Patient abusing alcohol or drugs? Help starts with a single question

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Applied Evidence

Patient abusing alcohol or drugs? Help starts with a single question

J Fam Pract. 2013 February;62(2):63-69

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References

Friedman PD. Alcohol use in adults. N Engl J Med. 2013;368:365-373.
Williams RH, Vinson DC. Validation of a single question screen for problem drinking. J Fam Pract. 2001;50:307-312.
Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;74:783-788.
Dawson DA, Pulay AJ, Grant BF. A comparison of two single-item screeners for hazardous drinking and alcohol use disorder. Alcohol Clin Exp Res. 2010;34:364-374.
Bush K, Kivlahan DR, Mcdonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789-1795.
Dawson DA, Grant BF, Stinson FS, et al. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res. 2005;29:844-854.
Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170:1155-1160.
American Psychiatric Asociation. Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. (DSM-IV-TR). Arlington, Va: American Psychiatric Association; 2000.
Saha TD, Stinson FS, Grant BF. The role of alcohol consumption in future classifications of alcohol use disorders. Drug Alcohol Depend. 2007;89:82-92.
Vinson DC, Kruse RL, Seale JP. Simplifying alcohol assessment:two questions to identify alcohol use disorders. Alcohol Clin Exp Res. 2007;31:1392-139.
Aertgeerts B, Buntinx F, Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis. J Clin Epidemiol. 2004;57:30-39.
Johnson JA, Lee A, Vinson DC, et al. Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study. Alcohol Clin Exp Res. 2012;July 26 [Epub ahead of print].
Center for Adolescent Substance Abuse Research. The CRAFFT Screening Tool. Boston MA:2009 [updated 2012). Available at: http://www.ceasar-boston.org/clinicians/crafft.php. Accessed January 15, 2013.
Knight JR, Sherritt L, Harris SK, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27:67-734.
Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988;297:663-668.
Fleming MF, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039-1044.
Bertholet N, Daeppen JB, Wietlisbach V, et al. Brief alcohol intervention in primary care reduces alcohol consumption: Systematic review and meta-analysis. Arch Intern Med. 2005;165:986-995.
Kaner EFS, Dickinson HO, Beyer F, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2);CD004148.-
Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26:36-43.
Cuijpers P, Riper H, Lemmers L. The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction. 2004;99:839-845.
U.S.Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554-556.
Saitz R, Alford DP, Bernstein J, et al. Screening and brief intervention ffor unhealthy drug use in primary care settings: randomized clinical trials are needed. J Addict Med. 2010;4:131-136.
Field CA, Baird J, Saitz R, et al. The mixed evidence for brief intervention in emergency departments, trauma care centers, and inpatient hospital settings: what should we do? Alcohol Clin Exp Res. 2010;34:2004-2010.
DiClemente CC, Prochaska JO. Toward a comprehensive transtheoretical model of change: stages of change and addictive behaviors. In: Miller WR, Heather N, eds. Treating Addictive Behaviors. New York, NY:Plenum Press;1998:3–24.
Mason P, Butler CC. Health Behavior Change: A Guide for Practitioners. 2nd ed. London UK:Elsevier; 2010.
Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York NY: Guilford Press;2002.
Hettema J, Steele J, Miller WR. Motivational interviewing. Ann Rev Clin Psych. 2005;1:91-111.
Rollnick S, Butler CC, Kinnersley P, et al. Motivational interviewing. BMJ. 2010;340:c1900.-
Rosner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867.-
Swift R, Oslin DW, Alexander M, et al. Adherence monitoring in naltrexone pharmacotherapy trials: a systematic review. J Stud Alcohol Drugs. 2011;72:1012-1018.
Pettinati HM, Silverman BL, Battisti JJ, et al. Efficacy of extended-release naltrexone in patients with relatively higher severity of alcohol dependence. Alcohol Clin Exp Res. 2011;35:1804-1811.
Mann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol Clin Exp Res. 2004;28:51-63.
Rosner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010(9);CD004332.-
Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2012;October 17 [Epub ahead of print].
Azrin NH. Improvements in the community-reinforcement approach to alcoholism. Behav Res Ther. 1976;14:339-348.
Azrin NH, Sisson RW, Meyers R, Godley M. Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psychiatr. 1982;13:105-112.
Keane TM, Foy DW, Nunn B, et al. Spouse contracting to increase antabuse compliance in alcoholic veterans. J Clin Psychol. 1984;40:340-344.
Arbaizar B, Diersen-Sotos T, Gomez-Acebo I, et al. Topiramate in the treatment of alcohol dependence: a meta-analysis. Actas Espanolas de Psiquiatria. 2010;38:8-12.
Johnson BA. Update on neuropharmacological treatments for alcoholism: scientific basis and clinical findings. Biochem Pharmacol. 2008;75:34-56.
Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA. 2000;284:963-971.
Johnson BA, Ait-Daoud N, Seneviratne C, et al. Pharmacogenetic approach at the serotonin transporter gene as a method of reducing the severity of alcohol drinking. Am J Psychiatr. 2011;168:265-275.
Pettatini HM, Oslin D, Lampman KM, et al. A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatr. 2010;167:668-675.
Anton RF, Myrick H, Wright TM, et al. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatr. 2011;168:709-717.
Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33:1582-1588.
Elkashef A, Kahn R, Yu E, et al. Topiramate for the treatment of methamphetamine addiction: a multi-center placebo-controlled trial. Addiction. 2012;107:1297-1306.
Colfax GN, Santos GM, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial. Arch Gen Psychiatr. 2011;68:1168-1175.
Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology. 2012;37:1689-1698.
Gray KM, Carpenter MJ, Baker NL, et al. A double-blind randomized controlled trial of N-acetylcysteine in cannabis-dependent adolescents. Am J Psychiatr. 2012;169:805-812.
Farrell M, Wodak A, Gowing L. Maintenance drugs to treat opioid dependence. BMJ. 2012;344.-
Pinto H, Maskrey V, Swift L, et al. The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment. J Subst Abuse Treat. 2010;39:340-352.
Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use HIV risk behavior and criminality: a meta-analysis. Addiction. 1998;93:515-532.
Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA. 2000;283:1303-1310.
Clausen T, Anchersen K, Waal H. Mortality prior to during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. Drug Alcohol Depend. 2008;94:151-157.
Clark RE, Samnaliev M, Baxter JD, et al. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011;30:1425-1433.
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: Treatment Improvement Protocol (TIP) Series 40. Rockville Md: Substance Abuse and Mental Health Services Administration; 2004.
Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med. 2003;349:949-958.
Fiellin DA. Buprenorphine: effective treatment of opioid addiction starts in the office. Am Fam Physician. 2006;73:1513.-
Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintainance treatment for opioid dependence. Cochrane Database Syst Rev. 2011;(4):CD001333.-
Krupitsky E, Nunes EV, Ling W, et al. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011;377:1506-1513.

