Improving Substance Abuse Screening and Intervention in a Primary Care Clinic

Improving Substance Abuse Screening and Intervention in a Primary Care Clinic Lori A. Neushotz and Joyce J. Fitzpatrick Despite recent efforts to educate primary care providers in the identification and management of patients presenting with substance abuse problems, many opportunities to identify and intervene with these patients are overlooked. This project was designed to identify factors that interfere with rates of screening and brief intervention (SBI) of substance abuse problems in a primary care clinic in a major academic medical center in New York City. Six informants representing the disciplines of medicine, nursing, and social work in the primary care clinic provided information regarding SBI. Analysis was focused on substantiation of the need for enhanced diffusion of knowledge related to screening for substance abuse problems to improve rates of SBI in primary care. Recommendations for improvement included continued promotion of SBI by influential role models and opinion leaders, improvement in primary care providers’ perceptions of the perceived characteristics of SBI to improve rates of adoption, implementation of interdisciplinary educational initiatives toward the goal of improving rates of SBI in the primary care clinic, and initiation of translational research at the clinic supporting SBI in primary care. D 2008 Elsevier Inc. All rights reserved.

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UBSTANCE ABUSE PROBLEMS are a serious medical and public health issue responsible for increasing levels of morbidity and mortality as well as a considerable burden of disease in the United States and worldwide (Holman, English, Milne, & Winter, 1996). The 1996 U.S. Preventative Services Task Force recommended screening for alcohol dependence, abuse, and risky or harmful drinking by health care workers (Conigliaro, Lofgren, & Hanusa, 1998). The National Institute on Alcohol Abuse and Alcoholism [NIAAA] (2003, 2005) recommended that all primary care patients be screened for From the New York, NY, and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. Address reprint requests to Lori A. Neushotz, DNP, RN, CASAC, Mount Sinai Medical Center, Gustuve Levy Place, New York, NY 10079. E-mail address: [email protected] n 2008 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$34.00/0 doi: 10.1016/j.apnu.2007.04.004

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alcohol use. The New York City Department of Health and Mental Hygiene (2005) offered a continuing medical education program to New York State licensed physicians and nurse practitioners (NPs) promoting screening and brief intervention (SBI) of all primary care patients for alcohol problems. Screening and brief intervention is a cliniciandelivered counseling technique that helps patients reduce risky behavior (NIAAA, 2005). It is a fourstep nonconfrontational, nonjudgmental, and matter-of-fact approach that assesses current alcohol use, assesses for current abuse or dependence problems (American Psychiatric Association, 2000), provides patients with advice and assistance to maintain healthy use, and provides follow-up to support efforts to maintain positive changes. The principles of SBI may be applied to address problematic use of other drugs of abuse. The NIAAA (2005) standards identify problem drinkers as those who consume more than the recommended daily, weekly, or per-occasion

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amounts of alcohol. Maximum recommendations are 1 standard drink per day (12 oz. of beer, 5 oz. of wine, or 1.5 oz. of distilled 80% proof spirits) for adult women and persons older than 65 years not to exceed 7 drinks per week and 2 drinks per day for adult men not to exceed 14 drinks per week. Risky or binge drinking is identified as intake of more than 4 drinks per drinking episode for women and 5 drinks for men, not necessarily exceeding the weekly maximum of 14 drinks recommended by the NIAAA. Illicit drug use is a contributing factor to many health-related consequences, including the transmission of HIV/AIDS, hepatitis B and C, and tuberculosis (National Institute of Drug Abuse, 2003). In this project, any illicit drug use was classified as problematic, including abuse of prescription medication and use of illicitly procured street drugs. SUBSTANCE ABUSE SCREENING

Primary health care is a natural setting for screening alcohol-related health problems and substance abuse problems (Miller, Ornstein, Nietert, & Anton, 2004). Primary care providers (PCPs) are in a unique position to address substance abuse problems, either at the early stages of problem use or at later stages when comorbid health and psychological distress occur. However, PCPs often fail to recognize alcohol and other substance abuse problems or intervene appropriately when problems are suspected (Anderson et al., 2004). Several screening tools and instruments are available to assist in screening for a potential abuse or addiction problem. Patient self-report of substance abuse is the means used by many PCPs to screen for substance abuse; however, the reliability and validity of self-reports are questionable (Magura & Kang, 1996). Although self-report tests and quantity/frequency questions are useful in assessing current problematic drug and alcohol use, patient self-report may be impeded by fears of stigmarelated concerns and potential consequences. The CAGE alcohol use screening tool is the most widely researched and used screening tool because of its brevity and reliability (Saitz, 1999; Saitz et al., 2002; Saitz, Horton, Sullivan, Moskowitz, & Samet, 2003). CAGE screening is relatively nonconfrontational and may be completed in less than 1 minute. A positive response to one or two questions signifies a possible alcohol problem,

