A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 13: Management of Substance Abuse
Which screening tests are most useful in
primary care practice?
The CAGE test is a non-threatening quick screening
test for detecting drug use in adults (see Table 13-4)
and the POSIT test useful for screening adolescents
aged 12-19. The questions below are designed to
assess key substance-using behaviors. The letters in
CAGE correspond to important emotions or behaviors
indicative of drug use.
C
A
G
E
Table 13-4: The CAGE Screening Test
1. Have you felt that you ought to Cut down
on your drinking or drug use?
2. Have people Annoyed you by criticizing
your drinking or drug use?
3. Have you ever felt bad or Guilty about your
drinking or drug use?
4. Have you ever had a drink or used drugs
first thing in the morning (Eye opener) to
steady your nerves, to get rid of a hangover,
or to get the day started?
The Problem Oriented Screening Instrument for
Teenagers (POSIT) examination is a 139 item yes/no
questionnaire for assessing adolescent risk factors in
substance abuse, physical health, mental health, family
and peer relationships, educational and vocational
status, social skills, leisure and recreation, aggressive
behavior, and delinquency. A nonexperienced
provider can conduct the test in 20 to 25 minutes. The
questionnaire is available free in English and Spanish
from the National Clearinghouse for Alcohol and Drug
Information by mail at P.O. Box 2345, Rockville, MD
20847-2345 or by telephone at 1-800-729-6686.
What would provide a more in-depth
assessment of drug and alcohol use?
Two detailed evaluations of drug and alcohol use are the
Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (DSM-IV) and Addiction Severity Index
(ASI) for alcohol or drug use. The DSM-IV defines
the diagnostic criteria for substance dependence
as a maladaptive pattern of substance use, leading
to clinically significant impairment or distress, as
manifested by 3 or more of the following, occurring at
any time in the same 12-month period:
1. Presence of drug withdrawal symptoms
2. Escalation of drug doses
3. Persistent inability to reduce or control drug use
4. Increased time spent obtaining drugs
5. Personal and business activities reduced by drug use
6. Development of drug tolerance
7. Knowing drug use’s negative health and personal
effects, yet continuing to use drugs
TREATMENT OF SUBSTANCE
ABUSE PROBLEMS
What should you do before referring a person
for treatment?
The decision to refer a person for drug abuse treatment
should come after the provider has detected a
substance use problem, conducted initial evaluations
to determine the degree of drug use and physical harm
done by the drug use, and provided brief interventions
to stop drug abuse. After the diagnosis and brief
interventions (if appropriate), the provider should refer
the patient to a drug treatment system or an addiction
physician.
What role does the primary care provider’s
attitude play in successful drug abuse
treatment?
Drug abuse treatment is successful if the provider
addresses his or her own biases about addiction,
understands the factors contributing to addiction,
provides appropriate pharmacologic and behavioral
care, and recognizes that drug addiction is a chronic
disease problem. Many drug abuse treatment failures
are associated with hostile or unsupportive providers
whose behaviors are based on the assumption that drug
use is voluntary. Since successful drug abuse therapy
depends on adherence to treatment regimens, any
factors that facilitate adherence will foster successful
treatment outcomes. The patient’s perception that the
primary care provider is nonjudgmental and supportive
is an essential factor in successful therapy.
How can the primary care provider enhance
the success of drug abuse treatment?
The primary care provider must prevent or treat
exogenous factors that negatively affect successful
drug abuse therapy. We now recognize significant
environmental (social), genetic, biologic, and behavioral
factors that facilitate drug addiction:
13
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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