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Quick Guide
For Clinicians

Based on TIP 24
A Guide to Substance Abuse
Services for Primary Care
Clinicians

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Contents
Why a Quick Guide?  . . . . . . . . . . . . . . . . . . . 2
What is a TIP?  . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . 4
Warning Signs and Risk Factors 
for Alcohol and Illicit Drug Use . . . . . . . . . . . 6
Screening Instruments . . . . . . . . . . . . . . . . 10
Following Up a Screening . . . . . . . . . . . . . . 21
Brief Intervention  . . . . . . . . . . . . . . . . . . . . 22
Assessment  . . . . . . . . . . . . . . . . . . . . . . . . 29
Goals and Effectiveness of Treatment  . . . . 31
Treatment Models and Approaches . . . . . . 34
Legal Issues   . . . . . . . . . . . . . . . . . . . . . . . .38
Phone and Internet Resources    . . . . . . . . .39

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Quick Guide
For Clinicians

This Quick Guide is based almost entirely on information con
tained in TIP 24, published  in 1997 and based on information
updated through May 1996. No additional research has been
conducted to update this topic since publication of the original
TIP.
Based on TIP 24
A Guide to Substance
Abuse Services for Primary
Care Clinicians

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2
A Guide to Substance Abuse Services for Primary Care Clinicians

WHY A QUICK GUIDE?

This Quick Guide was developed to accompany A
Guide to Substance Abuse Services for Primary
Care Clinicians, Number 24 in the Treatment
Improvement Protocol (TIP) Series published by
the Center for Substance Abuse Treatment (CSAT),
Substance Abuse and Mental Health Services
Administration. This Quick Guide is based entirely
on TIP 24 and is designed to meet the needs of
the busy clinician for concise, easily accessed
"how-to" information.

The Guide is divided into 10 sections (see
Contents). These sections will help readers quick
ly locate relevant material.

Clinicians can use the Resources on page 39 to
keep updated with current information on the
most recent developments in the field of sub
stance abuse treatment.

For more information on the topics in this Quick
Guide, readers are referred to TIP 24.

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What Is A TIP? 3

WHAT IS A TIP?

The TIP series has been in production since 1991.
This series provides the substance abuse treat
ment and related fields with consensus-based,
field-reviewed guidelines on substance abuse
treatment.

TIP 24, A Guide to Substance Abuse Services for
Primary Care Clinicians

 Addresses the concerns of readers who are pri
mary care clinicians
 Includes extensive research
 Lists numerous resources for further informa
tion
 Provides a reference for substance abuse treat
ment for primary care clinicians
See the inside back cover for information on how
to order TIPs and other related products.

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4
A Guide to Substance Abuse Services for Primary Care Clinicians

INTRODUCTION

Since substance abuse disorders are often chron
ic conditions that progress slowly, primary care cli
nicians are in an ideal position to screen for alco
hol and drug problems. Studies have shown that
primary care clinicians can help patients decrease
alcohol consumption through office-based inter
ventions that take only 10 or 15 minutes.

General Recommendations for Primary Care
Clinicians
Screening
1) Periodically and routinely screen all patients
for substance use disorders
2) Ask questions about substance abuse in the
context of other lifestyle questions
3) Use the Alcohol Use Disorder Identification Test
(AUDIT) to screen for alcohol problems among
English-speaking, literate patients, or use the first
three quantity/frequency questions from AUDIT,
supplemented by the CAGE questionnaire 
4) Use the CAGE-AID (CAGE Adapted to Include
Drugs) to screen for drugs use among patients
Alcohol-related disorders occur in up to 26 percent
of general medicine clinic patients, a prevalence
rate similar to those for such other chronic dis
eases as hypertension and diabetes.