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whereas a positive response to three or four questions signifies probable alcohol dependence. CAGE is a mnemonic for the following questions that make up the screening: 1. Have you ever thought you should cut down on your drinking? 2. Have you ever become annoyed when people criticized your drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever taken an eye-opener drink to feel better in the morning? Laboratory biomarkers are also recommended to assist in the detection of substance abuse problems (Miller et al., 2004). Abnormal findings, including elevations in mean corpuscular volume, gammaglutamyltransferase, and carbohydrate-deficient transferring, may signify problematic drinking (Miller, 2004). Urine toxicology screening may confirm provider concerns of an active substance abuse problem. EDUCATION

Educational efforts have been underway for the past 10 years to enhance providers' knowledge of addiction and SBI. Both nursing and medical school education programs have incorporated addictions components to their curricula (Arthur, 1998; Miller, Sheppard, Colenda, & Magen, 2001). Educational interventions have been shown to improve identification of substance-abusing patients in primary care settings (Talashek, Gerace, Miller, & Lindsey, 1995). Educational efforts may not impact provider attitudes toward substanceabusing patients; instead, provider attitudes may contribute to inadequate SBI of substance abuse problems presenting in the primary care setting (Happell & Taylor, 2001; Miller et al., 2001). Selfreported attitudes of 340 general practitioners from four countries participating in a World Health Organization randomized and controlled trial (Anderson et al., 2004) were measured to evaluate the effectiveness of training and support in increasing rates of SBI. The findings confirmed that training in SBI increased rates of SBI only for practitioners who were secure and committed to working with drinkers. Despite recent efforts to educate PCPs in the identification, recognition, and management of

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primary care patients misusing and abusing alcohol and other substances, many opportunities to identify and intervene with patients presenting with problem drinking and substance abuse in the primary care setting are overlooked (Gassman, 2003). Maximizing the adoption of evidencebased practice has been argued to be a major factor in determining health care outcomes. Gaps between evidence-based recommendations and current care are not achieved simply by informing clinicians about the evidence (Sanson-Fisher & Robert, 2004). ROGERS' THEORY OF DIFFUSION

This project was focused on the identification of factors that interfere with the diffusion of SBI in the primary care clinic of a major academic medical center. The theory of diffusion of innovations set forth by Rogers (2003) provided the framework to effect adoption of best evidence SBI practice. Diffusion is the process through which an innovation is communicated through certain channels over time among the members of a social system (Rogers, 2003). The main elements of diffusion are (1) an innovation, (2) communication channels, (3) time, and (4) a social system (Figure 1; Rogers, 2003). The characteristics of an innovation that determine the probability and speed of its adoption are relative advantage, compatibility, complexity, trialability, and observability (Rogers, 2003). Relative advantage is the extent to which the innovation is perceived to be better than current practice. Decisions about implementing best evidence practice are driven not only by patient welfare but also by the interplay between the interests of the patient,

the clinician, and the health care system (SansonFisher, Robert, 2004). Preventive interventions such as substance abuse screening are low in relative advantage and generally slow to be adopted. The rewards are delayed in time and relatively intangible, and the unwanted consequence may not occur (Rogers, 2002). Compatibility is the extent to which the innovation is perceived to be consistent with values, experience, and current needs (Rogers, 2003). The innovation must address an issue that clinicians or others may perceive to be a problem to increase the probability of its adoption. Substance abuse screening is compatible with the patient population at this major medical center as evidenced by the growing population of HIV-positive and hepatitis C-positive patients. Complexity is the degree to which the innovation is difficult to see or understand (Rogers, 2003). Simple and well-defined procedures are more likely to be adopted as compared with more complex ones (Sanson-Fisher, Robert, 2004). Substance abuse detection and intervention are highly complex activities. Attempts to intervene are hampered by patients' resistance and lack of accuracy in self-reporting. Clinicians may have insufficient expertise in the consulting skills necessary to achieve change (Sanson-Fisher, Robert, 2004). Trialability is defined by Rogers (2003) as the degree to which the innovation may be tested and modified. This allows time for clinicians to explore the implementation of the procedure, its acceptability to patients, and the potential outcomes. Observability is the degree to which the innovation results are visible to others. Visibility of an innovation stimulates peer discussion—if respected and influential clinicians argue

Fig 1. Elements of diffusion.

