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Substance abuse intervention services in public STD clinics: A pilot experience
Journal of Substance Abuse Treatment 34 (2008) 356 – 362
Regular article
Substance abuse intervention services in public sexually transmitted disease clinics: A pilot experience Jiang Yu, (Ph.D.)a,4, Philip W. Appel, (Ph.D.)a, Barbara E. Warren, (Psy.D.)b, Steve Rubin, (B.A.)c, Rodolfo Gutierrezc, Brett Larson, (M.A.)d, Harold Robinson, (B.A.)d a
New York State Office of Alcoholism and Substance Abuse Services, Albany, NY 12203, USA The Lesbian, Gay, Bisexual, and Transgender Community Center, New York, NY 10011, USA c New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control, New York, NY 10001, USA d New York City Department of Health and Mental Hygiene, Bureau of HIV Prevention and Control, New York, NY 10013, USA b
Received 26 March 2007; received in revised form 16 April 2007; accepted 1 May 2007
Abstract Past research reported a gap in substance abuse treatment for patients in sexually transmitted disease (STD) clinics. Studies in New York City indicate that approximately 20% of patients with STD show symptoms of alcohol and substance abuse, but only 1% have ever received treatment services. This article reports findings from a pilot project that implemented early intervention service procedures in an STD clinic in New York City. Services implemented included screening for substance use problems, brief interventions, and referral for treatment. Four main issues were explored in this pilot study: the feasibility of implementing early intervention services in an STD clinic; the extent to which patients would accept such interventions; the extent to which STD staff would be ready to integrate substance abuse services into their primary care protocols; and the likelihood of sustaining such services in an STD environment. Results and recommendations are provided and discussed. D 2008 Elsevier Inc. All rights reserved. Keywords: Substance abuse screening; Intervention services; Service implementation; STD clinics
1. Introduction 1.1. Substance abuse interventions in sexually transmitted disease clinics There is a significant gap between the prevalence of possible substance disorders among patients of sexually transmitted disease (STD) clinics and their current receipt of substance abuse treatment or related services. Research
The opinions and conclusions expressed in this article are those of the authors and do not necessarily reflect those of the New York State Office of Alcoholism and Substance Abuse Services, the New York City Department of Health and Mental Hygiene, and the Lesbian, Gay, Bisexual, and Transgender Community Center. 4 Corresponding author. New York State Office of Alcoholism and Substance Abuse Services, 1450 Western Avenue, Albany, NY 12203, USA. 0740-5472/08/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2007.05.005
indicates that about 20% of patients in public STD clinics display evidence of possible substance disorders, but only 1% are currently receiving treatment services (Appel, Piculell, Jansky, & Griffy, 2006). Thus, introducing formal substance abuse intervention services in STD clinics has great potential for identifying many individuals at risk for the adverse consequences of substance disorders.1 Past research has reported that screening and brief interventions tend to decrease the frequency and severity of drug and alcohol use, to reduce the risk of trauma, and to increase the likelihood of seeking specialized substance abuse treatment among patients in emergency rooms and
1 The term bsubstanceQ is used in this article to indicate both drugs and alcohol, and the term bdisorderQ is used in this article to indicate abuse and dependence, unless otherwise indicated.
J. Yu et al. / Journal of Substance Abuse Treatment 34 (2008) 356 – 362
other primary care settings, leading to fewer hospital days and emergency room visits (Welte, Perry, Longabaugh, & Clifford, 1998). Cost–benefit and cost-effectiveness analyses, on the other hand, have also demonstrated net cost savings from these interventions (Substance Abuse and Mental Health Services Administration, 1999). Compared to emergency rooms and other acute care environments, STD clinics pose both unique opportunities for and unique challenges to providing intervention services. Similar to emergency room settings where the early intervention service model was developed (New York State Office of Alcoholism and Substance Abuse Services [NYS OASAS], 1996), the STD environment is pressure packed, the volume of patients is high, and most patients deal with acute physical symptoms and mental anguish. However, unique to the STD environment, patients usually have a strong immediate primary concern of a possible STD diagnosis, and added to their stress is an even more serious concern of testing positive for human immunodeficiency virus (HIV). Patients with STD are anxious to see a physician, to receive medical treatment, and to leave the clinic. Given these characteristics, STD clinics are likely to be overburdened with various services for patients’ primary care needs, and patients may be unwilling to address issues and to accept services other than the primary care they are seeking. Without adequate previous research and well-disseminated projects, the feasibility of conducting substance abuse intervention services in an STD clinic environment remains unclear and untested. 1.2. Research issues As the risks of STD and HIV infections are significantly increased by substance disorders, public health and substance abuse treatment communities are challenged to provide effective intervention and treatment services for the STD population. To this end, researchers and practitioners from three leading service agencies in New York City designed and conducted a pilot project that aimed to implement substance abuse intervention services in STD clinics. The pilot project was developed to explore four areas: (1) the extent to which early intervention services can be implemented and institutionalized in an STD clinic where patient volume is high and the time interval for service is brief; (2) the extent to which patients would accept substance abuse interventions when their primary concern is of an acute STD nature that generates much distress and embarrassment; (3) the extent to which STD staff would be ready to integrate substance abuse intervention services into their already overburdened service protocols; and (4) the extent to which implemented services would be effective in terms of engaging, screening, and counseling patients. The pilot project was conducted in one of the public STD clinics in New York City during the early summer of 2005.