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Introduction 5

5) Ask "Have you used street drugs more than five
times in your life?" A positive answer suggests
further screening and possibly assessment are
needed
6) Ask high-risk patients about alcohol and drug
use in combination
7) Ask pregnant women "Do you use street
drugs?" If the answer is yes, advise abstinence
8) Use the CAGE, the AUDIT, or the Michigan
Alcoholism Screening TestGeriatric Version
(MAST-G) to screen patients over 60
9) Screen adolescents for substance abuse every
time they seek medical services
Brief Intervention
1) Perform a brief intervention with patients whose
substance abuse problems are less severe
2) Include in the brief intervention feedback about
screening results and risk of use, information
about safe consumption limits and advice about
change, assessment of patient's readiness to
change, negotiated goals and strategies for
change, and arrangements for followup visits
Assessment and Treatment
1) Refer high-risk patients to a specialist, if possi
ble, for in-depth assessment
For more detailed information, see TIP 24, 
pp. xvxvii.

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6
A Guide to Substance Abuse Services for Primary Care Clinicians

WARNING SIGNS AND RISK FACTORS
FOR ALCOHOL AND ILLICIT DRUG USE

Physical Signs: General

Dental caries
Swollen hands or feet
Swollen parotid glands
Leukoplakia in mouth
Gingivitis
Perforated septum
Needle track marks
Skin abscesses, burns on inside of lips
Disrupted menstrual cycle
Physical Signs: Neurological

Dilated or constricted pupils
Slurred, incoherent, or too rapid speech
Inability to focus (both visually and mentally)
It is important for primary care clinicians to know
patients' drinking levels in order gauge their poten
tial risk for developing problems.

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Warning Signs and Risk Factors for Alcohol and Illicit Drug Use 7

Unsteady gait
"Nodding off"
Blackouts or other periods of memory loss
Insomnia or other sleep disturbances
Withdrawal symptoms 
Agitation
Psychiatric

Depression
Anxiety 
Low self-esteem
Low tolerance for stress
Other mental health disorders
Feelings of desperation 
Feelings of loss of control over one's life
Feelings of resentment 
Behavioral

Use of other substances
Aggressive behavior in childhood
Conduct disorders; antisocial personality
Impulsiveness and risk taking 
Alienation and rebelliousness 

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8
A Guide to Substance Abuse Services for Primary Care Clinicians

School-based academic or behavioral problems
Involvement with criminal justice system
Poor interpersonal relationships
Social and Sexual History

Legal status (minor, in custody)
Alcohol or drug use by friends
Level of education 
Occupation/work history 
Sexual preference 
Number of sexual relationships
Types of sexual activity engaged in 
Whether the patient practices safe sex
Family

Use of drugs and alcohol by parents, siblings
Inherited predisposition to alcohol or drug
dependence
Family dysfunction
Family trauma 
Marital/cohabitation status
Domestic violence and other abuse history 

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Warning Signs and Risk Factors for Alcohol and Illicit Drug Use 9

Demographic

Male gender
Inner city or rural residence combined with low-
socioeconomic status
Lack of employment opportunities
Low-Risk and At-Risk
Low-risk drinkers consume less than an average
of one to two drinks per day, do not drink more
than three or four drinks per occasion, and do not
drink in high risk situations (i.e. while pregnant,
driving a car, etc.).

At-risk drinkers occasionally exceed recommended
guidelines for use. While they are at risk for alco
hol related problems, they may never experience
negative consequences as a result of their drink
ing and represent a prime target for preventive,
educational efforts by primary care clinicians. 

For more detailed information, see TIP 24, 
pp. 45, pp. 4647.

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10
A Guide to Substance Abuse Services for Primary Care Clinicians

SCREENING INSTRUMENTS 

CAGE-AID
Asking the following questions of every adult rou
tinely and periodically is a cost-effective way of
screening for substance abuse and detecting pos
sible problems at an early stage in their develop
ment

Have you ever felt you ought to cut down on your
drinking or drug use?
Have people annoyed you by criticizing your
drinking or drug use?
Have you felt bad or guilty about your drinking or
drug use?
Have you ever had a drink or used drugs first
thing in the morning to steady your nerves or to
get rid of a hangover (eye-opener)?
Scoring: Item responses on the CAGE are scored
0 for "no" and 1 for "yes" answers. Consider con
ducting a brief intervention (explained on page
22) with any patient who scores a one or higher.