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for and demonstrate application of the innovation (Sanson-Fisher & Robert, 2004). For this project, communication channels supporting the diffusion of SBI were evaluated. The social system of the primary care clinic was analyzed to identify structures and norms supporting and/or interfering with SBI. The project sought to identify opinion leaders and change agents supporting SBI. The rate of adoption of SBI to current PCP practice was also evaluated, and potential difficulties experienced by providers in achieving best evidence SBI practice were identified. LITERATURE REVIEW

The overall incidence rate of substance abuse problems, primarily alcohol problems, presenting in primary care settings has been noted to be generally between 7% and 8% (Olfson, Tobin, Cassells, & Weissman, 2002). Research had demonstrated substance abuse rates as high as 11%–16% in low-income immigrant patient populations (Miranda, Azocar, & Komaromy, 1998; Parker, Mat, & Maviglia, 1997). Davis, Bush, Kivlahan, Dobie, and Bradley (2003) reported on substance abuse rates as high as 31.1% in a population of female veterans. The literature confirms that simple screening tools may identify substance abuse problems in patients presenting to primary care. Primary care providers' recommendations regarding alcohol consumption may significantly decrease rates of consumption. A body of evidence suggests that screening interviews alone may not be adequate in identifying substance-abusing patients as a result of discrepancies in patient self-reports (Magura & Kang, 1996). There is an abundance of literature and research addressing PCPs' knowledge of substance abuse screening tools, specifically for alcohol, in primary care settings (Edlund, Unutzer, & Wells, 2004; Miller et al., 2004). Patient self-report of substance abuse has been the means used by many institutions to screen for substance abuse; however, the reliability and validity of selfreports are questionable. Magura and Kang presented a meta-analytical review of 24 studies since 1985 that examined the validity of drug self-reports in high-risk populations. Only studies using a biological criterion of validity, including urine toxicology and hair analysis, were included. Studies measuring self-report only were excluded;

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although they may be internally consistent and reliable, they may not be valid (Magura, 1996). Self-report validity varied greatly and could not be predicted from study to study. The authors concluded that the magnitude of drug use underreporting could seriously bias prevalence estimates and treatment outcome studies. Research unequivocally had supported the benefit of SBI for problem drinking in the primary care setting. Whitlock, Pollen, Green, Orleans, and Klein (2004) systematically reviewed the literature for evidence of the efficacy of brief intervention for alcohol abuse in the primary care setting. They concluded that behavioral counseling by PCPs for risky and harmful alcohol abuse could provide an effective public health approach to reducing risky and harmful alcohol use. The meta-analytical research by Ballesteros, Duffy, Querejeta, Arino, and Gonzalez-Pinto (2004) confirmed the findings of Whitlock et al. (2004). The efficacy of brief intervention for hazardous drinking in primary care settings was calculated by an intention-to-treat approach. Of potentially 739 randomized trials representing four countries (United States, United Kingdom, Australia, and Spain), 13 were chosen for dose effect analysis. Brief interventions outperformed minimal interventions and usual care. The findings confirmed previous meta-analyses producing positive findings on the efficacy of brief interventions. Aalto, Pekuri, and Seppa (2003) examined obstacles to the identification and intervention of alcohol-misusing patients presenting to primary care in Finland. Six focus groups involving 18 general practitioners and 19 RNs were recruited to explore obstacles. A deductive reasoning framework was applied to identify obstacles; lack of information regarding early-stage drinking problems, lack of self-efficacy, lack of time to carry out SBI, lack of guidelines for SBI, and uncertainty about justification for discussion regarding alcohol abuse were identified as the primary obstacles to SBI. Obstacles to SBI in primary care settings include but are not limited to lack of providers' knowledge and self-efficacy (Miller et al., 2004), attitudes, lack of clear and concise guidelines for SBI (Aalto et al., 2003), lack of time, and lack of psychiatric referral sources (Trude & Stoddard, 2003). Educational initiatives to enhance providers' knowledge and decrease the stigma associated with substance abuse incorporate

