## Substance Abuse in Brief Fact Sheet

Fall 2006, Volume 4, Issue 2

**Identifying and Helping Patients With Co-Occurring Substance Use and
Mental Disorders: A Guide for Primary Care Providers**

**Table of Contents**

Identifying Patients With COD

Patient History

Warning Signs

Screening

COD Red Flags

Triple Threat: SUDs, MDs, and HIV/AIDS

Treatment for Patients With COD

Ways To Help Patients With CODs

Resources

Publications

Web Sites

Ordering Information

Substance Abuse in Brief Fact Sheet

References

It is estimated that approximately 4.6 million American adults have both
substance use disorders (SUDs) and mental disorders (MDs).[^1] Other
terms for these co-occurring disorders (CODs) are dual diagnosis and
comorbidity. Early recognition and treatment of these disorders are
essential to improving treatment outcomes and quality of life for these
patients.[^2] This publication will help primary care providers identify
patients with CODs and provide appropriate treatment for these patients.

**Identifying Patients With COD**

Primary care providers, such as physicians, physician's assistants, and
nurse practitioners, are in an excellent position to help their patients
with both SUDs and mental disorders MDs. These disorders may exacerbate
or be related to other health problems, such as headaches,
cardiovascular disease, high blood pressure, diabetes, digestive
disorders, and cirrhosis,[^3]^,^ [^4] so patients with CODs may often
seek medical care from primary care providers. Hence, primary care
providers may have established a relationship with their patients
conducive to discussing SUDs and MDs.

Barriers to identifying and treating co-occurring disorders in the
primary care setting include the following:

-   **Low rates of screening,**[^5]^,^ [^6] **correct
    diagnosis,**[^7]^,^ [^8] and **appropriate referral.**^5^

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-   **Patient denial.**[^9] Patients may not realize they have a
    problem. Approximately one-third of patients do not disclose
    self-perceived SUDs or MDs to their primary care provider.[^10]

-   **Patient reluctance to talk to the provider.** Stigma and shame of
    CODs still exist, and many patients are afraid to admit they have a
    problem.^3^

-   **Provider attitudes.**^7,^ [^11] Providers may fail to make the
    possible link between physical symptoms and SUDs and/or MDs when
    assessing a physical problem. Providers' preconceptions and
    attitudes can also hinder identification of such disorders.

-   **Inadequate training.** Many providers receive inadequate education
    on CODs and their effects on other medical conditions.^3^

-   **Time constraints due to short appointment times.**^9^

Some barriers can be overcome by incorporating three components into the
primary care practice: (1) obtaining an annual patient history on
substance use and mental health issues, (2) being aware of warning signs
that may be related to an SUD or MD, and (3) screening routinely for
CODs.

***Patient History***

All patients should complete an annual health history, including
questions about personal and family history of substance use and mental
health issues.[^12] Questions about victimization, trauma, personal, and
social issues (e.g., unemployment, legal problems, homelessness,
financial or marital difficulties) should be included because these can
be related to SUDs and MDs.^11,\ 12,^ [^13] Primary care providers
should ask questions about substance use and mental health symptoms,
preferably in the context of other lifestyle questions so that these
potentially sensitive topics seem less threatening to patients.[^14] An
open, empathetic, and nonjudgmental attitude is essential to encouraging
patients to talk about their symptoms.^11^

***Warning Signs***

Most patients will not visit a primary care setting with obvious,
immediate signs of an MD, such as delirium, confusion, or
disorientation, or an SUD such as odor of alcohol on the breath or
marijuana on clothing, dilated pupils, slurred speech, or needle marks.
However, warning signs---"red flags"---for SUDs and MDs can manifest in
subtle physical or behavioral symptoms (see below). For example, many
patients with CODs present with physical complaints, such as insomnia,
fatigue, chest pain, cardiac arrhythmia, headaches, or impotence. When
other physical or psychological causes cannot be found, an SUD, an MD,
or a COD should be considered. These disorders should also be considered
when a patient with a chronic disease, such as chronic pain, diabetes,
heart disease, gastrointestinal disorders, or hypertension, fails to
respond to treatment.[^15]

