In 2017, approximately 20 million individuals age 12 and older had a substance use disorder (SUD).1 Over 1 million individuals over the age of 65 were diagnosed with an SUD in 2014.2 In 2015, 14.2% of adolescents age 12 to 17 reported use of alcohol or any illicit drugs during the past 30 days, indicating a very high risk of SUD development.3 The current opioid overdose crisis is an extreme example of how substance misuse can have catastrophic effects.
The burden of SUDs is complicated and costs the US hundreds of billions of dollars per year.1,4 Alcohol is the most commonly misused substance among all age-groups and marijuana is the most commonly misused illicit drug.1 Despite the high prevalence of SUDs, treatment remains quite low; only an estimated 20% of the 20 million individuals who need treatment receive it.1
Individuals who use substances are most likely to seek care outside of mental health or substance treatment centers.1 This finding supports the competencies described by the Association for Multidisciplinary Education and Research in Substance use and Addiction that depict the important knowledge and skills needed by all APRNs to address substance use.5 Screening in primary care settings including primary care offices and outpatient clinics provides opportunities to intervene across the continuum of substance use. The United States Preventive Service Task Force (USPSTF) currently recommends screening for unhealthy alcohol use in adults and teens in primary care settings.6 Although the USPSTF has deemed that insufficient evidence exists to recommend routine screening for illicit drug use in primary care, screening for other drug use is recommended by the US Surgeon General's report on Alcohol, Drugs, and Health and by the Substance Abuse and Mental Health Service Administration for all individuals age 12 and older.1,6,7
Despite recommendations for routine screening and intervention, asking a patient about alcohol and illicit drug use can be difficult to broach and lack of a systematic screening process may be a barrier. Primary care providers cannot simply rely on remembering to raise the concern of substance use; specific tools for screening and basic intervention are needed.8 This article reviews key screening tools NPs can use in the primary care setting, as well as treatment options such as brief interventions and pharmacologic therapies.
Clinician attitudes and assumptions
According to Harris, some APRNs may feel uncomfortable broaching the topic of substance use.9 It can be easy to engage in everyday practice norms that do not meet the standard of care; this pattern can unknowingly prolong that discomfort. For example, nonclinical terminology may perpetuate stigma and disrupt therapeutic relationships. For example, language such as “dirty tox” should be replaced with “unexpected positive toxicology.”10 Stigmatizing language is sometimes encouraged through standard clinical terminology. The term “medication-assisted treatment” is commonly used relative to substance use but not for treatment of hypertension or diabetes mellitus.10 The term “substance abuse” is not favorable; “substance misuse” is preferred.
Because patients also use stigmatizing language that may perpetuate poor self-esteem, it may be helpful to explore the meaning of the language relative to the patient's self-perception. For example, if a patient states that he has been “sober in the past,” the clinician can respond with, “What did sobriety look like for you?” The conversation is mutually beneficial as there are opportunities to become aware of unconscious biases and assumptions.
Screening is the first step to intercept risky alcohol or other substance use.11 Substance use screening tools identify patients whose substance use behaviors put them at risk for unintended consequences. Risky substance use is any pattern of use (quantity, frequency, duration) that increases an individual's risk of causing harm to self or others.12 The National Institute on Drug Abuse (NIDA) single screen questions may be easily implemented in the primary care setting to identify risky consumption of alcohol and other substances.13 (See Screening resources for SUDs.)
The NIDA Quick Screen alcohol question stems from a single alcohol screener by Smith and colleagues.14 The tool was found to be 81.8% sensitive and 79.3% specific for identifying unhealthy alcohol use in primary care patients. The NIDA Quick Screen alcohol question is adjusted for gender and age and asks how many times in the past year the individual has consumed five or more drinks per day (men) or four or more drinks per day (men over the age of 65 or women).13 Any person who answers, “Never,” screens negative but should be provided education regarding the risks of alcohol use and screened the following year. Any individual who reports using once or more screens positive, and the clinician should explore alcohol use and provide intervention for these patients.13
The NIDA Quick Screen (for other substances) was adapted from a single question screener by Smith and colleagues, which was 100% sensitive and 73.5% specific for detection of a drug use disorder in primary care settings.15 Any positive screen for tobacco or misuse of prescription drugs puts a person at-risk and warrants education and discussion.