Asking potentially sensitive questions about sub
stance abuse in the context of other behavioral
lifestyle questions appears to be less threatening
to patients.

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Screening Instruments 11

The AUDIT Questionnaire
The AUDIT is designed to be used as a brief struc
tured interview or self-report survey that can easi
ly be incorporated into a general health interview,
lifestyle questionnaire, or medical history. Patients
tend to answer it most accurately when

 The interviewer is friendly and nonthreatening
 The purpose of the questions is clearly related
to a diagnosis of their health status
 The patient is alcohol- and drug-free at the time
of the screening
 The information is considered confidential
 The questions are easy to understand
Health workers should try to establish these con
ditions before the AUDIT is given. Answers should
be recorded carefully.

In addition to these general considerations, the
following interviewing techniques should be used:

 Try to interview patients under the best possible
circumstances
 Look for signs of alcohol or drug intoxication
patients who have alcohol on their breath or
appear intoxicated may be unreliable respondents
 It is important to read the questions as written
and in the order indicated

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12
A Guide to Substance Abuse Services for Primary Care Clinicians

Circle the number that comes closest to the
patient's answer.

1.How often to do you have a drink containing
alcohol?
(0) Never
(1) Monthly or less
(2) Two to four times a month
(3) Two to three times a week
(4) Four or more times a week

2.How many drinks containing alcohol do you
have on a typical day when you are drinking?
[Code number of standard drinks.*]
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7 to 9
(4) 10 or more

3.How often do you have six or more drinks on
one occasion?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily
*In determining the response categories it has been assumed that one drink
contains 10 g of alcohol. In countries where the alcohol content of a standard
drink differs by more than 25 percent from 10 g, the response category
should be modified accordingly.

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Screening Instruments 13

4.How often during the last year have you found
that you were not able to stop drinking once you
had started?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily

5.How often during the last year have you failed to
do what was normally expected from you
because of drinking?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily

6.How often during the last year have you needed
a first drink in the morning to get yourself going
after a heavy drinking session?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily

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14
A Guide to Substance Abuse Services for Primary Care Clinicians

7. How often during the last year have you had a
feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily

8.How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly 
(2) Monthly
(3) Weekly
(4) Daily or almost daily

9.Have you or someone else been injured as a
result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year

10.Has a relative or friend or a doctor or other 
health worker been concerned about your drink
ing or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year

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Screening Instruments 15

Procedures for scoring AUDIT

Question 1: Never = 0
Monthly or less = 1
Two to four times per month = 2
Two to three times per week = 3
Four or more times per week = 4

Question 2: 1 or 2 = 0
3 or 4 = 1
5 or 6 = 2
7 to 9 = 3
10 or more = 4

Questions 38: Never = 0
Less than monthly = 1
Monthly = 2
Weekly = 3
Daily or almost daily = 4

Questions 910:No = 0
Yes, but not in the last year = 2
Yes, during the last year = 4

The minimum score (for non-drinkers) is 0 and the
maximum possible score is 40. A score of 8 or
more indicates a strong likelihood of hazardous or
harmful alcohol consumption.

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A Guide to Substance Abuse Services for Primary Care Clinicians

TWEAK Test 
Use the TWEAK test to screen pregnant women.
T Tolerance: How many drinks can 
you hold?
W Have close friends or relatives worried or 
complained about your drinking in the 
past year?
E Eye-opener: Do you sometimes take a 
drink in the morning when you first get up?
A Amnesia: Has a friend or family member 
ever told you about things you said or did 
while you were drinking that you could 
not remember?
K Do you sometimes feel the need to 
cut down on your drinking?
Scoring: A 7-point scale is used to score the test.
The "tolerance" question scores 2 points if a
woman reports she can hold more than five drinks
without falling asleep or passing out. A positive
response to the "worry" question scores 2 points,
and a positive response to the last three ques
tions scores 1 point each. A total score of 2 or
more indicates a woman is likely to be a risky
drinker. 

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Screening Instruments 17

Screen all adults age 60 or older for alcohol and
prescription drug abuse as part of their regular
physical.

