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A Closer Look: Q&A with Richard Saitz

Dr. Richard Saitz

Dr. Richard Saitz is Professor and Chairman of the Department of Community Health Sciences at Boston University School of Public Health and Professor of Medicine at Boston University School of Medicine and a Faculty member of the Clinical Addiction Research & Education (CARE) Unit at Boston Medical Center. Dr. Saitz is a primary care internist, epidemiologist and a health services researcher. His research focuses on screening and interventions for unhealthy alcohol and other drug use and improving the quality of care for people with addictions across the spectrum of use, particularly in general medical care settings.

We followed up with Dr. Saitz after reading about his most recent publication, which showed a “single screening question” to be an effective tool to identify unhealthy alcohol and/or other drug use.

 

1.  What question did your research team ask in the single-screening question research?

“How many times in the past year have you had X or more drinks in a day?” (where X is five for men and four for women). If asked to clarify, the research assistant provided definitions of a standard drink (12 oz. of beer, 5 oz. of wine, or 1.5 oz. of 80 proof distilled spirits).

“How many times in the past year have you used an illegal drug or used a prescription medication for non- medical reasons?” If asked to clarify the meaning of “nonmedical reasons,” the research assistant added “for instance, because of the experience or feeling it caused.”

2.  How did your research team decide to narrow down screening to one question? Has the use of single-screening questions (SSQs) been effective with respect to other health issues?

It is clear that for screening for many conditions, the simplest, briefest approach is feasible and often more than adequate as a first step.  More detail can be obtained later from the subgroup of people at risk.  Over the past 40 years, alcohol screening questionnaires have ranged from 2-4 questions. Heavy drinking episodes are most harmful and most people who exceed drinking limits report such (binge) episodes. So it made sense to ask about them directly as a marker of unhealthy use.  The National Institute on Alcohol Abuse and Alcoholism began recommending the approach and we thought it should be validated scientifically.  Similarly, for drug use, any use can have risks for many drugs, so we thought it best just to ask the simple question.  The National Institute on Drug Abuse recommends asking about use of a number of categories of drugs.  To simplify it, we thought it made sense to lump them together, and then get further detail from those who reported any use.  I should also mention that it isn’t just that it is one item.  The other key features are that the answer is simple and easy to score (for example, any more than 0 is a positive test) and the question makes people comfortable because it asks how many times—making it more likely that people will report use.

3.  Did results vary for participants along identity lines (i.e. gender, age, familiarity with physician)?

In the current study of how well the questions do for separating out those with more severe problems, we did not analyze by those characteristics.  When  we reported on the validity of these items for identifying unhealthy use, we did such analyses and found no effects of race/ethnicity or gender.

4.  How should physicians follow up, once participant response indicates alcohol or drug dependence?

First, these items identify the full spectrum of unhealthy use.  Once identified, the clinician should ask the patient if it is okay if they share the meaning of the answers (feedback). If okay, they should provide feedback about the results — something like “Your answers indicate that your drinking/drug use increases risks to your health.”  They can use the numerical result of the single item to note whether the patient is likely to have a more or less severe disorder.  It makes sense to confirm severity by asking about symptoms of a disorder.  Ask the patient what they think about this risk. Do they understand? Agree? Disagree?  A conversation should ensue to identify any consequences of relevance to the patient.

The physician should then ask permission to give advice. If given permission, the physician should state clearly that the patient should cut down or quit.  People with dependence should be encouraged to abstain.   Again the physician should ask what the patient thinks about the advice.  Depending on the patient’s readiness to make a change and interest in various options, the physician can negotiate and work with the patient to agree on a plan.  In any case, patients should be asked to follow-up to enable the physician to see progress made.  Any conversation should be done with empathy and with support of the patient’s confidence and ability to make a change.

The purpose of understanding the level of severity is to obtain a sense of how urgent it is to do something, and what the goal of the brief counseling will be (e.g. cut down, abstain, further treatment needs).

5.  Would you recommend the use of this SSQ for non-medical providers such as social workers?

Yes. The screening is likely useful in electronic communication, or in person, and by anyone trained to ask the question and address the result.  Furthermore, the person who asks the question need not be the same person who addresses the result.

6.  What, if anything, is lost in physician-patient relationship building by narrowing the amount of questions in screening and assessments? What is gained?

Currently most physicians do not ask about alcohol and drugs at all with valid tools.  They do not ask multiple questions.  There are many reasons for this but one is that questionnaires are too long for use in routine practice. Single items have the promise of improving the relationship by addressing the topic (as opposed to not addressing it at all).  Once uncovered, and with an idea of severity, further conversations will or should ensue.

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