Although primary care providers should not immediately identify mental
disorder symptoms as being caused by an SUD, it is important to note
that many mental disorders, including mood, anxiety, sleep, and sexual
disorders, can be induced by substance use. The only difference between
substance-induced mental disorders and independent mental disorders is
that all or most of the symptoms of a substance-induced disorder are a
direct result of substance use, abuse, or withdrawal rather than mental
illness. When substance-induced disorders are suspected, primary care
providers should continue to evaluate psychiatric symptoms and their
relationship to abstinence or ongoing substance abuse over time. ^11^

**COD Red Flags\***^11,\ 13,\ 15,^ [^16]

-   Nasal irritation (SUD only)

-   Unexplained bruises (SUD only)

-   Enlarged liver or spleen, abnormal liver function, hepatitis, or
    cirrhosis in later stages (SUD only)

-   Withdrawal symptoms (SUD)

-   Headaches

-   Chest pain or cardiac arrhythmia

-   Gastrointestinal symptoms

-   Hypertension

-   Sexual dysfunction

-   Fatigue

-   Apathy or flat affect

-   Social withdrawal

-   Changes in concentration, mood, activity level, sleeping, appetite,
    or weight

-   Feeling of worthlessness or inappropriate guilt

-   Fear, worry, or repetitive, intrusive thoughts or actions

-   Problems with cognition or impulse control

-   History of physical or mental trauma

\*These symptoms appear in combination and may indicate other problems
as well as COD.

***Screening***

Standardized screening instruments help identify patients with potential
CODs. Ideally, every patient should be screened. At the very least, any
patient presenting with signs or symptoms of either a mental or a
substance use problem should be evaluated for both disorders.^16^
Although many SUD and MD screening tools can be used in a primary care
setting (e.g., the CAGE-AID,^14^ the Mental Health Screening
Form-III,^11^ the Primary Care Evaluation of Mental Disorders Patient
Health Questionnaire™^20^), busy healthcare providers may find
administering these tools time consuming.

Recent research has shown that one- or two-item screeners are effective
in identifying those at risk for an SUD or MD (see exhibit 1).[^17]^,^
[^18]^,^ [^19]^,^ [^20] Because the screener questions can be answered
in seconds, they can be asked during routine visits. Computerized
screeners, such as the Drug Abuse Problem Assessment for Primary
Care[^21]^,^ [^22] (DAPA-PC), are also effective when time is limited.
The DAPA-PC is an Internet-based, self-administered screener for alcohol
and drug use that scores patient responses, generates a patient profile
for the healthcare provider, and offers motivational messages and advice
to the patient. A similar screener for identifying CODs has recently
been developed.[^23]

+-----------+-----------------------------------+--------------+------+
| **E       |                                   |              |      |
| xhibit 1. |                                   |              |      |
| Brief     |                                   |              |      |
| Screening |                                   |              |      |
| Tests**   |                                   |              |      |
+===========+===================================+==============+======+
| **        | **Questions**                     | **Possible   | **   |
| Problem** |                                   | Responses**  | Posi |
|           |                                   |              | tive |
|           |                                   |              | Scre |
|           |                                   |              | en** |
+-----------+-----------------------------------+--------------+------+
| Al        | When was the last time you had    | 1\) never    | in   |
| cohol^18^ | more than four (for women)/five   |              | the  |
|           | (for men) drinks in 1 day?        | 2\) in the   | past |
|           |                                   | past 3       | 3    |
|           |                                   | months       | mo   |
|           |                                   |              | nths |
|           |                                   | 3\) over 3   |      |
|           |                                   | months ago   |      |
+-----------+-----------------------------------+--------------+------+
| Alcohol   | In the last year:                 | yes or no    | yes  |
| or        |                                   |              | to   |
| Drugs^17^ | 1\) Have you ever drunk alcohol   |              | ei   |
|           | or used drugs more than you meant |              | ther |
|           | to?                               |              | ques |
|           |                                   |              | tion |
|           | 2\) Have you felt you wanted or   |              |      |
|           | needed to cut down on your        |              |      |
|           | drinking or drug use?             |              |      |
+-----------+-----------------------------------+--------------+------+
| Depre     | During the past 2 weeks:          | yes or no    | yes  |
| ssion^20^ |                                   |              | to   |
|           | 1\) Have you often been bothered  |              | ei   |
|           | by feeling down, depressed, or    |              | ther |
|           | hopeless?                         |              | ques |
|           |                                   |              | tion |
|           | 2\) Have you often been bothered  |              |      |
|           | by little interest or pleasure in |              |      |
|           | doing things?                     |              |      |
+-----------+-----------------------------------+--------------+------+