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

How many times in the last year have you had a lot more to drink than you intended?
How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

Have you ever felt that you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

FAST TRACK

Cutting down on drug use may be a reasonable step toward change if a patient isn’t ready to think about stopping completely.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

References

Friedman PD. Alcohol use in adults. N Engl J Med. 2013;368:365-373.
Williams RH, Vinson DC. Validation of a single question screen for problem drinking. J Fam Pract. 2001;50:307-312.
Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;74:783-788.
Dawson DA, Pulay AJ, Grant BF. A comparison of two single-item screeners for hazardous drinking and alcohol use disorder. Alcohol Clin Exp Res. 2010;34:364-374.
Bush K, Kivlahan DR, Mcdonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789-1795.
Dawson DA, Grant BF, Stinson FS, et al. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population. Alcohol Clin Exp Res. 2005;29:844-854.
Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170:1155-1160.
American Psychiatric Asociation. Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. (DSM-IV-TR). Arlington, Va: American Psychiatric Association; 2000.
Saha TD, Stinson FS, Grant BF. The role of alcohol consumption in future classifications of alcohol use disorders. Drug Alcohol Depend. 2007;89:82-92.
Vinson DC, Kruse RL, Seale JP. Simplifying alcohol assessment:two questions to identify alcohol use disorders. Alcohol Clin Exp Res. 2007;31:1392-139.
Aertgeerts B, Buntinx F, Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis. J Clin Epidemiol. 2004;57:30-39.
Johnson JA, Lee A, Vinson DC, et al. Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study. Alcohol Clin Exp Res. 2012;July 26 [Epub ahead of print].
Center for Adolescent Substance Abuse Research. The CRAFFT Screening Tool. Boston MA:2009 [updated 2012). Available at: http://www.ceasar-boston.org/clinicians/crafft.php. Accessed January 15, 2013.
Knight JR, Sherritt L, Harris SK, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27:67-734.
Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ. 1988;297:663-668.
Fleming MF, Barry KL, Manwell LB, et al. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA. 1997;277:1039-1044.
Bertholet N, Daeppen JB, Wietlisbach V, et al. Brief alcohol intervention in primary care reduces alcohol consumption: Systematic review and meta-analysis. Arch Intern Med. 2005;165:986-995.
Kaner EFS, Dickinson HO, Beyer F, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007(2);CD004148.-
Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26:36-43.
Cuijpers P, Riper H, Lemmers L. The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction. 2004;99:839-845.
U.S.Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554-556.
Saitz R, Alford DP, Bernstein J, et al. Screening and brief intervention ffor unhealthy drug use in primary care settings: randomized clinical trials are needed. J Addict Med. 2010;4:131-136.
Field CA, Baird J, Saitz R, et al. The mixed evidence for brief intervention in emergency departments, trauma care centers, and inpatient hospital settings: what should we do? Alcohol Clin Exp Res. 2010;34:2004-2010.
DiClemente CC, Prochaska JO. Toward a comprehensive transtheoretical model of change: stages of change and addictive behaviors. In: Miller WR, Heather N, eds. Treating Addictive Behaviors. New York, NY:Plenum Press;1998:3–24.
Mason P, Butler CC. Health Behavior Change: A Guide for Practitioners. 2nd ed. London UK:Elsevier; 2010.
Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York NY: Guilford Press;2002.
Hettema J, Steele J, Miller WR. Motivational interviewing. Ann Rev Clin Psych. 2005;1:91-111.
Rollnick S, Butler CC, Kinnersley P, et al. Motivational interviewing. BMJ. 2010;340:c1900.-
Rosner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867.-
