I n t e g r i t y - S e r v i c e - E x c e l l e n c e Headquarters U.S. Air Force 1 Primary Care Screening for Alcohol Misuse & Alcohol Use Disorders

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 2 Agenda Why is this important? Origins Policy & Requirements Frequency & Location Screening, Assessment, & Intervention Process

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 3 Why is this important in Primary Care? Heavy alcohol use is common and associated with significant health & behavior problems Alcohol problems often undetected Behaviors are changeable Providers influence patient behavior

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 4 Origins FE Warren’s Responsible Drinking Campaign Scientific, broad-based, community-oriented program is a slogan that is part of a larger program No underage drinking, No DUIs, 1 drink/hour, 3 drinks/sitting Results: 68% reduction in alcohol related incidents 24% reduction in DUI arrests 93% reduction in underage drinking arrests 70% reduction in Article 15’s 8% increase in available-for-duty rate 90 SVS turned a profit for first time in years

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 5 Policy & Requirements CSAF: Adapt for AF-wide use AF committed to reducing alcohol misuse MDG plays key role in this campaign Culture of Responsible Choices (CoRC) Integrated base-wide effort SG role is screening, assessment, & treatment

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 6 When & Where? Screen every Airman at least once annually at annual Preventive Health Assessment and/or routine clinic visits

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 7 Primary Care Screening, Assessment, & Intervention Step 1: Initial Screening Step 2: Additional Screening Step 3: Further Assessment Step 4: Intervention (& Referral, when indicated) Step 5: Follow-up Follow Primary Care Alcohol Screening Flowchart

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 8 Step 1: Initial Screening Ask: “Do you drink alcohol?” If yes, and underage, refer to ADAPT program If yes, and of age, go to Step 2 (Additional Screening) If no, no further action necessary

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 9 Step 2: Additional Screening Ask: “In the past 30 days, have you consumed four or more drinks in one day?” If yes, go to Step 3 (Further Assessment) If no, offer preventive education Reinforce patient’s current healthy drinking behavior Educate about health & behavior risks of high risk drinking Recommend staying within healthy drinking limits Recommend lower drinking limits or abstinence as indicated clinically

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 10 Step 2: Additional Screening Healthy Drinking Limits per NIAAA: Healthy Men < 65: No more than 4 drinks/day, 14 drinks/week Healthy Men > 65: No more than 3 drinks/day, 7 drinks/week Healthy Women: No more than 3 drinks/day, 7 drinks/week Modify as indicated based on health status Staying within these guidelines lowers the risk of injury or illness

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 11 Step 3: Further Assessment Choose one or more of the following screening tools: AUDIT C (positive screen = 3 or greater) AUDIT (positive screen = 7 or greater) CAGE (positive screen = 2 or greater) Other Options: Clinical interview, MAST, UNCOPE, DSM Screener Refer to Alcohol Screening Tools Chart for comparison of various tools AUDIT C is recommended

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 12 Step 3: Further Assessment If patient screens negative: Offer preventive education Educate patient about health & behavioral risks of continued high risk drinking

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 13 Step 3: Further Assessment If patient screens positive, make appropriate fitness for duty determinations and go to Step 4 (Intervention) Consider PRP, flying, weapons bearing status, etc. If provider suspects fitness for duty issues, alcohol abuse, or alcohol dependence, the patient must be referred to ADAPT program (IAW AFI )

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 14 Step 4: Intervention Use empathic, non-confrontational style Offer patient choices about how to make changes Emphasize patient’s responsibility for changing drinking behavior Convey confidence in patient’s ability to change drinking behavior

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 15 Step 4: Intervention Brief Intervention: Advise & Assist State your concern “I’m concerned about your drinking.” Give your advice “I think you should stop drinking.” “I think you should cut back.” Gauge readiness “What do you think?”

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 16 Step 4: Intervention Ask “As part of your healthcare, are you interested in changing your level of drinking?” If no, educate patient about health & behavioral risks of continued high risk drinking If yes, conduct the brief intervention, set a goal, and schedule follow-up

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 17 Step 4: Intervention Recommend lower limits or sobriety, as indicated Help patient set a goal Keep patient involved in goal setting Encourage self evaluation & reflection Weigh what they like about drinking against reasons for cutting down Provide educational materials Schedule follow-up appointment

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 18 Step 4: Intervention Reasons to recommend or consider abstinence: Diagnosis of alcohol dependence or abuse Pregnant or trying to conceive Contraindicated medication History of blackouts History of repeated, failed attempts to cut down Family history of alcohol problems History of injuries or psychosocial problems related to drinking Presence of medical or psychiatric condition that could potentially be aggravated by alcohol use

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 19 Step 4: Intervention Some patients may be willing to stop, but may be unable to do so without more intensive support Consider referral for substance abuse rehabilitation services Both inpatient & outpatient available Schedule referral appointment with patient in the office

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 20 Step 4: Intervention Where available, consider utilizing behavioral health provider in BHOP to help develop intervention plan Consider referral to Life Skills Support Center if you suspect patient has a significant co-morbid behavioral health condition Consider referral to ADAPT if you suspect alcohol use disorder in the absence of any significant co- morbid behavioral health conditions

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 21 Step 5: Follow-up Care Encourage & support patient’s efforts Review results Congratulate & reinforce positive changes Acknowledge difficulties in making changes Reassess motivation for change Revise goals as indicated Follow-up as often as needed until goals met

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 22 Step 5: Follow-up Care Monitor patient for symptoms of depression or anxiety Symptoms may resolve after 2-4 weeks of abstinence Monitor GGT as appropriate Potential indicator of treatment compliance Maintain contact with treatment center and/or counselors to whom you referred patient Request periodic updates on patient progress

I n t e g r i t y - S e r v i c e - E x c e l l e n c e 23 Questions?