• Michigan Quality Improvement Consortium. Screening, diagnosis and referral for substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Screening and management of substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

Substance use disorders

Diagnosis
Management
Screening
Treatment

Family Practice
Internal Medicine
Pediatrics

Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians

• 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

• Adolescents and adults at health maintenance visits or initial pregnancy visit
• Adolescents and adults with substance use disorders

Screening

1. Use of a validated screening tool (Alcohol Use Disorders Identification Test [AUDIT], Michigan Alcohol Screening Test-Geriatric [MAST-G], CAGE Survey, Substance Abuse Subtle Screening Inventory [SASSI], TWEAC [for pregnant women])
2. General screening (at wellness visits)
3. Targeted screening for those at risk

Diagnosis

Assessment of symptoms and behaviors

Treatment/Management

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

Not stated

Searches of Electronic Databases

The Michigan Quality Improvement Consortium (MQIC) project leader 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.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Review

Not stated

Expert Consensus

Using information obtained from literature searches and available health plan guidelines on the designated topic, the Michigan Quality Improvement Consortium (MQIC) project leader 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 "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 project leader 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.

Not applicable

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

External Peer Review
Internal Peer Review

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 (project leader distributes final draft to medical directors' committee, measurement and implementation groups to solicit feedback).

The MQIC project leader also forwards the approved guideline draft to appropriate state medical specialty societies 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 August 2007.

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

Detection/Screening

• 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 alcohol 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), TWEAC (for pregnant women), Michigan Alcohol Screening Test (MAST, MAST-Geriatric [MAST-G]), CAGE Survey, and Substance Abuse Subtle Screening Inventory (SASSI).

Substance dependence or abuse 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., RN, 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, Cocaine Anonymous) or Employee Assistance Program, or (especially if substance dependent) a substance abuse or behavioral health specialist. [D]
• Pharmacologic management should be conducted by or in collaboration with physicians who have expertise in the area of substance use disorders. [D]
• Schedule appropriate follow-up within 30 days to re-assess and support behavior change

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

None provided

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.

Not stated

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.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Michigan Quality Improvement Consortium. Screening, diagnosis and referral for substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

2003 Aug (revised 2007 Aug)

Michigan Quality Improvement Consortium - Professional Association

Michigan Quality Improvement Consortium

Michigan Quality Improvement Consortium Medical Director's Committee

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

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.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Screening and management of substance use disorders. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

None available

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