Michigan Alcoholism Screening
TestGeriatric Version (MAST-G)
The following are yes or no questions: 

1. After drinking have you ever noticed an
increase in your heart rate or beating in your
chest?
2. When talking with others, do you ever underes
timate how much you actually drink?
3. Does alcohol make you so sleepy that you often
fall asleep in your chair?
4. After a few drinks, have you sometimes not
eaten or been able to skip a meal because you
didn't feel hungry?
5. Does having a few drinks help decrease your
shakiness or tremors?
6. Does alcohol sometimes make it hard for you
to remember parts of the day or night?
7. Do you have rules for yourself that you won't
drink before a certain time of the day?
8. Have you lost interest in hobbies or activities
you used to enjoy?

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18
A Guide to Substance Abuse Services for Primary Care Clinicians

9. When you wake up in the morning, do you ever
have trouble remembering part of the night
before?
10. Does having a drink help you sleep?
11. Do you hide your alcohol bottles from family
members?
12. After a social gathering, have you ever felt
embarrassed because you drank too much?
13. Have you ever been concerned that drinking
might be harmful to your health?
14. Do you like to end an evening with a nightcap?
15. Did you find your drinking increased after-
someone close to you died?
16. In general, would you prefer to have a few
drinks at home rather than go out to a social
event?
17. Are you drinking more now than in the past?
18. Do you usually take a drink to relax or calm
your nerves?
19. Do you drink to take your mind off your prob
lems?
20. Have you ever increased your drinking after
experiencing a loss in your life?
21. Do you sometimes drive when you have had
too much to drink?

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Screening Instruments 19

22. Has a doctor or nurse ever said they were wor
ried or concerned about your drinking?
23. Have you ever made rules to manage your
drinking?
24. When you feel lonely does having a drink
help?
Scoring: 5 or more "yes" responses are indicative
of an alcohol problem.

Suggestions for Screening
All adolescents should be asked about alcohol
and drug use, particularly marijuana.

Risk Factors for Adolescent Drug Use
 Physical or sexual abuse
 Parental substance abuse
 Parental incarceration
 Dysfunctional family relationships
 Peer involvement with drugs or alcohol
 Smoking tobacco 
Red Flags
 Marked change in physical health 
 Deteriorating performance in school or job
 Dramatic change in personality, dress, or
friends

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A Guide to Substance Abuse Services for Primary Care Clinicians

 Involvement in serious delinquency or crimes
 HIV high-risk activities
 Serious psychological problems
Pregnant women and women older than 60, as
well as women who have experienced a major
life transition, should be queried about their
psychoactive prescription drug use and use of
over-the-counter sleep aids.
Clinicians will want to use the screening instru
ment that best meets the needs of their patient
population.
When treating patient populations at high risk
for drug abuse, ask questions regarding alcohol
and drug use at the same time.
For more detailed information, see TIP 24, 
pp. 1221, pp. 116119, p. 127.

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Following Up on Screening 21

FOLLOWING UP ON SCREENING

 All patients who undergo screening for alcohol or
drug use should be told the results of the screen.
 Patients with positive results to a screen will
need some type of followup. Assessment ques
tions should cover severity of the suspected
alcohol or drug involvement, the types and fre
quency of problems connected with the
patient's use, and other special medical and
psychiatric considerations.
 If a patient's response to a brief assessment
suggests a diagnosis of substance abuse or
dependence, the clinician should initiate a refer
ral for an in-depth assessment.
 The clinician can initiate a brief, office-based
therapeutic intervention in these situations:
 Screening reveals only mild to moderate 
substance abuse problems
 The patient appears to be at risk for 
experiencing negative consequences as a 
result of current patterns
 Coexisting illness or conditions may be 
worsened by continued drinking or other 
medications
 Patient refuses referral for further 
assessment or treatment
For more detailed information, see TIP 24, 
pp. 2326

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22

Brief interventions as secondary prevention tools
have the potential to help an estimated 15 to 20
million heavy drinkers in the U.S. by minimizing
serious adverse consequences such as costly
emergency room visits, domestic violence, or road
accidents.
A Guide to Substance Abuse Services for Primary Care Clinicians