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experiential learning with a person in recovery from a substance abuse problem. In 2002, Rogers focused attention on substance abuse prevention. Under ordinary conditions, the diffusion process for an innovation, even one with considerable relative advantage, requires a lengthy period. Preventive innovations are new ideas that require action at one point in time to avoid unwanted consequences at some future time (Rogers, 2003). Thus, preventive innovations are relatively slow to be adopted. The rewards to the individual from adopting a preventive innovation are delayed in time and relatively intangible, and the unwanted consequence may not occur anyway. PROJECT ANALYSIS

The analysis took place from January to April 2006 in the primary care clinic of a major metropolitan academic hospital in New York City. The clinic is staffed by 197 physician PCPs (MD PCPs), composed of 37 attending physicians and 160 residents. In addition, 3.6 NP PCPs also provide primary care services. One social worker (SW) is on site to address the mental health issues of all clinic patients. Seven RNs are employed at the clinic. The total patient clinic population is 11,688. Primary care providers treat an average of 1,500 patients per week. Patients aged between 18 and 65 years are provided with primary care treatment at the clinic. Seventy percent (n = 8,182) of the patients are female, and 30% (n = 3,506) are male. Eighty-five percent (n = 9,935) of the patients are unemployed and living under the poverty level. Fifty-five percent (n = 6,428) of the patients are Hispanics, predominantly Puerto Ricans; in addition, 35% (n = 4,090) are African Americans, 7% (n = 818) are Caucasians, and 3% (n = 351) are of other ethnic origins. Eighty percent (n = 9,340) of the patients are Medicaid recipients; the rest (n = 2,348) are insured privately or by Medicare. Statistics measured at the clinic showed that 19% (n = 190) of 1,000 patients randomly screened speak Spanish only; the other 81% (n = 810) speak English or are bilingual. This analysis used the principles of process research, a type of analysis that seeks to determine the time-ordered sequence of a chain of events over time (Rogers, 2003). Historical information regarding substance abuse screening practices at the clinic over an 8-year period was extracted from meetings

with administrative and clinical staff at the primary care clinic. The departmental division chief, the nursing director, one physician PCP, one NP PCP, one RN, and one SW provided information regarding screening practices at the clinic. Recordings included the following information reported by the informants: ⁎ when substance abuse screening was initiated at the clinic; ⁎ what protocols, policies, and procedures for substance abuse screening were initiated and are currently in place; ⁎ what reinvention and improvements have been made; ⁎ how information regarding procedures and protocols for substance abuse screening is transmitted to PCPs at the clinic; ⁎ educational initiatives to improve screening practices; ⁎ continuing medical education activities provided to enhance clinicians' knowledge of symptoms of addictive illnesses and screening tools available to detect addictive illnesses; and ⁎ knowledge of PCPs regarding substance abuse SBI. Information was extracted from the notes of one initial 1-hour meeting with the nursing director of outpatient services and one initial 1-hour meeting with the medical division chief of the outpatient primary care clinic. Notes, records, and reflections of these meetings were recorded. Historical information and current practice guidelines regarding substance abuse screening at the primary care clinic were extracted from clinic records. Current screening tools, including the patient self-report form completed at the time of admission to the clinic, were analyzed in accordance to current screening tools recommended in the literature. Application of the elements of diffusion theory guided an analysis of the diffusion of SBI at the primary care clinic. The recall problem was specifically a concern in this project because data collection incorporated historical and retrospective information regarding substance abuse screening at the medical center. Diffusion research is dependent on historical data to determine the date of adoption of new ideas; this retrospective analysis has limitations. Rogers (2003) recommended gathering data at various periods during the diffusion process to significantly reduce recall bias. In this project, retrospective data

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Table 1. Informant Responses

