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Department of Veterans Affairs
Veterans Health Administration
Office of Quality & Performance
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Title: Management of Substance Use Disorders
in Primary amd Specialty Care.
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| Citation: |
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Management of Substance Use Disorder in the
Primary Care Setting. Washington, DC: VA/DoD Evidence-Based Clinical
Practice Guideline Working Group, Veterans Health Administration,
Department of Veterans Affairs , and Health Affairs, Department
of Defense, September 2001. Office of Quality and Performance publication
10Q-CPG/SUD-01
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Completion Date:
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July 2001
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Release Date:
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September 2001
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Source(s):
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The Management of Substance Use Disorders guideline was developed
by and written for clinicians by clinical experts from the DoD,
VHA, academia, and a team of guideline facilitators from the private
sector. An experienced moderator facilitated the multidisciplinary
working group that included psychiatrists, psychologists, mental
health professionals specializing in addiction and withdrawal therapies,
family practitioners, nurses, social workers, chaplains, pharmacists,
and rehabilitation specialists.
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Adaptation:
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The development process of the guideline incorporated information
from several sources into a format which maximally facilitated clinical
decision-making (Woolf, 1992). This effort drew, among others,
from the following sources: American Psychiatric Association Practice
Guideline for the Treatment of Patients with Substance Use Disorders
(American Psychiatric Association, 1995); Pharmacological Management
of Alcohol Withdrawal: A Meta-Analysis and Evidence-Based Practice
(Mayo-Smith et al., 1997); Evidence review reports published by
the COCHRANE DRUGS AND ALCOHOL GROUP of the Cochrane Collaboration
(http://www.update-software.com/cochrane);
Several Department of Health and Human Services (DHHS) publications
focusing on the assessment and treatment of substance abuse and
alcohol problems in primary care; Pharmacotherapy for Alcohol Dependence,
Evidence Report/Technology Assessment Number 3, January, 1999.
Agency for Health Care Policy and Research (AHCPR).
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Guideline Status:
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This is a current release of the guideline. An update is targeted
for Fall 2003.
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Developer(s):
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Veterans Health Administration (VHA), Department of Veterans Affairs
(VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) – Federal Government Agency [U.S.]
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Funding Source:
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U.S. Government
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Committee:
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Management of Substance Use Disorders Work Group
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Group Composition:
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The list of contributors
to this guideline includes physicians, psychologists, addiction
therapists, primary care providers, and experts in the field of
guideline and algorithm development.
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Disease/Condition:
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Substance Use Disorders
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Category:
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Screening, Assessment, Diagnosis, Evaluation, Treatment, and Follow-Up.
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Intended Users:
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Designed for use by primary care providers. The guideline can
also be used to coordinate and standardize care in specialized treatment
programs and as a teaching tool for students and house staff.
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Target Population:
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Persons eligible for care in the VA or DoD health care delivery
system.
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Contact Person(s):
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VHA:
Daniel Kivlahan, PhD
Director, VA Center of Excellence in Substance Abuse Treatment and
Education
VA Puget Sound
Seattle, WA
(206) 764-2608
Daniel.kivlahan@med.va.gov
Richard Suchinsky, MD
Associate Chief Consultant for Addictive Disorders
Department of Veterans Affairs
Washington, DC 20420
(202) 273-8437
Richard.Suchinsky@hq.med.va.gov
DoD:
Shannon Miller, MD, CMRO MAJ, USAF, MC
Mental Health Flight
74th Medical Group
4881 Sugar maple Drive
Room # 1DD46
Wright Patterson AFB, OH 45433
(937) 257-8722/8719
Shannon.miller@wpafb.af.mil
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GOALS/OBJECTIVES
- To promote evidence-based management
of patients with substance use disorders.
- To identify the critical decision
points in the management of patients with substance use disorders.
- To allow flexibility to local policies
or procedures, such as those regarding referrals to or consultation
with specialists
- To improve local management of patients
with substance use disorders and thereby improve patient outcomes.
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INTERVENTIONS AND PRACTICES
The guideline consists of five modules
that are designed to assist clinicians in primary care settings
and specialized treatment settings with early detection of symptoms,
assessment of treatment readiness, determination of the appropriate
setting and intensity of treatment, and delivery of individualized
interventions. The guideline also contains two appendices that
provide screening and assessment instruments and a DoD clinical
instruction.
Module A: Assessment and Management in
Primary Care
Includes screening, brief intervention, and
specialty referral considerations.