BRIEF INTERVENTION

Selecting Appropriate Patients for Brief
Intervention
In response to screening questionnaires patients
can be categorized into one of three groups:

1.Patients who do not appear to have any alcohol-
or drug-related problems. These patients require
no further intervention.
2.Patients with positive but low scores on any
screening tests or who occasionally use marijua
na. These patients may be appropriate candi
dates for brief intervention.
3.Patients with several positive responses to
screening questionnaires and suspicious drink
ing or drug use histories, symptoms of sub
stance dependence, or current use of illicit
drugs. These patients need further assessment.

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Brief Intervention 23

Conducting Brief Interventions
1) Give feedback about screening results,
impairment and risks while clarifying the find
ings
 Give prompt feedback to the screening.
 Present results in a straightforward, nonjudg-
mental manner and in terms a patient can read
ily understand.
 Concerns about potential or actual health
effects should be stressed. For example, "At this
level of consumption, you are at increased risk
for some health problems as well as accidents." 
 Avoid being adversarial and pay attention to
semantics. For example, the phrase "people for
whom substance abuse is creating a problem"
is less off-putting then the labels "alcoholic" or
"addict." 
 Remain tolerant of the range of patient reac
tions, including astonishment, embarrassment,
hostility, and denial.
 Try to avoid arguments or discussions about
how much others can drink without adverse
consequences.
 Be reassuring that alcohol and drug problems
are not anyone's "fault" and can certainly be
addressed during visits.

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24
A Guide to Substance Abuse Services for Primary Care Clinicians

2) Inform the patient about safe consumption
limits and offer advice about change
 Explain what acceptable and safe use levels are
for the relevant substance. Low-risk drinking is
no more than two drinks per day for men and
one drink per day for women. 
 Patients should understand concepts of toler
ance and metabolism.
 Abstinence from illegal drugs is always the ulti
mate goal. For example, "Thank you for being
honest with me about your marijuana use. One
concern of mine is your asthma, because mari
juana smoke does affect your lungs. Why don't
we work out a plan to help you quit?"
 Clearly state recommendations about consump
tion goals, keeping these in the context of
lifestyle issues and living habits. For example,
"In reviewing your response to our screening
questionnaire, I notice that you are drinking a
lot of beer on weekends. You don't seem to
have any direct problems as a result, but I'm
concerned that driving while intoxicated is not
safe and you have a young family to consider."
 Clinician authority in offering advice can be
strongly motivating.

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Brief Intervention 25

3) Assess the patient's readiness to change 
 A patient's reaction to initial feedback about
screening results offers strong clues about
readiness to change.
 People with substance abuse disorders general
ly fall into one of five stages along a continuum
that provides a useful framework for monitoring
progress:
1) Precontemplation: Not seeing the behavior as
a problem or not wanting to change the behavior.
2) Contemplation: Beginning to understand that
the behavior is causing difficulties in living or
taking a toll on their health and happiness. 
3) Preparation/Determination: Considering vari
ous options for change.
4) Action: Taking concrete steps to change the
behavior in a specific way. 
5) Maintenance: Avoiding relapse into problem
behavior. 
 Be prepared for resistance and setbacks. 
 Avoid the temptation to regard resistance as a
challenge to authority or to react in an authori
tarian way.
 Have an emphatic and supportive attitude and
create an atmosphere that the patient will be

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26
A Guide to Substance Abuse Services for Primary Care Clinicians

comfortable returning to even if goals are not
successfully achieved.
4) Negotiate goals and strategies for change
 With alcohol, suggest that the client reduce con
sumption to below unsafe or potentially haz
ardous levels. For example, "Can we set a spe
cific date to reduce your alcohol use? Could you
cut back, beginning this week?"
 If a patient who is using illegal drugs does not
feel ready to discontinue use, suggest a taper
ing schedule.
 The clinician can only remind the patient that
reducing or stopping alcohol use or abstaining
from other drug use will eliminate the health or
social problems substance use is causing:
Ultimately the patient must choose the goal.
 Suggest that patients keep track of consump
tion in a daily diary to make them more aware
of how much they consume. Even patients who
are not ready to change their behavior may be
willing to keep a diary.
 Patients will be more motivated to change if
they are helping to set goals and develop strate
gies for change. Some studies have found that
self-help manuals can be a helpful adjunct for
planning change.