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2. Methods 2.1. Identifying intervention models Introducing substance abuse intervention services in primary health care and other nontreatment settings has become a major focus, as shown in the federal Screening, Brief Intervention, Referral, and Treatment (SBIRT) initiative. A principal source of the SBIRT initiative was New York State’s Healthcare Intervention Services (HIS) model, which is the core design element of this pilot study. As early as 1989, the NYS OASAS introduced HIS in a statewide demonstration to test an early intervention approach to substance abuse problems in the primary health care environment. This was initiated at hospital inpatient and outpatient sites, in urban, suburban, and rural locations. Within 3 years, it expanded from 9 to 17 hospitals (NYS OASAS, 1996). The HIS program model focuses on identifying the substance abuse problems of individuals presenting in health care settings outside the treatment system to: (1) engage persons who may be experiencing, or are at risk for developing, substance disorders; (2) determine the nature and extent of substance problems; (3) provide appropriate intervention based on preliminary assessment; and (4) arrange for the appropriate placement of persons in need of treatment. Routine screening tools are brief, nonthreatening, and specific for the population served. Common screening tools include the CAGE Questionnaire (Ewing, 1984), TWEAK (Russell, 1994), and T-ACE (Sokol, Martier, & Ager, 1989; Substance Abuse and Mental Health Services Administration, 2005). Medical history, physical symptoms, and behavior cues can also be reviewed as part of the screening protocol. Individuals who screen positive are then assessed by an addiction professional. Preliminary assessment is designed to establish whether a substance abuse problem exists. Information from the patient is obtained through a face-to-face interview performed by an addiction professional dedicated to providing HIS services. The addiction professional, known as an binterventionistQ in the HIS service model, elicits information to determine the extent of the problem and the most appropriate intervention. Preliminary assessment includes using criteria for substance disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). The interventionist may conclude that the patient has no problem, is at risk of developing one, or suffers from abuse or dependence. A brief intervention is conducted for patients determined to be at risk for developing a substance problem. The goals of a brief intervention are to increase the patient’s awareness of the hazards associated with substance use and to decrease the substance-using behavior. Strategies of motivation to change are employed in the intervention process. Brief interventions are usually performed one-to-one, and the
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number of sessions varies depending on the setting and the population served. A full intervention, which includes determining the preliminary level of care, motivating the patient to accept a referral for treatment, developing placement options, making referrals, and following up with treatment progress, is conducted for individuals with substance disorders (NYS OASAS, 1996). 2.2. Including BMI in the service model Patients with STD visit public clinics to seek immediate medical consultation and relief, and are unlikely to return to the clinic for a follow-up other than the one directly related to their STD condition. As a result, any effort to intervene with the substance abuse problems of patients with STD in a clinic environment presents the challenge that the delivery of services must be completed during the patient’s primary health care visit. To cope with this challenge, the brief motivational intervention (BMI) technique would be used as the main vehicle of service delivery. BMI has been successfully employed in encouraging patients in primary care medical settings who screened positive for cocaine or heroin abuse to accept a referral for treatment. The length of BMI sessions varies from 5 to 40 minutes and averages 10–20 minutes. Studies reported significant reductions in heroin and cocaine use after a BMI while patients were waiting for laboratory test results or to speak with their physician about a health concern (Bernstein, Bernstein, & Levenson, 1997; Bernstein et al., 2005). In the pilot design, service delivery through BMI involves the following steps: (1) Establishing rapport: After mutual introductions, the interventionist asks the patient his or her reasons for involvement and his or her expectations of the session. (2) Asking permission to discuss drugs: The interventionist discusses with the patient the purpose of the intervention to further engage the patient. (3) Discussing the pros and cons of substance use: The interventionist discusses with the patient his or her reasons for using substances and for quitting or cutting down on substance use. (4) Discussing the gap between continuing to use drugs and the patient’s desired quality of life: The interventionist elicits from the patient what he or she feels the pros are in using substances, as well as his or her perceived barriers to quitting substance use. (5) Negotiating an action plan: The interventionist discusses with the patient his or her past success in making important life changes and how he or she achieved it. (6) Making a referral: The interventionist provides the patient with information and options on treatment services.
(7) Evaluation: Finally, the interventionist asks the patient to fill out an evaluation of the session, which includes a readiness-to-change survey. 2.3. Implementing services in STD clinics Between May and July 2005, intervention services were piloted three mornings a week at the participating STD clinic. When prospective patients registered at the clinic, they filled out a screening form that included a modified CAGE (the core CAGE-A questions were asked relative to the past 30-day and the past 12-month time frames), questions on their demographics, whether they had health care insurance, and whether they had previous substance abuse detoxification or treatment experiences. For this particular pilot, only patients who registered and who expected to see the physician were screened. The back of the modified CAGE form was a patient disposition form indicating whether the patients scored positive or negative; whether they wanted to speak with the on-site interventionist (and, if they did, whether they reported to the interventionist); and the intervention services they received. The registration materials, including medical records and the modified CAGE form, would go to a public health adviser (PHA) who would score the screening form. Using the patient disposition form, the PHA would ask a patient who screened positive whether he or she might want to talk to an interventionist (counselor) about substance disorder issues. The PHA would take the patient to the phlebotomy station for further treatment and forward the patient’s screening disposition form to the interventionist. Because there is usually a waiting period between the phlebotomy and the doctor’s examination, this interval was the most opportune time to conduct substance abuse interventions. The interventionist, after receiving and reviewing the screening disposition form, would call the patient by his or her triage number for consultation. When providing intervention services during this time, the interventionist would reassure the patient that he or she would not miss his or her appointment with the doctor and that his or her primary health care concern would be addressed. The interventionist would use the answers to the modified CAGE as a basis for directing one’s efforts to engage the patient. After consulting with the patient, the interventionist would ask that patient to complete a satisfaction survey, which included an item on readiness to change substance use immediately and intention to follow through with any referrals for substance abuse treatment or other action steps discussed. Then the patient would report to the physician for primary care. If a patient was highly resistant to consultation or refused to engage beyond the initial BMI steps, the session was terminated and the patient was given a printed resource/ referral brochure. The session would be recorded as bassess and refer onlyQ without a BMI.
J. Yu et al. / Journal of Substance Abuse Treatment 34 (2008) 356 – 362
At the end of each day of service, the interventionist would retrieve the disposition forms from the PHA for those patients who screened negative and would file them with other materials for further analysis.
