Patient Safety / Quality

Spotting alcohol and substance abuse

Some 22.5 million Americans ages 12 and older have an alcohol or substance abuse problem, but only 2.3 million receive treatment. To identify and help the other 20 million, some primary care pro­viders now routinely screen patients.

If you work in a primary care setting that doesn’t have a substance-abuse screening program, consider starting one. Screenings don’t take much time, and they can save lives.

When to screen

Current recommendations say you should screen all patients routinely and periodically. If you decide to use targeted screening instead, you’ll need to establish criteria for your selections. Remember, the likelihood of bias and subjectivity decreases the more routine the process becomes.

According to guidelines from the Agency for Healthcare Research and Quality (AHRQ), the optimal interval for screening hasn’t been determined. However, screening patients on their first visit and then annually after that may be beneficial. You might screen young adults and those in high-risk categories more frequently.

Screening tools

Screening tools range from a simple four-question survey to a large questionnaire that’s scored by a computer. Choose a tool you feel comfortable using. (See Using the Alcohol Use Disorders Identification Test and More screening tools for substance abuse.)

You may add screening-tool questions to your clinical interview or keep them as a separate part of your assessment. Depending on your skill and comfort level, you can ask the questions directly or have the patient complete a self-report. Or you can let the patient decide. No matter how you elicit answers, remain non­judg­mental. Keep the focus on screening as a part of an overall health improvement plan.


Your interview should reveal the answers to questions such as these:

  • Does the patient consume alcohol or use other drugs?
  • If so, how often?
  • How much does the patient ingest and how long does it take to ingest it?
  • Does the patient spend a lot of time thinking about how to get more of the substance?
  • Does the patient spend a lot of time thinking about when he or she will be able to use the substance again?
  • Does the patient think he or she has lost control over his or her use or behavior while using?
  • Does the patient have to use more to achieve the same effect?
  • Does the patient report or does the medical history indicate that substance abuse has led to physical problems (trauma or associated illnesses, such as HIV/AIDS, seizure disorders, or hepatitis C), psychological conditions (anxiety, depression, or mood swings), or social consequences (loss of employment, impaired relationships, or legal problems)?

Screening tools may also include laboratory tests, such as urine toxicology screens. These tools are less effective in identifying people at risk for substance abuse. Also, they may damage the nurse-patient relationship because patients may view them as intrusive. (See How much is too much?)

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Information for patients

You’ll need educational resources, such as handouts and more in-depth reading material, for both staff members and patients. You can order the “Substance Abuse Tool Box” from the Virginia Department of Substance Abuse Services. You can also request resources from the various Screening, Brief Intervention, and Referral to Treatment (SBIRT) projects. Or visit a website that provides resource materials for free or a small fee, such as http://www.nattc.org (the national office of the Addiction Technology Transfer Center) and http://www.samhsa.gov (the Substance Abuse and Mental Health Services Administration).

As you gather materials, think about where you’ll store them and which other staff members will have access. When you become comfortable with the screening process, you might decide to teach other nurses in your office to screen patients. Or you may ask all the nurses working with you to help plan the screening program and practice screening as a group. That way, all patients visiting your primary care setting can be screened and offered appropriate intervention.

Intervention and referral

Consider these questions about the results of your screening:

  • If the results are questionable, will the patient have a repeat screen?
  • Who will repeat the screen and when will they do it?
  • When the results indicate a patient’s substance abuse puts him or her at risk, which staff member will intervene?

Effective interventions to help reduce the misuse of alcohol, in particular, can take as little as 5 minutes and include feedback, advice, and goal-setting. (See 5 A’s for alcohol misuse intervention.)

What should you say to patients when their screen indicates an alcohol or substance use illness? Advise them in general terms to try to reduce or end alcohol or substance abuse. And help them make the connection between their health problems as well as other problems and the abuse.

Consider the steps you’ll take to ensure that your patient is referred for a full assessment. Which staff member will direct the referral? Has someone in your office developed a relationship with substance abuse treatment professionals who will help make referrals?

During future visits or phone calls, continue talking to your patients about their substance use. Ask about any changes since the last visit or call. And find out if they are following your recommendations and following up on your referral.

To enhance follow-up care, collaborate with other providers and programs that offer screening, assessment, and treatment. Collaborate with nurses who specialize in treating substance abuse disorders, such as certified addictions registered nurses and advanced practice certified addictions registered nurses.

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Continuity and confidentiality

Review your screening process and develop your script. Make sure your process is culturally sensitive to the patients in your setting. Consider how you’ll ensure continuity between screenings and follow-up.

The results of your substance abuse screenings will require a higher than usual level of confidentiality. That means you’ll need a plan for teaching staff members about confidentiality. And you’ll need to control access to the results. You also need to consider how to collect outcome data—such as the number of patients screened, results of screening, levels of interventions, and referrals made—confidentially.

Staff education

Make sure you have a plan for continuing education for yourself and other staff members who are part of the process. Continuing education is available at conferences and seminars and in online courses. Nursing journals such as the Journal of Addictions Nursing have continuing education articles, as well. You will also find opportunities for continuing education by contacting your local treatment agencies and visiting their websites. And don’t forget to talk with pharmaceutical company representatives who visit your office. Frequently, they know of educational opportunities sponsored by their companies.

Ready to screen

After considering the questions above and creating your program, you’ll be ready to screen your first patient:

  • Introduce yourself and tell the patient what you are going to do.
  • Explain why routine office visits now include substance abuse screening.
  • Ask the questions or let the patient fill out the questionnaire.
  • Score the completed questionnaire and determine if the patient needs intervention.
  • Meet with the patient to review the results and offer feedback.
  • Arrange a referral to a substance abuse professional, as indicated.

Congratulations! You’re ready for your second patient.


Carolyn Baird is a therapist at Isaly Counseling Associates in McMurray, Pennsylvania, and a nursing instructor at Waynesburg University in Pennsylvania.

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