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Brief Intervention 27

 A written contract is a good idea since some
times patients forget what they agreed to do.
5) Arrange for followup treatment
 Monitor any health problems or abnormal
physical markers.
Express trust in the patient.
 Confront the patient if he or she is not honest
about reporting substance use.
 The use of any form of objective monitoring
beyond self-reports of substance abuse must be
negotiated between the clinician and the
patient.
 Tell patients exactly who will see their medical
charts and what information about screening
and intervention will be recorded.
 One researcher found that reduction of alcohol
consumption correlated with the number of
practitioner intervention sessions that were
delivered.
Deciding to Refer for Further 
Assessment or Treatment
Clinicians should be prepared for the brief inter
vention to fail: The patient may not be able to
achieve or maintain the mutually established goal
of reducing or stopping use after one, or even sev
eral, tries. Clinicians cannot force a patient to

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28
A Guide to Substance Abuse Services for Primary Care Clinicians

undergo further assessment. However, if problem
use persists after a brief intervention, those dis
cussions should serve as a springboard for a
more in-depth assessment or specialized treat
ment.

For more detailed information, see TIP 24, 
pp. 2638.

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Assessment 29
The first step to understanding local substance
abuse treatment resources is to collect informa
tion about the specialized services in your area
and have a contact person at each one.
ASSESSMENT

In-depth substance abuse assessment requires
specialized skills and consumes a substantial
amount of time. However, even clinicians who will
not perform substance abuse assessments
should have a basic understanding of their ele
ments and objectives so they can 

 Initiate appropriate referrals
 Participate effectively as a member of the treat
ment team, if required
 Better fulfill a monitoring responsibility with
respect to patient progress
 Carry out needed medical case management
functions as appropriate
What assessment does
 Examines problems related to use (e.g., med
ical, behavioral, social, and financial)
 Provides data for a formal diagnosis
 Establishes severity of an identified problem 

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A Guide to Substance Abuse Services for Primary Care Clinicians

 Helps to determine appropriate level of care
 Guides treatment planning
For more detailed information, see TIP 24, 
pp. 4151.

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Goals and Effectiveness of Treatment 31

GOALS AND EFFECTIVENESS OF
TREATMENT

While each individual in treatment will have spe
cific long- and short-term goals, all specialized
substance abuse programs have three similar
generalized goals:

 Reducing substance abuse or achieving a sub
stance-free life
 Maximizing multiple aspects of life functioning 
 Preventing or reducing the frequency and 
severity of relapse
For most patients, the primary goal of treatment is
attainment and maintenance of abstinence.
However, until the patient accepts that abstinence
is necessary, treatment programs try to minimize
the effects of continuing use and abuse through

 Education 
 Counseling 
 Self-help groups that stress reducing risky
behavior, building new relationships with drug-
free friends, changing recreational activities and
lifestyle patterns, substituting substances used
with less risky ones, etc.

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32

All the long-term studies find that "treatment
works"the majority of substance-dependent
patients eventually stop compulsive use and have
less frequent and severe relapse episodes.

Some important things to remember about alco
hol and other drug treatment are

 No single approach is effective for all persons
with alcohol problems
 Treatment of other life problems associated with
drinking improves outcomes
 Therapists and patient (and problem) character
istics, treatment process, posttreatment adjust
ment factors and the interactions among these
variables also determine outcomes
 Patients who significantly reduce alcohol con
sumption or become totally abstinent usually
improve their functioning
The Role of the Primary Care Clinician
Throughout Treatment

 Learn about treatment resources in the commu
nity that offer appropriate services
 Keep in touch with the specific treatment pro
gram where the patient is enrolled to ascertain
A Guide to Substance Abuse Services for Primary Care Clinicians

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32

All the long-term studies find that "treatment
works"the majority of substance-dependent
patients eventually stop compulsive use and have
less frequent and severe relapse episodes.