Adolescents. Substance use among adolescents is common; it is estimated that by the time adolescents reach adulthood, 50% will have used an illicit drug and over 80% will have used alcohol. Marijuana vaping is a rising trend in the US for teens, with 7.5% of 12th-graders reporting marijuana vaping in the past 30 days.16
Substance use in children has a significant impact on health; in fact, adolescents of all age-groups are at risk for the most severe health issues related to substance use. Growth and development are affected, and substance use can lead to risky behaviors, such as unprotected sex and violence. The American Academy of Pediatrics recommends screening for substance use in all primary care visits in children ages 12 to 17 years old.17 Screening can help to identify SUDs and provide opportunities to counsel adolescents regarding the dangers of use. NPs should be sensitive to the developmental stage of the adolescent as well as the need for confidentiality when screening.
There are several valid and reliable tools available to screen for alcohol and other substance misuse in adolescents. The Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) is recommended by NIDA. This screen takes less than 2 minutes to complete and is valid for adolescents ages 12 years through 17 years. The BSTAD was established as a tool with a high degree of sensitivity; 0.95 for tobacco, 0.96 for alcohol, and 0.80 for marijuana, all with a 95% confidence level.18 The BSTAD can be administered via a computerized survey before a visit, and positive results can be addressed during the visit. Self-administered screens via a computer or tablet are as effective as clinician-administered screens and offer a time-efficient strategy to meet the universal screening recommendation for adolescents.19 The BSTAD is a quick screen, so positive results will warrant further assessment. A negative result should be praised and used as a teachable moment to continue healthy behaviors.
The Cars, Relax, Alone, Forget, Family, Friends, Trouble (CRAFFT) screener is a tool with high sensitivity and specificity, 0.80 and 0.86 respectively, for identifying substance misuse in adolescents ages 12 to 18 years.20 The tool may be a first-step screen but the positive numerical score provides NPs with substance use severity, which can inform diagnosis. The CRAFFT tool like the BSTAD, can be either self-administered or assessed by a clinician. This screen consists of two parts and a total of nine questions, making the average completion time longer than the BSTAD. This is the only tool that asks the adolescent about drinking and driving, an important consideration as motor vehicle accidents are the leading cause of deaths among adolescents.21 The CRAFFT tool is recommended by the 2019 AAP Bright Futures: Recommendations for Preventive Pediatric Health Care.18 Positive screens will require further assessment and possibly a brief intervention and referral to treatment. Screening and brief intervention is useful for the adolescent population.19
Older adults. Trends in substance use and SUDs over the past decades have shown decreasing prevalence as individuals age, but the numbers and consequences remain significant. Substance use among older adults is increasing as the baby boomer generation is aging, some individuals in this generation have more open societal attitudes surrounding the use of alcohol and illicit drugs. It is estimated that SUDs among those 65 years and older will rise to a prevalence of 5.7 million in 2020 from about 2.8 million in 2006.22
Substance use poses unique risks and consequences for the aging population. This patient population's ability to metabolize alcohol and other substances is decreased making them more sensitive to the effects. SUD can exacerbate chronic conditions such as cardiovascular disease, diabetes mellitus, and cognitive impairment. Older adults take more prescription medications, which is important for NPs to note, as substances can interact with medications. Opioid misuse among older adults nearly doubled in the past decade.23 NPs should be aware that opioids prescribed for pain conditions can lead to misuse if not carefully prescribed and monitored.
Among the many different tools that can screen for unhealthy substance use, few have been designed specifically for the older adult population. The NIDA quick screening tool described above is appropriate for individuals over the age of 18. The Substance Use Brief Screen (SUBS) is a self-administered screen that is valid in individuals ages 18-65. Given the complexity and time constraints within primary care visits for older adults, using a brief self-administered screen as a prescreen may make the ability to universally screen all patients more realistic.24 A positive screen on a 1- or 2-item tool, such as the NIDA Quick Screen or SUBS would indicate that a longer more reliable screen is needed.25
The CAGE (mnemonic for Cut down, Annoyed, Guilty, and Eye-opener) and the CAGE-AID (adapted to include drug use) remains one of the most commonly used screening tools.26,27 The CAGE is also the most-studied screen among older adults. The CAGE was developed in 1974 when the substance use and misuse landscape was very different than it is today. The tool sought to detect “alcoholism,” a stigmatizing term that is no longer used. Limitations of the tool include missing substance misuse that is earlier on the spectrum of use and inability to detect binge-substance use, which is problematic in older adults as well as other adults.25
Substance use occurs on a continuum that ranges from abstinence to SUD. Brief interventions that follow every screening should take into consideration where the patient lies on the continuum and if (and how much) an individual desires to change. The NP can ask the individual these questions in a nonthreatening manner by using nonjudgmental, open-ended questions. The brief intervention allows the NP to gauge an individual's readiness for change and should be framed in a way that keeps the conversation open for further intervention.