3. Results 3.1. Results of screening Table 1 presents the general screening results. During the pilot period, 285 patients were offered screening forms, and 97% participated in the screening process. Twenty-one percent of those who participated in the screening had a positive screening result (i.e., they scored at least one positive on one of the two sets of the original four CAGE items, with one set being within the period of past 30 days and the other being within the period of past 12 months). Fifty-six percent of the patients who screened positive accepted an offer to speak with, and were counseled by, the interventionist. Nonresponses from patients could be attributed to some procedural issues, in addition to the patients’ refusal of the intervention. For instance, three patients were paged but did not respond; in two instances, the patients’ screening forms were late in reaching the interventionist; and one other patient could not be paged because the clinic triage number was omitted on the screening form. The demographic information about the screened patients is contained in Table 2. Several characteristics are observed. The majority of the patient sample is male (70%), and close to half contains ethnic minorities. Because of the location of the clinic, homosexual and bisexual patients make up a relatively large proportion of the total patient sample (27%). The average age of the sample is 28 years. Table 2 also indicates a higher percentage of male patients in the positive group than in the negative group. Homosexual patients are less likely to score positive. Furthermore, Asian patients seem to have a higher representation in the positive group compared to their proportion in the total sample. 3.2. Results of counseling To measure patients’ responses to the intervention process, those who consulted the interventionist were surveyed with a questionnaire (satisfaction survey), which was developed to examine each specific component of the BMI strategy used in the pilot project. The satisfaction survey examined how patients were treated by STD clinic staff; how they felt when staff brought up the subject of Table 1 Screening results Number Number Number Number
of of of of
clients clients clients clients
offered screening screened who screened positive who accepted intervention
285 276 57 32
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Table 2 Demographic information of screened patients
Characteristics Gender Male Female Race African American Asian Caucasian Latino Unknown Sexual orientation Heterosexual Homosexual Bisexual Unknown
Total (N = 251) [%]
Screened positive (n = 32) [%]
Screened negative (n = 219) [%]
71 29
78 22
70 30
21 7 46 20 7
17 12 43 17 11
22 6 46 20 6
63 25 10 2
66 17 12 5
63 27 9 1
substance issues; whether they thought giving patients help with possible substance problems in the clinic was a good idea; their readiness to change their substance use behavior on that day and to follow through with any help they received; and how helpful various aspects of the session with the interventionist were for them (Dunn, Deroo, & Rivera, 2001). A key issue in implementing a substance abuse intervention service is to be respectful of patients’ possible concerns regarding confidentiality and on being asked about a personal matter that was not the primary focus of their clinic visit. In this pilot, 97% of the patients seen by the interventionist reported that the staff were very respectful when talking to them about their substance use. Furthermore, although 34% were happy that the substance abuse issue was brought up because they were looking for information or other help, 45% were surprised that the substance abuse issue was brought up but indicated being comfortable with it. Especially noteworthy is that 87% felt that many patients with STD could benefit from similar services (Table 3). The satisfaction survey also assessed the perceived effectiveness of each of the BMI components of the intervention and the overall helpfulness of the session. Using a rating from 1 = not helpful 5 = very helpful, between 74% and 87% of the patients reported the session as being moderately helpful to very helpful in having Table 3 Patient satisfaction survey Survey item
% Confirmed
Staff were respectful Happy that the issue was addressed as one was looking for help Surprised that the issue was addressed but was comfortable Others attending the clinic would benefit from screening
97 34 45 87
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someone to talk to about their substance use (81%); in getting information about how substance use affects their health (74%); in discussing the pros and cons of their substance use (81%); in talking about their life in general and what they wished to change (81%); in making plans to change their substance use (74%); in getting referral and treatment information (73%); and overall (87%). Also included in the satisfaction survey were items on readiness to change substance use today and on the strength of intention to follow through with any help received. Regarding their readiness to change substance use today, 47% rated it z 8 on a scale of 1–10. Regarding the strength of their intention to follow through with any help received, 73% rated it 5 on a scale of 1–5 (1 = weak to 5 = strong). 3.3. Results of case analysis The substance abuse and related issues patients discussed with the interventionist provide a clinical context for the kinds of referral resources a fully implemented service may require. Patients readily discussed the particulars of their substance use and described the context in which they were using substances and their feelings and reasons for using substances. The BMI process encouraged patients to speak freely about their likes and dislikes around their substance use. In verbalizing contradictory information, patients were able to question their own assumptions about their use. The most frequent reasons given for drinking were: to relax, to be social, and to lower inhibitions. A significant number of patients also used drugs and alcohol to self-medicate for depression. A few respondents simply reported liking the taste of wine, beer, or hard liquor. In characterizing their drug and alcohol use, at least two thirds of the patients expressed varying degrees of concern about a current or past drug or alcohol problem. The overwhelming substance of choice was alcohol, and about 90% of the patients indicated significant concern about their alcohol use. Concerns ranged from the physical discomforts of occasional excessive use, to use frequently and regularly enough to involve blackouts and other serious physiological consequences. The next most often used substance is marijuana. Five patients reported frequent or excessive involvement with the substance. Marijuana use was also indicated by five other patients who described their use as minimal, moderate, or not current. For example, one 25-year-old bisexual student from the Caribbean preferred marijuana to alcohol because it was relaxing and it enhanced social and sexual relations. He planned to quit using marijuana, however, partly because it is an illegal substance and partly because of the stigma of being seen using it on campus. A 19-year-old bisexual female student from upstate New York had been criticized by her boyfriend for excessive use and plans to cut down because of concerns about the purity of the local substance. Patients were very definite about tobacco smoking and often associated it with drinking and, sometimes, illicit drug
use. Five patients expressed a desire to quit smoking immediately and requested information on smoking cessation. Five patients mentioned cocaine use in the context of polysubstance use. Two characterized their use as more than incidental. A 37-year-old white man who has been separated from his wife for a year found both drinking alcohol and using cocaine very helpful socially, but was concerned about escalating use and exposure to herpes while having unprotected sex. A 22-year-old male Latino gay from South America who drank alcohol excessively said he got energy from cocaine and ecstasy while dancing in clubs. He also used poppers (amyl nitrite) and had tried crystal methamphetamine on at least one occasion. He needed an immediate referral for medical problems. Some patients described concerns they felt needed to be addressed before they could discuss their drug and alcohol use (one patient was receiving rape counseling; two others were in psychotherapy; and several requested referrals for counseling or psychotherapy, with one describing himself as a sexaddicted individual). The interventionist made culturally appropriate referrals for all patients needing services. For instance, the 22-year-old male Latino gay with limited English proficiency was referred to a community health center where he could receive medical care and free substance abuse treatment conducted in Spanish. He was also referred to a provider serving gays and lesbians where he could attend Alcoholics Anonymous and Narcotics Anonymous groups in Spanish.