Some important things to remember about alco
hol and other drug treatment are

 No single approach is effective for all persons
with alcohol problems
 Treatment of other life problems associated with
drinking improves outcomes
 Therapists and patient (and problem) character
istics, treatment process, posttreatment adjust
ment factors and the interactions among these
variables also determine outcomes
 Patients who significantly reduce alcohol con
sumption or become totally abstinent usually
improve their functioning
The Role of the Primary Care Clinician
Throughout Treatment

 Learn about treatment resources in the commu
nity that offer appropriate services
 Keep in touch with the specific treatment pro
gram where the patient is enrolled to ascertain
A Guide to Substance Abuse Services for Primary Care Clinicians

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Goals and Effectiveness of Treatment 33

its quality and understand the approach and
services offered 
 Request formal reports regarding the treatment
plan and progress indicators from the program
on a periodic basis (with the patient's explicit
permission)
 Clarify the clinician's role in continued care of
the patient (e.g. treating specific medical condi
tions, writing prescriptions, and monitoring com
pliance through urine or other testing)
For more detailed information, see TIP 24, 
pp. 5657, p. 70.

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34
A Guide to Substance Abuse Services for Primary Care Clinicians

TREATMENT MODELS AND 
APPROACHES

The three historical orientations that still underlie
different treatment models are

1. A medical model, emphasizing
biological/genetic or physiological causes of
addiction that require treatment by a physician
utilizing pharmacotherapy to relieve symptoms.
2. A psychological model, focusing on an individ
ual's maladaptive motivational learning or emo
tional dysfunction as the primary cause of sub
stance abuse. The approach includes psy
chotherapy or behavioral therapy directed by a
mental health professional.
3. A sociocultural model, stressing deficiencies in
the social and cultural milieu or socialization
process that can be ameliorated by changing
the physical and social environment, particularly
through involvement in self-help fellowships or
spiritual activities and supportive networks.
Treatment authority is often vested in persons
who are in recovery themselves and whose
experiential knowledge is valued.
These three models have been woven into a
biopsychosocial approach in most contemporary
programs.

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Treatment Models and Approaches 35

The four major treatment approaches now preva
lent in public and private programs are

1.The Minnesota model of residential chemical
dependency treatment incorporates a biopsy-
chosocial model for addiction that focuses on
abstinence as the primary treatment goal and
uses the Alcoholics Anonymous 12-Step pro
gram as a major tool for recovery and relapse
prevention. This approach evolved from earlier
precursors and initially required 28 to 30 days
to complete. More recent models have short
ened inpatient stays considerably and substitut
ed intensive outpatient treatment followed by
less intensive continuing care.
2.Drug-free outpatient treatment uses a variety of
counseling and therapeutic techniques, skills
training, and educational supports and little or
no pharmacotherapy to address the specific
needs of individuals moving from active sub
stance abuse to abstinence. This is the least
standardized treatment approach and varies
considerably in both intensity, duration of care,
and staffing patterns. Most of these programs
see patients only once or twice weekly and use
some combination of counseling strategies,
social work, and 12-Step or self-help meetings.
3.Methadone maintenanceor opioid substitu
tiontreatment specifically targets chronic hero-

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36
A Guide to Substance Abuse Services for Primary Care Clinicians

in or opioid addicts who have not benefited
from other treatment approaches. The
methadone or other long-acting opioid, when
administered in adequate doses, reduces drug
craving, blocks euphoric effects from continued
use of heroin or other illegal opioids, and elimi
nates the rapid mood swings associated with
short-acting and usually injected heroin. The
approach, which allows patients to function nor
mally, focuses on rehabilitation and the develop
ment of a productive lifestyle.
4.Therapeutic community residential treatment is
best suited to patients with a substance abuse
dependence diagnosis who also have serious
psychosocial adjustment problems and require
resocialization in a highly structured setting.
Treatment generally focuses on negative pat
terns of thinking and behavior that can be
changed through reality-oriented individual and
group therapy, and participation in a therapeutic
milieu with hierarchical roles, privileges, and
responsibilities. Tutorials, remedial and formal
education, and daily work assignments in the
communal setting or conventional jobs are usu
ally required.