Brief interventions can last anywhere from 5 to 30 minutes, and every screened individual should receive a brief intervention in the form of educational counseling regarding recommended alcohol intake, smoking cessation, dangers of illicit substance use, and signs of SUDs.28 For those who screen positive, further exploration of the use pattern is warranted.
Strong evidence supports motivational brief intervention for reduction of at-risk alcohol consumption.29,30 An early review of 32 controlled trials found that mild or moderate alcohol use can be effectively addressed with only one session of brief intervention.31 Later research found that brief interventions targeted at alcohol use in primary care worked better with more than one session.32 Effective brief interventions for alcohol use do not necessarily require specialist referrals.33
Brief interventions have been found particularly effective in decreasing tobacco use even without nicotine replacement therapies or pharmacologic interventions.34,35 Literature on brief interventions for other substance use is lacking with the exception of interventions with or without medication therapies for nonmedical opioid use in acute care and ambulatory care settings.28,36-43 In 2015, a randomized controlled trial of ED patients with harmful opioid use found that patients who were started on buprenorphine in the ED and had a primary care follow-up had self-reported decreased opioid use at 30 days.39 Another earlier study found significant heroin and cocaine abstinence after a brief interventions in the urgent care, homeless shelters, and women's clinics.41
Patients with dangerous use behaviors who require care from a substance use specialty setting but are reluctant to receive it may still benefit from ongoing brief discussions and pharmacotherapy treatment from the primary care setting. There are several FDA-approved medications available to treat opioid, alcohol, and tobacco use disorders in primary care. The best medication choice for a patient depends on that patient's goals and any contraindications for use.
Alcohol use disorders. The need for pharmacologic intervention in nonspecialty settings for alcohol use disorders is astounding: In 2016, only 7.7% of the 15.1 million adults who needed treatment received care in a specialty setting.44 There are three FDA-approved medications to treat alcohol use disorders. Naltrexone and acamprosate have the best available evidence for treatment of risky or dangerous alcohol use.32 (See A standard drink and heavy and binge drinking defined.) Either medication is an appropriate initial treatment with patient-specific considerations. Short-term treatment with naltrexone has been shown to decrease relapse and increase overall treatment retention.45 Naltrexone is available in a generic oral form taken once daily and in a monthly injectable form (name-brand only). While the long-acting form may improve adherence, both medications may be helpful to help patients achieve longer periods of abstinence and reduce the number of drinking days.46,47
Naltrexone has precautions for acute hepatic disease so baseline and subsequent liver function tests are recommended.47,48 Adequate studies on patients with kidney impairment have not been conducted, so patients with kidney impairment should also be monitored.
Naltrexone is an opioid antagonist and cannot be used in individuals who are treated with opioids. However, the medication may be a beneficial option for an individual with concurrent alcohol and opioid use disorders.
Acamprosate can be particularly helpful for the individual with chronic alcohol consumption who wants to cut back or stop but has difficulty due to the withdrawal. In a randomized controlled trial, acamprosate significantly reduced a patient's likelihood of returning to alcohol consumption post abstinence and showed a reduction in the number of drinking days.32 It is recommended that acamprosate treatment be maintained through relapse.32 Acamprosate is thought to act by normalizing central glutamatergic dysregulation and is recommended for moderate-severe alcohol use disorder.47 This medication is metabolized in the renal system and may be ideal for a patient with hepatic disease.49
Disulfiram is a medication that was approved to treat alcohol use disorder in 1951. The medication interferes with the body's ability to metabolize alcohol; a toxic reaction can occur if the patient consumes anything with alcohol before the medication has cleared the body. Disulfiram is ideal for patients who wish to be abstinent.37,38 A family member or close friend may want to help make sure a patient consistently adheres to this medication regimen so that the patient reaps the greatest benefit from the medication.50,51 This medication can impair liver function, so baseline tests are recommended prior to initiation. Given that disulfiram has several contraindications depending on the patient's medical history, it is optimal for NPs and other clinicians to refer interested patients to a specialty setting when possible.