**Triple Threat: SUDs, MDs, and HIV/AIDS**

Healthcare providers should be aware that some people with CODs are
infected with HIV.[^24] CODs may interfere with effective HIV care
because of many factors, including poor adherence to antiretroviral
therapy.^24,^ [^25] In addition, the presence of HIV infection may
result in more severe co-occurring symptoms. Patients with HIV should be
screened regularly for CODs. The Health Resources and Services
Administration's report, *A Guide to Primary Care of People With
HIV/AIDS*, provides valuable information on managing co-occurring
disorders in patients with HIV/AIDS.^13^

**Treatment for Patients With COD**

All patients who screen positive for a COD need a thorough assessment.
The Quadrants of Care Model, a framework that classifies persons with
CODs into four basic groups based on symptoms and relative symptom
severity, helps determine appropriate patient care based on the type and
severity of the patient's symptoms (see exhibit 2).^11^ Patients with
severe CODs or those whose symptoms worsen should be referred for
further assessment and/or treatment by a specialist, but many patients
may delay or refuse seeing a substance abuse treatment or mental health
provider.^2^ In addition, the gap between the availability of treatment
slots and the brevity of formal treatment may result in referred
patients returning to the primary care provider for COD treatment.[^26]
Some patients may need to be screened for suicidality because persons
with CODs are at increased risk for committing suicide.^11^

Exhibit 2. Quadrants of Care Model

![](media/image1.jpeg){width="4.909722222222222in"
height="2.9770833333333333in"}

An effective way to address mild to moderate CODs in the primary care
setting is through a brief intervention. Brief interventions---short,
patient-centered interventions aimed at modifying behavior---have been
shown to be effective in reducing alcohol[^27] and drug use[^28] as well
as anxiety and depression[^29] when used in the primary care setting.
Brief interventions typically are provided over one to five visits and
consist of the following:^19,^ [^30]^,^ [^31]

1.  Providing simple, concise **feedback** on patients' risk for COD
    based on their histories, physical and behavioral warning signs,
    screening test results, and information on how these disorders
    affect them;

2.  Offering clear oral and written **advice**, including
    recommendations on safe alcohol consumption limits, the negative
    effects of alcohol and drug use, and behavior modification; and

3.  Establishing a mutually consented **plan of action** that addresses
    SUDs and MDs as appropriate and includes specific goals for behavior
    change, prescription of behavioral or pharmaceutical treatments,
    referrals for further assessment and treatment when appropriate, and
    followup plans, either in person or via the telephone

The National Institute on Alcohol Abuse and Alcoholism's publication
*Helping Patients Who Drink Too Much: A Clinician's Guide* and the
complementary *A Pocket Guide for Alcohol Screening and Brief
Intervention* provide valuable information about conducting brief
interventions in the primary care setting.

**Ways To Help Patients With CODs**

-   Provide feedback and advice in a clear, concise, nonjudgmental, and
    supportive manner. Empathy is particularly important because CODs
    are still associated with shame and guilt by many persons.^30^

-   Talk about these disorders in a matter-of-fact way---as treatable
    conditions---to put the patient at ease and encourage
    cooperation.^30,^ [^32]

-   Become familiar with and refer patients to 12-Step or mutual-help
    organizations such as Alcoholics Anonymous (www.aa.org), Double
    Trouble in Recovery (www.doubletroubleinrecovery.org), and Narcotics
    Anonymous (www.na.org).

-   Develop relationships with local substance abuse and mental health
    treatment providers, including those providing integrated treatment.

