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Guideline Summary
Guideline Title
Screening, diagnosis and referral for substance use disorders.
Bibliographic Source(s)
Michigan Quality Improvement Consortium. Screening, diagnosis and referral for substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2011 Sep. 1 p.
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Substance use disorders

Guideline Category
Diagnosis
Management
Screening
Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Intended Users
Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians
Substance Use Disorders Treatment Providers
Guideline Objective(s)
  • To achieve significant, measurable improvements in the screening and management of substance use disorders through the development and implementation of common evidence-based clinical practice guidelines
  • To design concise guidelines that are focused on key management components of substance use disorders to improve outcomes
Target Population
  • Adolescents and adults at health maintenance visits or initial pregnancy visit
  • Adolescents and adults with substance use disorders
Interventions and Practices Considered

Screening

Use of a validated screening tool (Alcohol Use Disorders Identification Test [AUDIT]; Michigan Alcohol Screening Test [MAST] or MAST-Geriatric [MAST-G]; CAGE Survey; Substance Abuse Subtle Screening Inventory [SASSI]; Tolerance, Worried, Eye-opener, Amnesia, and Cut down [TWEAC; for pregnant women]; Drug Abuse Screening Test [DAST])

Diagnosis

Assessment of symptoms and behaviors

Management

  1. Patient education
  2. Counseling
  3. Referral, if appropriate
  4. Pharmacological management
  5. Follow-up
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Michigan Quality Improvement Consortium (MQIC) health care analyst conducts a search of current literature in support of the guideline topic. Computer database searches are used to identify published studies, existing protocols and/or national guidelines on the selected topic developed by organizations such as the American Diabetes Association, American Heart Association, American Academy of Pediatrics, etc. If available, clinical practice guidelines from participating MQIC health plans and Michigan health systems are also used to develop a framework for the new guideline.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Using information obtained from literature searches and available health plan guidelines on the designated topic, the Michigan Quality Improvement Consortium (MQIC) health care analyst prepares a draft guideline to be reviewed by the Medical Directors' committee at one of their scheduled meetings. Priority is given to recommendations with [A] and [B] levels of evidence (see the "Rating Scheme for the Strength of the Evidence" field).

The initial draft guideline is reviewed, evaluated, and revised by the committee, resulting in draft two of the guideline. Additionally, the Michigan Academy of Family Physicians participates in guideline development at the onset of the process and throughout the guideline development procedure. The MQIC guideline feedback form and draft two of the guideline are distributed to the Medical Directors, as well as the MQIC measurement and implementation group members, for review and comments. Feedback from members is collected by the MQIC health care analyst and prepared for review by the Medical Directors' committee at their next scheduled meeting. The review, evaluation, and revision process with several iterations of the guideline may be repeated over several meetings before consensus is reached on a final draft guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

When consensus is reached on the final draft guideline, the Medical Directors approve the guideline for external distribution to practitioners with review and comments requested via the Michigan Quality Improvement Consortium (MQIC) health plans (health care analyst distributes final draft to Medical Directors' committee, measurement and implementation groups to solicit feedback).

The MQIC health care analyst also forwards the approved guideline draft to appropriate state medical specialty societies and physicians with expertise in the related field for their input. After all feedback is received from external reviews, it is presented for discussion at the next scheduled committee meeting. Based on feedback, subsequent guideline review, evaluation, and revision may be required prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in September 2011.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations below are based on the previous version of the guideline.

The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Adolescents and Adults

Screening for Substance Use Disorder

  • Screen by history for substance use at every health maintenance exam or initial pregnancy visit (repeat as indicated), using a validated screening tool (improves accuracy of detecting substance abuse or dependence)* [D].
  • Maintain high index of concern for substance use in persons with:
    • Family history of substance use disorder [B]
    • Recent stressful life events and lack of social supports
    • Chronic pain or illness, trauma
    • Mental illness (e.g., depression, bipolar disorder, etc.)
    • Drug-seeking behaviors
    • Physical and cognitive disabilities
    • Started alcohol use before age 15
    • Medical condition associated with substance use

*Validated tools include: Alcohol Use Disorders Identification Test (AUDIT), Tolerance, Worried, Eye-opener, Amnesia, and Cut down (TWEAC; for pregnant women), Michigan Alcohol Screening Test (MAST, MAST-Geriatric [MAST-G]), CAGE Survey, Substance Abuse Subtle Screening Inventory (SASSI), Drug Abuse Screening Test (DAST).