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Table 1. Continued

Elements of Rogers' Diffusion of Innovations

Elements of Rogers' Diffusion of Innovations

Innovation Section 1: Perceived characteristics Relative advantage Benefit to patient—Improved health and treatment of addictive illness; some patients resent screening, fear stigmatization, and resist recommendations for treatment: may harm patient–PCP relationship, and patients may drop out of treatment. Benefit to clinician—Clinicians in need of established and standardized screening tools for SBI; clinicians treating medically compromised patients, many health issues, and screenings required in limited time during office contact: difficulty referring patients identified as problematic Benefit to institutions—Substance abuse is an exclusion criterion for most research. Compatibility All informants believe that addiction is a treatable illness. Most informants have worked with addicted individuals throughout their clinical experience. Most informants believe that substance abuse problems are underidentified in the primary care clinic. Substance abuse incidence in high-risk hepatitis C population estimated at 40% of patients with active abuse and at 80% of those with history of abuse. Complexity Inaccurate patient self-report. Lack of clear and established SBI guidelines. PCPs unfamiliar with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnostic criteria for addiction, as well as knowledge deficit regarding symptoms of substance abuse problems and street slang Difficulty with obtaining referral sources. Trialability Patients resist divulging substance abuse. Self-report screening inadequate; CAGE also recommended. Clinic has and will continue to modify screening. Providers rely on social work and psychiatry to assist with SBI. Research initiatives to support SBI recommended. Observability Provider inconsistency in SBI; physician and PCP informants rate provider consistency in screening more favorably as compared with other respondents. SBI has improved; need for further improvement. Informants other than PCPs and physicians unaware of current CAGE screening done by PCPs. Completed by patient before PCP encounter; PCP initials form after review. CAGE screen now recommended in addition to self-screening. Communication Section 1: Interpersonal channels Policies and procedures related to SBI transmitted orally to PCPs and in orientation to the clinic. Faculty supports SBI in residency training; series of lectures regarding SBI incorporated in residency training program. Residency training program promotes use of self-screening tool and CAGE to identify substance abuse problems and encourages referral to specialist treatment as indicated.

Communication Section 1: Interpersonal channels Lectures specific to substance abuse screening and detection, treatment management, and referral provided in residency training. Grand rounds and case conference presentations address substance abuse problems. Nursing and social work informants express need for specialist-provided continuing medical education to provide knowledge related to addiction and promotion of SBI. Section 2: Mass media channels Informants claim familiarity with literature available in journals and New York City continuing medical education program Informants unsure of individual providers' knowledge of current literature. Express interest in literature recommendations to enhance knowledge of addictive illness and SBI. Time Substance abuse screening form was initiated at the clinic 8 years ago. Initially open-ended questions. Form updated in 2004: quantity/frequency questions as well as current and past drug use questions incorporated; CAGE screening recommended since 2005. Social System The clinic is staffed by 197 MD PCPs, composed of 37 attending physicians and 160 residents; in addition, 3.6 NP PCPs also provide primary care services. One SW is on site to address the mental health issues of all clinic patients, and seven RNs are employed at the clinic. Clinic was previously staffed by three SWs and two psychiatrists to address mental health problems presenting within the patient population. Institutional downsizing 3 years ago resulted in loss of all but one social work position. SBI was promoted by attending faculty in the residency program. Eight of 30 physician faculty completed faculty development educational series related to SBI. Collaboration with substance abuse specialists is available.

were compiled from several sources to increase the reliability of the information provided. FINDINGS

Variable informant responses regarding knowledge of and consistency in SBI were discovered relative to discipline. Seventy percent of the informants reported that quantity/frequency selfreport screening was done routinely. Physicians and SWs reported that screening occurred in 87%–90% of patient assessments; nurses reported a 25% compliance rate only. Informants reported that CAGE screening was done routinely only 44% of the time; physicians reported greater compliance rates than did nurses and SWs (MD PCPs, 85%;

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Fig 2. Obstacles to SBI.