-   Stay current on COD research and practices by visiting the Web sites
    of the Substance Abuse and Mental Health Services Administration's
    Co-Occurring Center for Excellence (coce.samhsa.gov), the National
    Mental Health Association (www.nmha.org), and the National Alliance
    on Mental Illness (www.nami.org), as well as by participating in
    COD-specific training or continuing education.

**Resources**

***Publications***

-   TIP 42, *Substance Abuse Treatment for Persons With Co-Occurring
    Disorders* (www.samhsa.gov).

-   *Helping Patients Who Drink Too Much: A Clinician's Guide*
    (pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf)

-   KAP Keys and Quick Guide for Clinicians Based on TIP 24: *A Guide to
    Substance Abuse Services for Primary Care Clinicians*, NCADI #s
    KAPT24 and QGCT24

-   KAP Keys and Quick Guide for Clinicians Based on TIP 34: *Brief
    Interventions and Brief Therapies for Substance Abuse*, NCADI #s
    KAPT34 and QGCT34

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-   KAP Keys and Quick Guide for Clinicians Based on TIP 42: *Substance
    Abuse Treatment for Persons With Co-Occurring Disorders*, NCADI #s
    KAPT42 and QGCT42

-   *HIV/AIDS: Is Your Client at Risk?* NCADI \# MS965

-   *Alcohol Use Among Older Adults: Pocket Screening Instruments for
    Health Care and Social Service Providers*, NCADI \# PHD883

-   *Special Feature Kit: Overcoming Addiction and Mental Disorders*,
    NCADI \# AMDKIT

-   *Building Bridges---Co-Occurring Mental Illness and Addiction:
    Consumers and Services Providers, Policymakers, and Researchers in
    Dialogue*
    (www.mentalhealth.samhsa.gov/publications/allpubs/SMA04-3892)

-   *Improving the Quality of Health Care for Mental and Substance Use
    Conditions* (fermat.nap.edu/catalog/11470.html)

-   *Co-Occurring Disorders: Integrated Dual-Disorders Treatment*
    (www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cooccurring)

See ordering information for National Clearinghouse for Alcohol and Drug
Information (NCADI) publications below.

***Web Site***

-   Substance Abuse Treatment Facility Locator
    (www.findtreatment.samhsa.gov; 1-800-662-HELP)

-   Mental Health Services Locator
    (www.mentalhealth.samhsa.gov/databases)

-   Co-Occurring Center for Excellence (COCE) (www.coce.samhsa.gov)

-   National Mental Health Information Center (NMHIC)
    (www.mentalhealth.samhsa.gov)

-   National Clearinghouse for Alcohol and Drug Information (NCADI)
    (www.ncadi.samhsa.gov)

-   Substance Abuse and Mental Health Services Administration
    (www.samhsa.gov)

######### **Ordering Information**

To order additional copies of *Substance Abuse in Brief Fact Sheet* and
the other SAMHSA products, contact

SAMHSA's National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, MD 20847-2345

Phone: 800-729-6686, TDD: 800-487-4889

Fax: 240-221-4292

Web site: www.ncadi.samhsa.gov

*Substance Abuse in Brief* *Fact Sheet* is produced under contract
number 270-04-7049 by JBS International, Inc., and The CDM Group, Inc.,
for the Center for Substance Abuse Treatment, Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S. Department of Health and
Human Services (HHS). An electronic version of *Substance Abuse in Brief
Fact Sheet* is available online at www.kap.samhsa.gov under Products. If
you wish to reference or reproduce this issue, citation of this
publication is appreciated.

**Recommended Citation:** Center for Substance Abuse Treatment.
Identifying and Helping Patients With Co-Occurring Substance Use and
Mental Disorders: A Guide for Primary Care Providers. *Substance Abuse
in Brief Fact Sheet* Fall 2006, Volume 4, Issue 2.

**Public Domain Notice:** All material appearing in this report is in
the public domain and may be reproduced or copied without permission.
This publication may not be reproduced or distributed for a fee without
the specific, written authorization of the Office of Communications,
SAMHSA, HHS.

DHHS Publication No. (SMA) 06-4187

Published 2006

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