4. Discussion Our experience with the pilot project appears to support positive replies to the above inquiries. Several aspects of the results are important to underscore. First, with active assistance from clinic management in integrating the service, near-universal screening of patients for substance abuse problems can be achieved in a public STD clinic environment. In this study, 97% of the patients completed the screening protocol during the registration process, which provides evidence for the possibility of achieving a high screening compliance rate in an environment as challenging as STD clinics. Second, a relatively large percentage of patients with STD experience possible alcohol and other substance abuse problems that may require intervention. The finding that 21% of the patients screened positive seems to indicate that, annually, close to 13,000 of N 61,000 individuals treated in all public STD clinics in New York City could benefit from substance abuse intervention services (NYC Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control, 2006). Third, the pilot result is procedurally significant in that a substance abuse interventionist or counselor dedicated to providing services on-site can reach a majority of the
J. Yu et al. / Journal of Substance Abuse Treatment 34 (2008) 356 – 362
patients who screened positive for substance problems despite a time-pressed condition within an STD clinic. For patients, receiving substance abuse screening and intervention did not appear to disrupt their receiving medical attention for the primary presenting problem. Although the majority of the patients who screened positive were counseled by the interventionist, there is evidence that intervention service penetration might be improved by training and by administrative actions that increase the integration of the service into the clinic. Fourth, there is substantial support from patient satisfaction survey results indicating that having a dedicated substance abuse intervention service on-site is needed; that substance abuse intervention enhances disease prevention; and that many patients would benefit from such a service. The results of this pilot project seem to suggest that substance abuse intervention services might be implemented and integrated into nontreatment health settings other than STD clinics. Fifth, the BMI as an intervention strategy appeared to work effectively with STD clinic patients who received services from the interventionist. As noted earlier, the specific components of a BMI session were rated as moderately helpful to very helpful by more than three quarters of patients who received interventions. Furthermore, N 85% of the patients indicated an overall helpfulness of the session and a strong endorsement of the strategy through their acceptance and positive rating of the interventionist’s performance. As part of intervention services, a series of referral recommendations was provided to patients in need, which included alcohol and substance abuse selfhelp groups, substance abuse counseling, psychotherapy, and immediate medical assistance. These referrals were indicative of the range of services that will need to be provided in future implementations. Finally, most pilot studies are exploratory in design and are limited in scope and in the amount of data they collect. Our pilot project exhibits similar limitations. Because of limited resources, our sample is relatively small; due to the same reason, our pilot was limited to one location. These limitations may reduce the generalizability of the data. For instance, the current pilot sample has a higher proportion of gay/lesbian individuals but a comparatively low proportion of ethnic minority groups, compared to other STD clinics serving different communities (NYC DOHMH, 2006). Thus, issues such as serving diverse STD populations with culturally sensitive procedures should be taken into consideration when designing service protocols in different locations. This pilot project focused on the feasibility of implementing early intervention services in an STD environment; however, with limited resources and a short time frame, important procedures, such as placement in treatment and posttreatment followup, could not be included as part of the pilot. The results of this study call for more comprehensive research to fill this gap.
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5. Conclusion Our experience and data indicate that substance abuse intervention services are needed and can be effectively implemented in an STD clinic. One prerequisite that we have noted several times in the article and would like to emphasize again is collaboration and assistance from clinic management in integrating the services. Another essential factor for conducting successful intervention services in STD clinics is a dedicated interventionist. To meet the challenge of conducting effective interventions with patients with STD, the interventionist may need considerable training before assuming this function, and ongoing training and practice sessions may also be required to enhance the techniques developed to engage and motivate patients with STD. This recommendation applies especially to counselors experienced in traditional substance abuse treatment settings. Furthermore, because the interventionist needs to effectively engage patients with STD from diverse socioeconomic, ethnic/racial, and sexual orientation/gender identity groups and to involve them in open discussions of sensitive, often stigmatized, behaviors, relevant training should also be arranged for that purpose. Regular supervision is critical for maintaining the interventionist’s efficacy and for moral support in a challenging role and setting. Finally, we realize from this pilot project that the successful implementation of services, to a large extent, relies on flexible and culturally competent protocols. The procedures proposed in this article are open to modification and adaptation to fit a unique service environment and a particular population to be served.
Acknowledgments This study was assisted by all staff members of the Chelsea STD Clinic, which is operated by the Bureau of STD Control of the New York City Department of Health and Mental Hygiene. The work involved in this study was supported by in-kind contributions from the New York State Office of Alcoholism and Substance Abuse Services, the Bureaus of STD Control and HIV Prevention and Control of the New York City Department of Health and Mental Hygiene, and the Lesbian, Gay, Bisexual, and Transgender Community Center. The authors thank Robert Gallati for his support during the course of the pilot project, and Lucia Perfetti Clark for her assistance in developing this manuscript.
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC7 American Psychiatric Press.
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Appel, P. W., Piculell, R., Jansky, H. K., & Griffy, K. (2006). Assessing alcohol and other drug problems (AOD) among sexually transmitted disease (STD) clinic patients with a modified CAGE-A: Implications for AOD intervention services and STD prevention. American Journal of Drug and Alcohol Abuse, 32, 129 – 153. Bernstein, E., Bernstein, J., & Levenson, S. (1997). Project ASSERT: An ED-based intervention to increase access to primary care, preventative services and the substance abuse treatment system. Annals of Emergency Medicine, 30, 181 – 189. Bernstein, J., Bernstein, E., Tassiopoulos, K., Hereen, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77, 49 – 59. Dunn, C., Deroo, L., & Rivera, F. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains, a systematic review. Addiction, 96, 1725 – 1742. Ewing, J. A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association, 252, 1905 – 1907. New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control (2006). Bureau of Sexually Transmitted Disease Control quarterly report. New York, NY7 NYC Department of Health and Mental Hygiene.
New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS). (1996). Changing directions: Reference manual for early intervention services. NYS Office of Alcoholism and Substance Abuse Services, Health and Planning Services report. Albany, NY7 New York State Office of Alcoholism and Substance Abuse Services. Russell, M. (1994). New assessment tools for drinking in pregnancy: TACE, TWEAK, and others. Alcohol Health and Research World, 18, 55 – 61. Sokol, R. J., Martier, S. S., & Ager, J. W. (1989). The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology, 160, 863 – 870. Substance Abuse and Mental Health Services Administration. (1999). Treatment improvement protocol #34: Brief interventions and brief therapies for substance abuse. Rockville, MD7 National Clearinghouse for Alcohol and Drug Information. Substance Abuse and Mental Health Services Administration. (2005). Review of instructional materials on fetal alcohol spectrum disorders. Rockville, MD7 FASD Center for Excellence. Welte, J., Perry, P., Longabaugh, R., & Clifford, P. R. (1998). An outcome evaluation of a hospital-based early intervention program. Addiction, 93, 573 – 582.