Swift R, Oslin DW, Alexander M, et al. Adherence monitoring in naltrexone pharmacotherapy trials: a systematic review. J Stud Alcohol Drugs. 2011;72:1012-1018.
Pettinati HM, Silverman BL, Battisti JJ, et al. Efficacy of extended-release naltrexone in patients with relatively higher severity of alcohol dependence. Alcohol Clin Exp Res. 2011;35:1804-1811.
Mann K, Lehert P, Morgan MY. The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis. Alcohol Clin Exp Res. 2004;28:51-63.
Rosner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010(9);CD004332.-
Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2012;October 17 [Epub ahead of print].
Azrin NH. Improvements in the community-reinforcement approach to alcoholism. Behav Res Ther. 1976;14:339-348.
Azrin NH, Sisson RW, Meyers R, Godley M. Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psychiatr. 1982;13:105-112.
Keane TM, Foy DW, Nunn B, et al. Spouse contracting to increase antabuse compliance in alcoholic veterans. J Clin Psychol. 1984;40:340-344.
Arbaizar B, Diersen-Sotos T, Gomez-Acebo I, et al. Topiramate in the treatment of alcohol dependence: a meta-analysis. Actas Espanolas de Psiquiatria. 2010;38:8-12.
Johnson BA. Update on neuropharmacological treatments for alcoholism: scientific basis and clinical findings. Biochem Pharmacol. 2008;75:34-56.
Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA. 2000;284:963-971.
Johnson BA, Ait-Daoud N, Seneviratne C, et al. Pharmacogenetic approach at the serotonin transporter gene as a method of reducing the severity of alcohol drinking. Am J Psychiatr. 2011;168:265-275.
Pettatini HM, Oslin D, Lampman KM, et al. A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatr. 2010;167:668-675.
Anton RF, Myrick H, Wright TM, et al. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatr. 2011;168:709-717.
Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009;33:1582-1588.
Elkashef A, Kahn R, Yu E, et al. Topiramate for the treatment of methamphetamine addiction: a multi-center placebo-controlled trial. Addiction. 2012;107:1297-1306.
Colfax GN, Santos GM, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial. Arch Gen Psychiatr. 2011;68:1168-1175.
Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis-dependent adults. Neuropsychopharmacology. 2012;37:1689-1698.
Gray KM, Carpenter MJ, Baker NL, et al. A double-blind randomized controlled trial of N-acetylcysteine in cannabis-dependent adolescents. Am J Psychiatr. 2012;169:805-812.
Farrell M, Wodak A, Gowing L. Maintenance drugs to treat opioid dependence. BMJ. 2012;344.-
Pinto H, Maskrey V, Swift L, et al. The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment. J Subst Abuse Treat. 2010;39:340-352.
Marsch LA. The efficacy of methadone maintenance interventions in reducing illicit opiate use HIV risk behavior and criminality: a meta-analysis. Addiction. 1998;93:515-532.
Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: a randomized controlled trial. JAMA. 2000;283:1303-1310.
Clausen T, Anchersen K, Waal H. Mortality prior to during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. Drug Alcohol Depend. 2008;94:151-157.
Clark RE, Samnaliev M, Baxter JD, et al. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011;30:1425-1433.
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: Treatment Improvement Protocol (TIP) Series 40. Rockville Md: Substance Abuse and Mental Health Services Administration; 2004.
Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med. 2003;349:949-958.
Fiellin DA. Buprenorphine: effective treatment of opioid addiction starts in the office. Am Fam Physician. 2006;73:1513.-
Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintainance treatment for opioid dependence. Cochrane Database Syst Rev. 2011;(4):CD001333.-
Krupitsky E, Nunes EV, Ling W, et al. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011;377:1506-1513.

Patient abusing alcohol or drugs? Help starts with a single question

References

If the patient is a teen

FOLLOW UP WITH A BRIEF INTERVENTION

Treat drug/alcohol problems

Use motivational interviewing to partner with patients

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