Diagnosing Substance Use Disorder (indicates a maladaptive pattern of substance use resulting in clinically significant impairment or distress)

Relevant issues include:

  • Recurrent substance use resulting in a failure to fulfill major role obligations
  • Recurrent substance use in situations that are physically hazardous
  • Recurrent substance-related legal problems
  • Substance use despite having persistent or recurrent social or interpersonal problems
  • Tolerance, withdrawal, use in larger amounts or over a longer period than intended
  • Persistent desire or unsuccessful efforts to cut down
  • Great deal of time spent in obtaining, using, or recovering from use of the substance
  • Reduction in social, occupational, or recreational activities because of substance use
  • Substance use continues despite knowledge of problems

Patients with Substance Use Disorder

Patient Education and Brief Intervention by Primary Care Physician (PCP) or Trained Staff (e.g., Registered Nurse [RN], Master of Social Work [MSW]) [A]

  • Assess patient's risk, understanding, and readiness to change.
  • Discuss the relationship of substance use to presenting medical concerns or psychosocial problems.
  • Negotiate goals and strategies for reducing consumption and other change.
  • Involve family members as appropriate.

Referral Considerations

  • Consider referral to community-based services (e.g., Alcoholics Anonymous, Narcotics Anonymous, etc.), an Employee Assistance Program, a substance abuse or behavioral health specialist, or a physician experienced in pharmacologic management of addiction. [D]
  • Initiate treatment within 14 days.
  • Frequent follow-up is helpful to support behavior change; preferably 2 visits within 30 days.

Definitions:

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is provided for the most significant recommendations (see the "Major Recommendations" field).

The guideline is based on several sources, including: Practice Guideline for the Treatment of Patients with Substance Use Disorders, Second Edition, American Psychiatric Association, August 2006 (www.psych.org External Web Site Policy).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Through a collaborative approach to developing and implementing common clinical practice guidelines and performance measures for substance use disorders, Michigan health plans will achieve consistent delivery of evidence-based services and better health outcomes. This approach also will augment the practice environment for physicians by reducing the administrative burdens imposed by compliance with diverse health plan guidelines and associated requirements.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This guideline lists core management steps for non-behavioral health specialists. Individual patient considerations and advances in medical science may supersede or modify these recommendations.

Implementation of the Guideline

Description of Implementation Strategy

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are disseminated through email, U.S. mail, and websites.

The MQIC health care analyst prepares approved guidelines for distribution. Portable Document Format (PDF) versions of the guidelines are used for distribution.

The MQIC health care analyst distributes approved guidelines to MQIC membership via email.

The MQIC health care analyst submits request to website vendor to post approved guidelines to MQIC website (www.mqic.org External Web Site Policy).

The MQIC health care analyst completes an annual statewide postcard mailing to physicians in all areas of medicine including primary care and specialties. The postcard provides the complete list of MQIC guidelines and includes which guidelines have been recently revised, which are coming up for revision, and any new published guidelines.

The statewide mailing list is derived from the Blue Cross Blue Shield of Michigan (BCBSM) provider database. Approximately 95% of the state's M.D.'s and 96% of the state's D.O.'s are included in the database.

The MQIC health care analyst submits request to the National Guideline Clearinghouse (NGC) to post approved guidelines to NGC website (www.guideline.gov External Web Site Policy).

Implementation Tools
Chart Documentation/Checklists/Forms
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Michigan Quality Improvement Consortium. Screening, diagnosis and referral for substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2011 Sep. 1 p.
Adaptation

The guideline is based on several sources, including: Practice Guideline for the Treatment of Patients with Substance Use Disorders, Second Edition, American Psychiatric Association, August 2006 (www.psych.org External Web Site Policy).

Date Released
2003 Aug (revised 2011 Sep)
Guideline Developer(s)
Michigan Quality Improvement Consortium - Professional Association
Source(s) of Funding

Michigan Quality Improvement Consortium

Guideline Committee

Michigan Quality Improvement Consortium Medical Directors Committee

Composition of Group That Authored the Guideline

Physician representatives from the 13 participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, Michigan Peer Review Organization, and the University of Michigan Health System

Financial Disclosures/Conflicts of Interest

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g., health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors Committee are asked to disclose all commercial relationships as well.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 14, 2004. The information was verified by the guideline developer on July 27, 2004. This NGC summary was updated by ECRI on November 28, 2005. The updated information was verified by the guideline developer on December 19, 2005. This NGC summary was updated by ECRI Institute on March 4, 2008. The updated information was verified by the guideline developer on March 12, 2008. This NGC summary was updated by ECRI Institute on February 15, 2010. The updated information was verified by the guideline developer on March 22, 2010. This NGC summary was updated by ECRI Institute on December 22, 2011. The updated information was verified by the guideline developer on January 9, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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