Regular article
Substance abuse intervention services in public sexually transmitted disease clinics: A pilot experience Jiang Yu, (Ph.D.)a,4, Philip W. Appel, (Ph.D.)a, Barbara E. Warren, (Psy.D.)b, Steve Rubin, (B.A.)c, Rodolfo Gutierrezc, Brett Larson, (M.A.)d, Harold Robinson, (B.A.)d a
New York State Office of Alcoholism and Substance Abuse Services, Albany, NY 12203, USA The Lesbian, Gay, Bisexual, and Transgender Community Center, New York, NY 10011, USA c New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control, New York, NY 10001, USA d New York City Department of Health and Mental Hygiene, Bureau of HIV Prevention and Control, New York, NY 10013, USA b
Received 26 March 2007; received in revised form 16 April 2007; accepted 1 May 2007
Abstract Past research reported a gap in substance abuse treatment for patients in sexually transmitted disease (STD) clinics. Studies in New York City indicate that approximately 20% of patients with STD show symptoms of alcohol and substance abuse, but only 1% have ever received treatment services. This article reports findings from a pilot project that implemented early intervention service procedures in an STD clinic in New York City. Services implemented included screening for substance use problems, brief interventions, and referral for treatment. Four main issues were explored in this pilot study: the feasibility of implementing early intervention services in an STD clinic; the extent to which patients would accept such interventions; the extent to which STD staff would be ready to integrate substance abuse services into their primary care protocols; and the likelihood of sustaining such services in an STD environment. Results and recommendations are provided and discussed. D 2008 Elsevier Inc. All rights reserved. Keywords: Substance abuse screening; Intervention services; Service implementation; STD clinics
1. Introduction 1.1. Substance abuse interventions in sexually transmitted disease clinics There is a significant gap between the prevalence of possible substance disorders among patients of sexually transmitted disease (STD) clinics and their current receipt of substance abuse treatment or related services. Research
The opinions and conclusions expressed in this article are those of the authors and do not necessarily reflect those of the New York State Office of Alcoholism and Substance Abuse Services, the New York City Department of Health and Mental Hygiene, and the Lesbian, Gay, Bisexual, and Transgender Community Center. 4 Corresponding author. New York State Office of Alcoholism and Substance Abuse Services, 1450 Western Avenue, Albany, NY 12203, USA. 0740-5472/08/$ – see front matter D 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2007.05.005
indicates that about 20% of patients in public STD clinics display evidence of possible substance disorders, but only 1% are currently receiving treatment services (Appel, Piculell, Jansky, & Griffy, 2006). Thus, introducing formal substance abuse intervention services in STD clinics has great potential for identifying many individuals at risk for the adverse consequences of substance disorders.1 Past research has reported that screening and brief interventions tend to decrease the frequency and severity of drug and alcohol use, to reduce the risk of trauma, and to increase the likelihood of seeking specialized substance abuse treatment among patients in emergency rooms and
1 The term bsubstanceQ is used in this article to indicate both drugs and alcohol, and the term bdisorderQ is used in this article to indicate abuse and dependence, unless otherwise indicated.
J. Yu et al. / Journal of Substance Abuse Treatment 34 (2008) 356 – 362
other primary care settings, leading to fewer hospital days and emergency room visits (Welte, Perry, Longabaugh, & Clifford, 1998). Cost–benefit and cost-effectiveness analyses, on the other hand, have also demonstrated net cost savings from these interventions (Substance Abuse and Mental Health Services Administration, 1999). Compared to emergency rooms and other acute care environments, STD clinics pose both unique opportunities for and unique challenges to providing intervention services. Similar to emergency room settings where the early intervention service model was developed (New York State Office of Alcoholism and Substance Abuse Services [NYS OASAS], 1996), the STD environment is pressure packed, the volume of patients is high, and most patients deal with acute physical symptoms and mental anguish. However, unique to the STD environment, patients usually have a strong immediate primary concern of a possible STD diagnosis, and added to their stress is an even more serious concern of testing positive for human immunodeficiency virus (HIV). Patients with STD are anxious to see a physician, to receive medical treatment, and to leave the clinic. Given these characteristics, STD clinics are likely to be overburdened with various services for patients’ primary care needs, and patients may be unwilling to address issues and to accept services other than the primary care they are seeking. Without adequate previous research and well-disseminated projects, the feasibility of conducting substance abuse intervention services in an STD clinic environment remains unclear and untested. 1.2. Research issues As the risks of STD and HIV infections are significantly increased by substance disorders, public health and substance abuse treatment communities are challenged to provide effective intervention and treatment services for the STD population. To this end, researchers and practitioners from three leading service agencies in New York City designed and conducted a pilot project that aimed to implement substance abuse intervention services in STD clinics. The pilot project was developed to explore four areas: (1) the extent to which early intervention services can be implemented and institutionalized in an STD clinic where patient volume is high and the time interval for service is brief; (2) the extent to which patients would accept substance abuse interventions when their primary concern is of an acute STD nature that generates much distress and embarrassment; (3) the extent to which STD staff would be ready to integrate substance abuse intervention services into their already overburdened service protocols; and (4) the extent to which implemented services would be effective in terms of engaging, screening, and counseling patients. The pilot project was conducted in one of the public STD clinics in New York City during the early summer of 2005.
