Getting to patients before it's too late
Early identification, intervention key to substance abuse prevention
by Brian Fitzgerald
Doctors and social workers often deal with substance abusers who are in the later stages of addiction -- when the destructive habit has already taken a heavy toll. But now faculty at Boston University's School of Medicine and School of Social Work are teaching students how to identify the problem in its early stages.
In 1995 both schools received $750,000 Faculty Development grants from the federal Center for Substance Abuse Prevention (CSAP). The major goal -- to develop "faculty experts" in drug and alcohol abuse prevention and intervention -- is being realized, according to SSW Associate Professor Maryann Amodeo and BUSM Assistant Professor Jeffrey Samet.
"It's a relatively new concept for medical schools and schools of social work," says Samet, who directs the BUSM faculty development program with Hortensia Amaro, a professor at the BU School of Public Health. "The fact is that prevention and early intervention can be extremely effective, but many faculty were trained in an era when graduate schools had few courses on the topic."
Amodeo, the SSW faculty development program codirector, agrees: "In spite of the lack of exposure to substance abuse in their own professional training, faculty members were expected to integrate current clinical techniques and research methods into their classroom teaching."
Boston University was the only institution to receive two CSAP awards in this funding cycle. BUSM was one of five schools of medicine and SSW was the only school of social work in the country to receive the grant.
BUSM: asking the right questions
"In primary-care settings, case studies show that brief interventions to cut down on alcohol use in earlier stages will ultimately prevent deaths," says Samet. "Traditionally, when alcoholic patients see their physicians, it's because of liver problems." But by that time it is often too late. He points out that cirrhosis of the liver kills 25,000 people a year in the United States.
Holding seminars twice a month to determine how physicians can help patients curb substance abuse, BUSM faculty members discuss methods of detecting drinking and drug habits, as well as intervention strategies.
"In treating a patient with a substance abuse problem, moti-vational enhancement is more effective than a confrontational approach," says Samet. A health survey that includes four CAGE questions, which the patient fills out in the waiting room, can reveal a lot. CAGE is an acronym for four questions on the screening test regarding alcohol use: Have you ever cut back? Have you ever been annoyed by people talking about your drinking? Have you ever felt guilty? Do you ever have an eye-opener (a drink in the morning)?
In November 1996 Samet published "Beyond CAGE" in the journal Archives of Internal Medicine. The article, which provides physicians with a clinical approach if they detect signs of substance abuse, advises them to tell patients about the adverse consequences of such behavior and then assess their readiness to change. A recovery effort can then be tailored to patients according to their willingness to stop.
In July Samet published Medical Clinics in North America, a book written with Brown University Medical School Professor Michael Stein and Yale University Medical School Professor Patrick O'Connor. The book contains information to help clinicians understand how to deal with alcohol and substance abuse in a medical setting. "The book reviews common dilemmas faced by internists when they are treating patients addicted to alcohol, cocaine, opiates, and prescription drugs," says Samet.
In addition, a training video is available for emergency medicine residents so they can better address alcohol and drug issues in the emergency room. The video was produced by Dr. Edward Bernstein, director of quality improvement in BUSM's emergency medicine department, and Dr. Gail D'Onofrio, former director of the Emergency Medicine Residency Program at the Boston Medical Center and now on the faculty at the Yale University School of Medicine.
The grant has also expanded BUSM's drug abuse prevention efforts into the community. Dr. Sheila Chapman, a BUSM assistant professor and primary-care physician at Boston Medical Center, is leading an effort to educate Boston's city employees about substance abuse treatment options. "The program is designed to make them more likely to use the city's Employee Assistance Program," says Samet. Training of department heads will begin January 15.
SSW: strengthening curriculum and research
Five SSW faculty have received intensive training in the substance-abuse prevention program: Professors Cassandra Clay, Lawrence Shulman, Joyce West Stevens, Judith Perlstein, and Wilma Peebles-Wilkins, dean of SSW. The grant funds allow these faculty "fellows" to spend one day a week during the academic year on substance abuse-related work.
"These faculty development grants were first awarded in the 1980s to medical schools to ensure that faculty were equipped to teach about alcohol and drug abuse," says Amodeo. "But the grants were later extended to include schools of social work and nursing and psychology departments when the funders learned that, as in medical schools, faculty in these disciplines had little expertise in assessment and intervention methods."
SSW's five faculty fellows are also involved in individual projects. Clay is part of a research team that evaluates an addiction research project sponsored by the Boston Public Health Commission. In an "internship" at the Harvard Pilgrim Health Plan, Perlstein has been assessing and treating substance abusers within a managed-care model. Shulman has been coleading a recovery group for HIV-infected substance abusers. Stevens has conducted research with African-American teenage girls, examining their views on drinking and drug use. Peebles-Wilkins has worked with the American Association of State Social Work Boards to conduct a national survey on impaired social workers.
These professors also attend a twice-monthly seminar led by Professor Melvin Delgado, codirector of the faculty development program. "The seminar serves an academic purpose, covering prevention and treatment methods," says Delgado. "It also provides a forum for us to discuss major issues in the field, along with individual faculty members' work and research. It's a great way to get feedback."
Delgado says that until recently there have been few social workers with expertise on substance abuse. "Historically, it's as though the problem didn't exist. For years the subject of substance abuse has come up in the classroom, and we've addressed it as best we could. The issue has been on the national agenda for more than 15 years, but the field has been slow in responding. Some of us have experience in this area, but it isn't comprehensive. But a grant like this in many ways epitomizes all the best of academe: it gives faculty members an opportunity to learn and then to teach each other and students what we have learned."