RNs, 25%; SWs, 0%). Only physicians agreed that knowledge of addictive illness was adequate (MD PCPs, 100%; RNs, 0%; SWs, 0%) and that educational initiatives regarding SBI were provided (MD PCPs, 100%; RNs, 33.3%; SWs, 0%). Respondents all reported a need for collaboration with psychiatry (83%), referral sources (66%), and continuing medical education (83%). Informant responses were analyzed using Rogers' diffusion theory as a framework. The findings support that perceived characteristics of SBI may impact the rate of diffusion at the clinic. Informants perceived relative advantage as low, compatibility and complexity as high, and trialability and observability as low (Table 1). Research had substantiated that innovations with low relative advantage that are highly complex diffuse slowly over time. Respondents identified obstacles to SBI (Figure 2), including inaccurate patient self-report (100%), stigma (50%), lack of providers' knowledge regarding SBI (66%), lack of standardized screening tools (66%), limited time to address multiple complex medical issues (50%), and lack of referral sources (66%). SUMMARY

In summary, previous research had substantiated rates of substance use disorders presenting in primary care to be generally between 7% and 8%, with certain high-risk populations presenting in the 11%–31% range. Primary care providers have a unique opportunity to intervene with patients presenting to primary care for comorbid health conditions related to substance abuse problems but often do not intervene appropriately. Complex challenges to SBI in primary care remain, including lack of PCPs' knowledge and efficacy, lack of time

to perform SBI, lack of clear and established guidelines for SBI, and lack of adequate and available referral sources. Although educational initiatives have been found to improve rates of SBI, more sustained effort is required. Bridging the evidence gap will not be achieved simply by informing clinicians about the evidence (Sanson-Fisher, Robert, 2004). Rogers' diffusion model argues that the characteristics of an innovation facilitate its adoption. Other factors influencing acceptance include promotion by influential role models, the degree of complexity of the change, compatibility with existing values and needs, and the ability to test and modify the innovation before adopting it (Sanson-Fisher, Robert, 2004). Research had shown that perceived relative advantage was the most important predictor of the rate of adoption of innovations (Rogers, 2003). Landrum (1998) advised that examining the perceived attributes of an innovation provides an opportunity to modify the innovation and strengthen the probability of its adoption. Advanced practice RNs specializing in addictions are in a unique position to promote SBI in primary care by providing educational and collaborative support to PCPs. Rogers (2002) recommended strategies to diffuse preventive interventions, including the following: ⁎ Change the perceived attributes of preventive innovations. Stress the relative advantage of screening to identify substance abuse problems. ⁎ Use champions to promote preventive innovations. Champions are persons of influence who encourage adoption of innovations within an organization. ⁎ Change the norms of the system regarding preventive innovations through peer support. Changing norms is a gradual process. ⁎ Use entertainment and education to promote preventive innovations. ⁎ Activate peer networks to diffuse preventive innovations. Diffusion is a social process of people talking about an innovation, giving it meaning, and then adopting the practice. IMPLICATIONS FOR NURSING

The prevalence of alcohol and substance abuse problems among patients presenting to primary health care mandates clinical competence in the

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area for NPs (Talashek et al., 1995). Nurses at all levels of practice form a core component of many health systems; their role in responding to problems related to substance abuse is crucial. Although the number of NPs providing primary care services is growing, much of the available research address MD PCPs' knowledge and rates of SBI only. Future research focusing on NPs knowledge and use of SBI to identify and intervene with substanceabusing patients is recommended. Although training and career preparation should encompass the development of innovative strategies and taking a leading role in the management of substance abuse patients (Nkowane & Saxena, 2004), content and clinical experiences with substance abusers were previously identified as lacking and needing to be provided through education (Miller et al., 2004; Naegle, 1983). Advances have been made in the addition of substance abuse curricula to nursing and physician education (Arthur, 1998; Gerace, Hughes, & Spunt, 1995), but research had confirmed that content remains inadequate (Arthur, 1998), with most educational programs incorporating only 4– 12 hours of substance abuse content. Advanced practice psychiatric nurses specializing in addictions are in a unique position to facilitate the diffusion of SBI for substance abuse problems and provide collaborative support to PCPs. Establishing collegial relationships and partnerships between primary care and psychiatry was recommended and has been initiated. Certified addictions RNs, clinical nurse specialists, and NPs specializing in addictions may provide educational and collaborative support to PCPs in hospital and outpatient settings. Recommendations include educational initiatives supporting and incorporating the principles of SBI in grand rounds and in-service presentations. Finally, nurses need to be involved at the administrative level in developing policies that support SBI. REFERENCES Aalto, M., Pekuri, P., & Seppa, K. (2003). Obstacles to carrying out brief intervention for heavy drinkers in primary health care: A focus group study. Drug and Alcohol Review, 22(2), 169–173. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.–TR). Washington, DC: American Psychiatric Press.

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