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2. Methods 2.1. Identifying intervention models Introducing substance abuse intervention services in primary health care and other nontreatment settings has become a major focus, as shown in the federal Screening, Brief Intervention, Referral, and Treatment (SBIRT) initiative. A principal source of the SBIRT initiative was New York State’s Healthcare Intervention Services (HIS) model, which is the core design element of this pilot study. As early as 1989, the NYS OASAS introduced HIS in a statewide demonstration to test an early intervention approach to substance abuse problems in the primary health care environment. This was initiated at hospital inpatient and outpatient sites, in urban, suburban, and rural locations. Within 3 years, it expanded from 9 to 17 hospitals (NYS OASAS, 1996). The HIS program model focuses on identifying the substance abuse problems of individuals presenting in health care settings outside the treatment system to: (1) engage persons who may be experiencing, or are at risk for developing, substance disorders; (2) determine the nature and extent of substance problems; (3) provide appropriate intervention based on preliminary assessment; and (4) arrange for the appropriate placement of persons in need of treatment. Routine screening tools are brief, nonthreatening, and specific for the population served. Common screening tools include the CAGE Questionnaire (Ewing, 1984), TWEAK (Russell, 1994), and T-ACE (Sokol, Martier, & Ager, 1989; Substance Abuse and Mental Health Services Administration, 2005). Medical history, physical symptoms, and behavior cues can also be reviewed as part of the screening protocol. Individuals who screen positive are then assessed by an addiction professional. Preliminary assessment is designed to establish whether a substance abuse problem exists. Information from the patient is obtained through a face-to-face interview performed by an addiction professional dedicated to providing HIS services. The addiction professional, known as an binterventionistQ in the HIS service model, elicits information to determine the extent of the problem and the most appropriate intervention. Preliminary assessment includes using criteria for substance disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). The interventionist may conclude that the patient has no problem, is at risk of developing one, or suffers from abuse or dependence. A brief intervention is conducted for patients determined to be at risk for developing a substance problem. The goals of a brief intervention are to increase the patient’s awareness of the hazards associated with substance use and to decrease the substance-using behavior. Strategies of motivation to change are employed in the intervention process. Brief interventions are usually performed one-to-one, and the
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number of sessions varies depending on the setting and the population served. A full intervention, which includes determining the preliminary level of care, motivating the patient to accept a referral for treatment, developing placement options, making referrals, and following up with treatment progress, is conducted for individuals with substance disorders (NYS OASAS, 1996). 2.2. Including BMI in the service model Patients with STD visit public clinics to seek immediate medical consultation and relief, and are unlikely to return to the clinic for a follow-up other than the one directly related to their STD condition. As a result, any effort to intervene with the substance abuse problems of patients with STD in a clinic environment presents the challenge that the delivery of services must be completed during the patient’s primary health care visit. To cope with this challenge, the brief motivational intervention (BMI) technique would be used as the main vehicle of service delivery. BMI has been successfully employed in encouraging patients in primary care medical settings who screened positive for cocaine or heroin abuse to accept a referral for treatment. The length of BMI sessions varies from 5 to 40 minutes and averages 10–20 minutes. Studies reported significant reductions in heroin and cocaine use after a BMI while patients were waiting for laboratory test results or to speak with their physician about a health concern (Bernstein, Bernstein, & Levenson, 1997; Bernstein et al., 2005). In the pilot design, service delivery through BMI involves the following steps: (1) Establishing rapport: After mutual introductions, the interventionist asks the patient his or her reasons for involvement and his or her expectations of the session. (2) Asking permission to discuss drugs: The interventionist discusses with the patient the purpose of the intervention to further engage the patient. (3) Discussing the pros and cons of substance use: The interventionist discusses with the patient his or her reasons for using substances and for quitting or cutting down on substance use. (4) Discussing the gap between continuing to use drugs and the patient’s desired quality of life: The interventionist elicits from the patient what he or she feels the pros are in using substances, as well as his or her perceived barriers to quitting substance use. (5) Negotiating an action plan: The interventionist discusses with the patient his or her past success in making important life changes and how he or she achieved it. (6) Making a referral: The interventionist provides the patient with information and options on treatment services.
(7) Evaluation: Finally, the interventionist asks the patient to fill out an evaluation of the session, which includes a readiness-to-change survey. 2.3. Implementing services in STD clinics Between May and July 2005, intervention services were piloted three mornings a week at the participating STD clinic. When prospective patients registered at the clinic, they filled out a screening form that included a modified CAGE (the core CAGE-A questions were asked relative to the past 30-day and the past 12-month time frames), questions on their demographics, whether they had health care insurance, and whether they had previous substance abuse detoxification or treatment experiences. For this particular pilot, only patients who registered and who expected to see the physician were screened. The back of the modified CAGE form was a patient disposition form indicating whether the patients scored positive or negative; whether they wanted to speak with the on-site interventionist (and, if they did, whether they reported to the interventionist); and the intervention services they received. The registration materials, including medical records and the modified CAGE form, would go to a public health adviser (PHA) who would score the screening form. Using the patient disposition form, the PHA would ask a patient who screened positive whether he or she might want to talk to an interventionist (counselor) about substance disorder issues. The PHA would take the patient to the phlebotomy station for further treatment and forward the patient’s screening disposition form to the interventionist. Because there is usually a waiting period between the phlebotomy and the doctor’s examination, this interval was the most opportune time to conduct substance abuse interventions. The interventionist, after receiving and reviewing the screening disposition form, would call the patient by his or her triage number for consultation. When providing intervention services during this time, the interventionist would reassure the patient that he or she would not miss his or her appointment with the doctor and that his or her primary health care concern would be addressed. The interventionist would use the answers to the modified CAGE as a basis for directing one’s efforts to engage the patient. After consulting with the patient, the interventionist would ask that patient to complete a satisfaction survey, which included an item on readiness to change substance use immediately and intention to follow through with any referrals for substance abuse treatment or other action steps discussed. Then the patient would report to the physician for primary care. If a patient was highly resistant to consultation or refused to engage beyond the initial BMI steps, the session was terminated and the patient was given a printed resource/ referral brochure. The session would be recorded as bassess and refer onlyQ without a BMI.
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At the end of each day of service, the interventionist would retrieve the disposition forms from the PHA for those patients who screened negative and would file them with other materials for further analysis.