Opioid use disorders. The current opioid epidemic, with high rates of overdose deaths, highlights the urgency to treat from all settings. The crisis dramatically changed the way that NPs prescribed controlled substances as several states began instituting PDMPs (Prescription Drug Monitoring Programs), online statewide registries that show the provider what controlled substances a patient has filled.52 The NP can use the PDMP as a therapeutic assessment tool to add to the discussion about substance use. Clinicians can detect early refills, long-term use of opioids, opioid doses over the recommended CDC daily morphine equivalencies, and general trends in types of substances prescribed. The CDC guidelines for prescribing opioids for chronic pain can be found at www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf. Unfortunately, some states do not provide access to PDMPs for providers out-of-state, and the information can take up to 1 month for pharmacies register information to databases. Nonetheless, PDMPs are invaluable assessment tools.
There are three FDA-approved options to treat opioid use disorders: naltrexone, methadone, and buprenorphine. The chosen treatment depends on a variety of factors, including the patient's preference and treatment goals.
Opioid detoxification is shown to have high relapse rates, but naltrexone is an opioid antagonist that may be appropriate for patients who are highly motivated for abstinence.53,54 Naltrexone comes in a monthly long-acting injectable and may help with adherence.
Methadone and buprenorphine agonize the opioid receptor to varying degrees. The purpose of providing an opioid agonist to treat opioid use disorder is to stop illicit opioid use. Both should be considered for individuals with co-occurring pain problems as they are also FDA-approved to treat pain. Methadone is a full opioid agonist often appropriate for patients with histories of heavy and problematic opioid use. It is only dispensed and administered for opioid use disorders at federally regulated clinics so some find this option to be inconvenient. Methadone has several inter- and intraindividual variations in metabolism but in general tends to interact with other drugs that use or affect the CYP3A4 and 2D6 enzymes.55,56 Patients with a cardiac history should be monitored due to risk of QT prolongation.48
Buprenorphine, a partial opioid agonist, is an FDA-approved medication to treat moderate to severe opioid use disorder that can be prescribed from a clinician's office. This medication is also metabolized with the CYP3A4 enzyme but, compared with methadone, carries a lower adverse reaction profile and risk of sedation if mixed with other sedatives (likely due to its lower intrinsic activity on the receptor).48,57,58
A recent Cochrane Review supports the efficacy for buprenorphine therapy to help stop the illicit use of opioids and increase treatment retention.38 The NP attends a 24-hour training (in-person or online options are available), receives a certificate of completion, and applies to the DEA for the “X” waiver.59 The training for NPs is available at no charge through several organizations. The clinician may refer to the Buprenorphine Waiver Management website for more information.59 A clinician new to prescribing buprenorphine might consider collaboration with an experienced prescriber.
Buprenorphine and methadone are both effective medications to help decrease risk of overdose in patients with prior overdose.59 However, if a person discontinues treatment with any of these medications, the patient will have a decreased tolerance to opioids and thus would be at an increased risk for opioid overdose. Education would include advising the patient to use less opioid if illicit use begins again and to use with another person present when possible. Certainly, prescription of a naloxone kit is essential for a person on opioid replacement therapy or found to be using opioids in a harmful way.
Tobacco use disorders. About 28 million individuals smoke one or more cigarettes per day.1 For guidance on the best methods to approach tobacco use cessation, please visit the American Academy of Family Physicians website, which offers a variety of reference tools including a helpful pharmacologic guide: www.aafp.org/patient-care/public-health/tobacco-nicotine/tools/toolkit.html.
Referral for specialty services
Referral to specialty services should be considered for any patient who wants or could benefit from comprehensive substance use treatment.11 The NP should practice good judgment and continue working with brief interventions to help transition ambivalent patients into specialty care. A consideration in referral to treatment should include whether the philosophy of the treatment center meets the patient's goals. For example, not all treatment facilities provide opioid agonist therapies. It may be helpful to have a list of treatment sites handy for referral purposes.
The NP in primary care has a unique opportunity to reach the large population of individuals who require substance use treatment services. NPs in this setting can screen for substance use and provide education with ongoing counseling for persons across the substance use continuum. NPs who have not had training in motivational interviewing can enhance their brief intervention practice by learning a few simple techniques. (See OARS-style interviewing.) Discussions about medications and referral for specialty treatment may be received well by patients depending on the patient's stage of change and nurse-patient relationship. There are ethical implications for all substance use treatment facilities to offer evidence-based treatments. In addition, there are cost-benefit opportunities for primary care and other ambulatory care settings to work from a harm reduction philosophy and to develop close working relationships with needle exchange programs, mobile substance use units, and homeless shelters to transition patients to regular care. Future directions in research include novel means of anticipating harmful substance use or recidivism, such as enhanced methods of biomarker monitoring. More research on treatments targeted to an individual's stage of change and use pattern on the continuum would be beneficial.
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