-----------------------------------------------
Legal Issues 37

Pharmacotherapy
The use of medication to manage alcohol and
drug abuse falls into four categories:

 Medications to manage withdrawal replaces
the abused drug with another, safer drug. The
latter can be gradually tapered until physiologi
cal homeostasis is restored.
 Medications to discourage substance use, can
precipitate an unpleasant reaction or diminish
the euphoric effects of alcohol and other drugs.
 Agonist substitution therapy replaces an illicit
drug with a prescribed medication. Opioid main
tenance treatment, currently the only type of
this therapy available, both prevents withdrawal
symptoms from emerging and reduces craving
among opioid-dependent patients.
 Medications to treat comorbid psychiatric
conditions are used for persons with co-occur-
ring mental health and substance abuse prob
lems. Prescribing medications for these patients
requires extreme caution, partly due to difficul
ties in making accurate differential diagnosis
and due to the dangers of intentional or unin
tentional overdose.
For more information see TIP 24, pp. 8197.

-----------------------------------------------
38

It is essential for primary care physicians to respect
their patient's autonomy and rights to confidentiality
if they are to be effective in screening and assessing
patients for substance use disorders.
A Guide to Substance Abuse Services for Primary Care Clinicians

LEGAL ISSUES

Things to keep in mind when treating/screening
patients:

 Though it is not required by law, doctors should
ask patients' permission before any laboratory
screens
 Laws regarding the extent of doctor-patient privi
lege vary from State to State
 All States permit health care professionals to
disclose information if the patient consents in
writing
 When documenting patient information, doctors
should use neutral chart notations that do not
identify issues as substance abuse related
 When doctors must communicate with a client's
employer because a client is entering treatment,
they should communicate in a way that does not
indicate a patient is entering treatment for alco
hol or other drugs

For more detailed information, see TIP 24, 
p. 69, p. 79, pp. 103114.

-----------------------------------------------
Phone and Internet Resources 39

PHONE AND INTERNET RESOURCES

Alcoholics Anonymous 
(212) 870-3400
www.aa.org
Narcotics Anonymous
(818) 773-9999
www.na.org
SAMHSA's National Clearinghouse for Alcohol and
Drug Information 
(800) 729-6686
(301) 468- 6433 fax
www.samhsa.gov

National Council on Alcoholism and Drug
Dependence, Inc. (NCADD)
(212) 206-6770
(212) 654-1690 fax
Hope Line: (800) 729-6686
www.ncadd.org
For more detailed information, see TIP 24, 
pp. 143145.

-----------------------------------------------
40
A Guide to Substance Abuse Services for Primary Care Clinicians

-----------------------------------------------
Ordering Information
TIP 24 A Guide to Substance
  Abuse Services for 
Primary Care Clinicians

TIP 24-Related Products
KAP Keys for Clinicians
based on TIP 24

Do not reproduce or distribute this publication for a fee without spe
cific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.

Easy Ways to Obtain Free Copies 
of All TIP Products
1. Call SAMHSA's National Clearinghouse for Alcohol
and Drug Information (NCADI) at 800-729-6686, 
TDD (hearing impaired) 800-487-4889
2 Visit CSAT's Website at www.csat.samhsa.gov

-----------------------------------------------
Other Treatment Improvement
Protocols (TIPs) that are relevant to
this Quick Guide:

See the inside back cover for ordering information for all
TIPs and related products.

DHHS Publication No. (SMA) 01-3581
Printed 2001
TIP 3, Screening and Assessment of Alcohol- and
Other Drug Abusing Adolescents (1994) BKD108
TIP 31, Screening and Assessing Adolescents for
Substance Use Disorders (1999) BKD306
TIP 34, Brief Interventions and Brief Therapies for
Substance Abuse (1999) BKD341
TIP 35, Enhancing Motivation for Change in
Substance Abuse Treatment (1999) BKD342