3. Results 3.1. Results of screening Table 1 presents the general screening results. During the pilot period, 285 patients were offered screening forms, and 97% participated in the screening process. Twenty-one percent of those who participated in the screening had a positive screening result (i.e., they scored at least one positive on one of the two sets of the original four CAGE items, with one set being within the period of past 30 days and the other being within the period of past 12 months). Fifty-six percent of the patients who screened positive accepted an offer to speak with, and were counseled by, the interventionist. Nonresponses from patients could be attributed to some procedural issues, in addition to the patients’ refusal of the intervention. For instance, three patients were paged but did not respond; in two instances, the patients’ screening forms were late in reaching the interventionist; and one other patient could not be paged because the clinic triage number was omitted on the screening form. The demographic information about the screened patients is contained in Table 2. Several characteristics are observed. The majority of the patient sample is male (70%), and close to half contains ethnic minorities. Because of the location of the clinic, homosexual and bisexual patients make up a relatively large proportion of the total patient sample (27%). The average age of the sample is 28 years. Table 2 also indicates a higher percentage of male patients in the positive group than in the negative group. Homosexual patients are less likely to score positive. Furthermore, Asian patients seem to have a higher representation in the positive group compared to their proportion in the total sample. 3.2. Results of counseling To measure patients’ responses to the intervention process, those who consulted the interventionist were surveyed with a questionnaire (satisfaction survey), which was developed to examine each specific component of the BMI strategy used in the pilot project. The satisfaction survey examined how patients were treated by STD clinic staff; how they felt when staff brought up the subject of Table 1 Screening results Number Number Number Number
of of of of
clients clients clients clients
offered screening screened who screened positive who accepted intervention
285 276 57 32
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Table 2 Demographic information of screened patients
Characteristics Gender Male Female Race African American Asian Caucasian Latino Unknown Sexual orientation Heterosexual Homosexual Bisexual Unknown
Total (N = 251) [%]
Screened positive (n = 32) [%]
Screened negative (n = 219) [%]
71 29
78 22
70 30
21 7 46 20 7
17 12 43 17 11
22 6 46 20 6
63 25 10 2
66 17 12 5
63 27 9 1
substance issues; whether they thought giving patients help with possible substance problems in the clinic was a good idea; their readiness to change their substance use behavior on that day and to follow through with any help they received; and how helpful various aspects of the session with the interventionist were for them (Dunn, Deroo, & Rivera, 2001). A key issue in implementing a substance abuse intervention service is to be respectful of patients’ possible concerns regarding confidentiality and on being asked about a personal matter that was not the primary focus of their clinic visit. In this pilot, 97% of the patients seen by the interventionist reported that the staff were very respectful when talking to them about their substance use. Furthermore, although 34% were happy that the substance abuse issue was brought up because they were looking for information or other help, 45% were surprised that the substance abuse issue was brought up but indicated being comfortable with it. Especially noteworthy is that 87% felt that many patients with STD could benefit from similar services (Table 3). The satisfaction survey also assessed the perceived effectiveness of each of the BMI components of the intervention and the overall helpfulness of the session. Using a rating from 1 = not helpful 5 = very helpful, between 74% and 87% of the patients reported the session as being moderately helpful to very helpful in having Table 3 Patient satisfaction survey Survey item
% Confirmed
Staff were respectful Happy that the issue was addressed as one was looking for help Surprised that the issue was addressed but was comfortable Others attending the clinic would benefit from screening
97 34 45 87
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someone to talk to about their substance use (81%); in getting information about how substance use affects their health (74%); in discussing the pros and cons of their substance use (81%); in talking about their life in general and what they wished to change (81%); in making plans to change their substance use (74%); in getting referral and treatment information (73%); and overall (87%). Also included in the satisfaction survey were items on readiness to change substance use today and on the strength of intention to follow through with any help received. Regarding their readiness to change substance use today, 47% rated it z 8 on a scale of 1–10. Regarding the strength of their intention to follow through with any help received, 73% rated it 5 on a scale of 1–5 (1 = weak to 5 = strong). 3.3. Results of case analysis The substance abuse and related issues patients discussed with the interventionist provide a clinical context for the kinds of referral resources a fully implemented service may require. Patients readily discussed the particulars of their substance use and described the context in which they were using substances and their feelings and reasons for using substances. The BMI process encouraged patients to speak freely about their likes and dislikes around their substance use. In verbalizing contradictory information, patients were able to question their own assumptions about their use. The most frequent reasons given for drinking were: to relax, to be social, and to lower inhibitions. A significant number of patients also used drugs and alcohol to self-medicate for depression. A few respondents simply reported liking the taste of wine, beer, or hard liquor. In characterizing their drug and alcohol use, at least two thirds of the patients expressed varying degrees of concern about a current or past drug or alcohol problem. The overwhelming substance of choice was alcohol, and about 90% of the patients indicated significant concern about their alcohol use. Concerns ranged from the physical discomforts of occasional excessive use, to use frequently and regularly enough to involve blackouts and other serious physiological consequences. The next most often used substance is marijuana. Five patients reported frequent or excessive involvement with the substance. Marijuana use was also indicated by five other patients who described their use as minimal, moderate, or not current. For example, one 25-year-old bisexual student from the Caribbean preferred marijuana to alcohol because it was relaxing and it enhanced social and sexual relations. He planned to quit using marijuana, however, partly because it is an illegal substance and partly because of the stigma of being seen using it on campus. A 19-year-old bisexual female student from upstate New York had been criticized by her boyfriend for excessive use and plans to cut down because of concerns about the purity of the local substance. Patients were very definite about tobacco smoking and often associated it with drinking and, sometimes, illicit drug
use. Five patients expressed a desire to quit smoking immediately and requested information on smoking cessation. Five patients mentioned cocaine use in the context of polysubstance use. Two characterized their use as more than incidental. A 37-year-old white man who has been separated from his wife for a year found both drinking alcohol and using cocaine very helpful socially, but was concerned about escalating use and exposure to herpes while having unprotected sex. A 22-year-old male Latino gay from South America who drank alcohol excessively said he got energy from cocaine and ecstasy while dancing in clubs. He also used poppers (amyl nitrite) and had tried crystal methamphetamine on at least one occasion. He needed an immediate referral for medical problems. Some patients described concerns they felt needed to be addressed before they could discuss their drug and alcohol use (one patient was receiving rape counseling; two others were in psychotherapy; and several requested referrals for counseling or psychotherapy, with one describing himself as a sexaddicted individual). The interventionist made culturally appropriate referrals for all patients needing services. For instance, the 22-year-old male Latino gay with limited English proficiency was referred to a community health center where he could receive medical care and free substance abuse treatment conducted in Spanish. He was also referred to a provider serving gays and lesbians where he could attend Alcoholics Anonymous and Narcotics Anonymous groups in Spanish.