Appendix A-1: Substance Use Disorders Screening and
Assessment Instruments
Appendix A-2: DoD Clinical Instruction DoD 1010.6
Module C: Care Management
Emphasizes chronic disease management for
patients unwilling or unable to pursue rehabilitation goals.
Module P: Addiction-Focused Pharmacotherapy
Addresses use of currently approved medications
as part of treatment for alcohol and opioid dependence.
Module R: Assessment and Management in
Specialty Care
Focuses on patients in need of further assessment
or motivational enhancement or who endorse rehabilitation goals.
Module S: Stabilization
Addresses detoxification and pharmacological
management of withdrawal symptoms.
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OUTCOMES CONSIDERED
Goals for the management of patients with
substance use disorders include the following:
Improved screening process
Efficient and effective initial assessment process
Establishment of initial intervention, including referral, for non-dependent
users, matching treatment to patient needs, increased use of pharmacotherapy
and psychotherapy and the monitoring of its affects on the patient,
improvement in the continuity of care and determination of referral
criteria.
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MAJOR RECOMMENDATIONS
The Substance Use Disorder guideline is
presented in an algorithmic format and is intended to provide a
systematic approach to the evaluation and management of patients
with substance use disorders.
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CLINICAL ALGORITHMS ARE PROVIDED FOR:
Module A:
Assessment and Management in Primary Care
Module C: Care
Management
Module P: Addiction-Focused
Pharmacotherapy
Module R:
Assessment and Management in Specialty Care
Module S: Stabilization
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TYPE OF EVIDENCE
The development process for the guideline
was evidence-based whenever possible. Evidence-based practice integrates
clinical expertise with the best available clinical evidence derived
from systematic research. Where evidence was ambiguous or conflicting,
or scientific data were lacking, the clinical experience within
the multidisciplinary group guided the development of consensus-based
recommendations.
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DESCRIPTION OF METHODS TO COLLECT EVIDENCE
Electronic searches of Cochrane Controlled
Trials Register (COCHRANE DRUGS AND ALCOHOL GROUP: http://www.update-software.com/cochrane)
were undertaken. Papers selected for further review were those
published in English-language peer-reviewed journals. Preference
was given to papers based on randomized, controlled clinical trials,
or nonrandomized case-control studies. Studies involving meta-analysis
were also reviewed.
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METHODS TO ASSESS THE QUALITY AND STRENGTH
OF THE EVIDENCE
The literature was critically analyzed
with evidence grading. The rating scale used for this document
was based on the evidence rating used by U.S. Preventative Services
Task Force (U.S. PSTF) Guide to Clinical Preventive Services, Second
Edition (1996).
The
Grading Scheme Used for the Guideline
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Quality
of Evidence (QE)
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| Grade |
Description |
| I |
Evidence
is obtained from at least one properly randomized controlled
trial. |
| II-1 |
Evidence
is obtained from well-designed controlled trials without randomization.
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| II-2 |
Evidence
is obtained from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group. |
| II-3 |
Evidence
is obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments could also be regarded
as this type of evidence. |
| III |
Opinions
of respected authorities are based on clinical experience, descriptive
studies in case reports, or reports of expert committees. |
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Strength
of Recommendation (SR)
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| Grade |
Description |
| A |
There
is good evidence to support the recommendation that the condition
be specifically considered. |
| B |
There
is fair evidence to support the recommendation that the condition
be specifically considered |
| C |
There
is insufficient evidence to recommend for or against the inclusion
of the condition, but a recommendation may be based on other
grounds. |
| D |
There
is fair evidence to support the recommendation that the condition
be excluded from consideration |
| E |
There
is good evidence to support the recommendation that the condition
be excluded from consideration |
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REVIEW METHODS
Peer Review
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ENDORSER(S)
VHA’s National Clinical Practice Guideline
Council
VA/DoD Clinical Practice Guideline Working Group
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QUALIFYING STATEMENTS
Clinical practice guidelines, which are
increasingly being used in health care, are seen by many as a potential
solution to inefficiency and inappropriate variations in care.
Guidelines should be evidenced-based as well as based upon explicit
criteria to ensure consensus regarding their internal validity.
However, it must be remembered that the use of guidelines must always
be in the context of a health care provider's clinical judgment
in the care of a particular patient. For that reason, the guidelines
may be viewed as an educational tool analogous to textbooks and
journals, but in a more user-friendly format.
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GUIDELINE AVAILABILITY
Electronic copies available from: Office
of Quality and Performance web site.
Print copies available from:
The Office of Quality and Performance (10Q)
Veterans Health Administration, Department of Veterans Affairs
810 Vermont, NW
Washington, DC 20420
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Copy Statement: No
copyright restrictions apply
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