury about tetanus, but we hardly ever see a real case of tetanus," she notes.
The screen takes only a few seconds for 40% of adult patients because they do not drink alcohol and answer "no" to the first question, explains D’Onofrio. "It takes about 10 seconds for the moderate drinkers who are under the low-risk limits, and it takes a total of about 30 seconds to go through the whole thing, including the CAGE questions," she says.
If a substance abuse problem is identified, have a quick, easy intervention to offer, says D’Onofrio. Nurses often feel I do not have time to deal with the answers,’ she says.
At Yale-New Haven’s ED, if a patient tests positive for a substance abuse problem, nurses give out printed material along with a referral to primary care provider, says D’Onofrio.
"Or if the problem if more severe, you could provide a list of referrals in the community," she advises. "Every city has Alcoholics Anonymous."
References
1. Rockett IRH, Putnam SL, Jia H, et al. Assessing substance abuse treatment need: A statewide hospital emergency department study. Ann Emerg Med 2003; 41:802-813.
2. Ewing, JA. Detecting alcoholism: The CAGE questionnaire. JAMA 1984; 252:1,905-1,907.
Sources and Resources
For more information about substance abuse screening in the ED, contact:
- Gail D’Onofrio, MD, MS, Associate Professor, Section of Emergency Medicine, Yale University School of Medicine, 333 Cedar St., New Haven, CT 16510. Telephone: (203) 785-4363. E-mail: [email protected].
- Ian Rockett, PhD, MPH, Professor and Associate Chair, Director of Educational Programs, Department of Community Medicine, West Virginia University, P.O. Box 9190, Morgantown, WV 26506-9190. Telephone: (304) 293-5325. Fax: (304) 293-6685. E-mail: [email protected].
- LindaWhitt, RN, BSN, CEN, Staff Nurse, Emergency Department, Bon Secours DePaul Medical Center, 150 Kingsley Lane, Norfolk, VA 23505. Telephone: (757) 889-5112. E-mail: [email protected].
An article summarizing recommendations of a 2001 conference on ED screening and intervention programs titled "Emergency Department Services for Patients with Alcohol Problems: Research Directions" can be downloaded for free from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) web site (www.niaaa.nih.gov). Click on "Publications," "Reports/Manuals/Guides/Briefs" and "Alcohol Problems Among Emergency Department Patients — 2001." Also, a book containing the conference presentations and list of recommendations can be obtained free by e-mailing Dan Hungerford, DrPH, at [email protected]. Also available free is "Helping Patients with Alcohol Problems: A Health Practitioner’s Guide," which includes "A Pocket Guide: Alcohol Screening and Brief Intervention." (Click on "Reports/Manuals/ Guides/Briefs.")
ED nurses at Yale-New Haven (CT) Medical Center suspected that a 61-year-old man complaining of dizziness, with a history of high blood pressure and noncompliance with medications, was unable to pay for his prescriptions.Subscribe Now for Access
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