4. Discussion Our experience with the pilot project appears to support positive replies to the above inquiries. Several aspects of the results are important to underscore. First, with active assistance from clinic management in integrating the service, near-universal screening of patients for substance abuse problems can be achieved in a public STD clinic environment. In this study, 97% of the patients completed the screening protocol during the registration process, which provides evidence for the possibility of achieving a high screening compliance rate in an environment as challenging as STD clinics. Second, a relatively large percentage of patients with STD experience possible alcohol and other substance abuse problems that may require intervention. The finding that 21% of the patients screened positive seems to indicate that, annually, close to 13,000 of N 61,000 individuals treated in all public STD clinics in New York City could benefit from substance abuse intervention services (NYC Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control, 2006). Third, the pilot result is procedurally significant in that a substance abuse interventionist or counselor dedicated to providing services on-site can reach a majority of the
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patients who screened positive for substance problems despite a time-pressed condition within an STD clinic. For patients, receiving substance abuse screening and intervention did not appear to disrupt their receiving medical attention for the primary presenting problem. Although the majority of the patients who screened positive were counseled by the interventionist, there is evidence that intervention service penetration might be improved by training and by administrative actions that increase the integration of the service into the clinic. Fourth, there is substantial support from patient satisfaction survey results indicating that having a dedicated substance abuse intervention service on-site is needed; that substance abuse intervention enhances disease prevention; and that many patients would benefit from such a service. The results of this pilot project seem to suggest that substance abuse intervention services might be implemented and integrated into nontreatment health settings other than STD clinics. Fifth, the BMI as an intervention strategy appeared to work effectively with STD clinic patients who received services from the interventionist. As noted earlier, the specific components of a BMI session were rated as moderately helpful to very helpful by more than three quarters of patients who received interventions. Furthermore, N 85% of the patients indicated an overall helpfulness of the session and a strong endorsement of the strategy through their acceptance and positive rating of the interventionist’s performance. As part of intervention services, a series of referral recommendations was provided to patients in need, which included alcohol and substance abuse selfhelp groups, substance abuse counseling, psychotherapy, and immediate medical assistance. These referrals were indicative of the range of services that will need to be provided in future implementations. Finally, most pilot studies are exploratory in design and are limited in scope and in the amount of data they collect. Our pilot project exhibits similar limitations. Because of limited resources, our sample is relatively small; due to the same reason, our pilot was limited to one location. These limitations may reduce the generalizability of the data. For instance, the current pilot sample has a higher proportion of gay/lesbian individuals but a comparatively low proportion of ethnic minority groups, compared to other STD clinics serving different communities (NYC DOHMH, 2006). Thus, issues such as serving diverse STD populations with culturally sensitive procedures should be taken into consideration when designing service protocols in different locations. This pilot project focused on the feasibility of implementing early intervention services in an STD environment; however, with limited resources and a short time frame, important procedures, such as placement in treatment and posttreatment followup, could not be included as part of the pilot. The results of this study call for more comprehensive research to fill this gap.
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5. Conclusion Our experience and data indicate that substance abuse intervention services are needed and can be effectively implemented in an STD clinic. One prerequisite that we have noted several times in the article and would like to emphasize again is collaboration and assistance from clinic management in integrating the services. Another essential factor for conducting successful intervention services in STD clinics is a dedicated interventionist. To meet the challenge of conducting effective interventions with patients with STD, the interventionist may need considerable training before assuming this function, and ongoing training and practice sessions may also be required to enhance the techniques developed to engage and motivate patients with STD. This recommendation applies especially to counselors experienced in traditional substance abuse treatment settings. Furthermore, because the interventionist needs to effectively engage patients with STD from diverse socioeconomic, ethnic/racial, and sexual orientation/gender identity groups and to involve them in open discussions of sensitive, often stigmatized, behaviors, relevant training should also be arranged for that purpose. Regular supervision is critical for maintaining the interventionist’s efficacy and for moral support in a challenging role and setting. Finally, we realize from this pilot project that the successful implementation of services, to a large extent, relies on flexible and culturally competent protocols. The procedures proposed in this article are open to modification and adaptation to fit a unique service environment and a particular population to be served.
Acknowledgments This study was assisted by all staff members of the Chelsea STD Clinic, which is operated by the Bureau of STD Control of the New York City Department of Health and Mental Hygiene. The work involved in this study was supported by in-kind contributions from the New York State Office of Alcoholism and Substance Abuse Services, the Bureaus of STD Control and HIV Prevention and Control of the New York City Department of Health and Mental Hygiene, and the Lesbian, Gay, Bisexual, and Transgender Community Center. The authors thank Robert Gallati for his support during the course of the pilot project, and Lucia Perfetti Clark for her assistance in developing this manuscript.
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC7 American Psychiatric Press.
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Appel, P. W., Piculell, R., Jansky, H. K., & Griffy, K. (2006). Assessing alcohol and other drug problems (AOD) among sexually transmitted disease (STD) clinic patients with a modified CAGE-A: Implications for AOD intervention services and STD prevention. American Journal of Drug and Alcohol Abuse, 32, 129 – 153. Bernstein, E., Bernstein, J., & Levenson, S. (1997). Project ASSERT: An ED-based intervention to increase access to primary care, preventative services and the substance abuse treatment system. Annals of Emergency Medicine, 30, 181 – 189. Bernstein, J., Bernstein, E., Tassiopoulos, K., Hereen, T., Levenson, S., & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77, 49 – 59. Dunn, C., Deroo, L., & Rivera, F. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains, a systematic review. Addiction, 96, 1725 – 1742. Ewing, J. A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association, 252, 1905 – 1907. New York City Department of Health and Mental Hygiene, Bureau of Sexually Transmitted Disease Control (2006). Bureau of Sexually Transmitted Disease Control quarterly report. New York, NY7 NYC Department of Health and Mental Hygiene.
New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS). (1996). Changing directions: Reference manual for early intervention services. NYS Office of Alcoholism and Substance Abuse Services, Health and Planning Services report. Albany, NY7 New York State Office of Alcoholism and Substance Abuse Services. Russell, M. (1994). New assessment tools for drinking in pregnancy: TACE, TWEAK, and others. Alcohol Health and Research World, 18, 55 – 61. Sokol, R. J., Martier, S. S., & Ager, J. W. (1989). The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology, 160, 863 – 870. Substance Abuse and Mental Health Services Administration. (1999). Treatment improvement protocol #34: Brief interventions and brief therapies for substance abuse. Rockville, MD7 National Clearinghouse for Alcohol and Drug Information. Substance Abuse and Mental Health Services Administration. (2005). Review of instructional materials on fetal alcohol spectrum disorders. Rockville, MD7 FASD Center for Excellence. Welte, J., Perry, P., Longabaugh, R., & Clifford, P. R. (1998). An outcome evaluation of a hospital-based early intervention program. Addiction, 93, 573 – 582.