• Alcohol, Tobacco, and other Substance Use Disorders in Primary Care

  • Topic outline

  • Course Introduction

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    Enroll in Substance Use Disorders Primary CareThis course teaches about the prevention and treatment of substance use disorders through online didactics, and provides the student a chance to practice techniques, with locally and globally available peers and mentors, that may reduce the prevalence and the health effects of substance use disorders. All components of this training (like all NextGenU.org trainings) are free, including registration, learning, testing, and a certificate of completion.

    The course consists of 6 modules to be completed through online study and peer activities. These modules provide:

    • a basic introduction to mental health and substance use services
    • an overview of stigma and how it can be addressed
    • an introduction to best practices for the management of substance use disorders in primary care
    • an introduction to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Package
    • a few key tips for monitoring and follow-up care for those suffering from substance use disorders, with a special emphasis on common co-morbidities
    • strategies to communicate with people seeking care and their families and caregivers

    Evaluation consists of a practice quiz in each module, and a final exam. You will also have an opportunity to provide feedback on the course to help us make the learning experience even better. We will give you all the results of your assessments, such as your final exam and peer activities. We can report your testing information and share your work with anyone (your school, employer, etc.) that you request. We hope this is a wonderful learning experience for you, and the assessment that you provide at the course’s conclusion will help us improve the training for future students.

    This course is cosponsored by: the Africa Mental Health Foundation, the Annenberg Physician Training Program in Addiction Medicine, and the University of Florida. This course uses competencies adapted from the WHO Mental Health Gap Action Programme (mhGAP), and resources from accredited, world-class organizations such as the National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA), the National Institute on Drug Abuse, the World Health Organization, and the World Medical Association. Course co-developers are: Veronic Clair, MD, MSc, CCFP, FRCPC; Sukhdeep Jassar, MPH; and Abednego Musau, MBChB. Our Advisory Group is: Erica Frank, MD, MPH; Stuart Gitlow, MD, MPH, MBA; Victoria Mutiso, PhD; David Ndetei, MD, PhD; Scott Teitelbaum, MD; and Randall F. White, MD, FRCPC. We also gratefully acknowledge major review and contributions from: Bernice Apondi; Chelsea Hitchen, BA; Sandra W. Kimani, MBChB; Mwiti K. Makathimo, Project Management, MBChB; Aggrey G. Mokaya; Johnston M. Muthoka, BSc, MBChB; and Jackson N. Njoroge, MBChB. 

  • Module 1: Introduction to Substance Use Disorder Services in Primary Care

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    This module will act as a foundation for the rest of this course, providing you with information on how primary health care can be used to lessen the burden of mental illness, including substance use disorders. Key terms such as ‘task-shifting’ will be introduced. You will also learn about the WHO mhGAP (Mental Health Gap Action Programme) principles of care and priority conditions. Finally, you will come to understand the science behind substance abuse and its effect on human health and social functioning.

    Competency covered in this module: 

    • Understand and be receptive to including mental health and substance use disorder services in primary care
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  • Module 1: Lesson 1: General Information

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    Learning Objectives:

    Upon completion of this module, students should be able to:

    • Know how primary health care can be involved in lessening the burden of mental illness, including substance use disorders
    • Understand the concept of 'task-shifting'
    • Be familiar with the WHO mhGAP principles of care and priority conditions
    • Understand the science behind substance abuse and its possible effects on health and social functioning
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  • Module 2: Addressing Stigma and Protecting Human Rights

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    This module will discuss stigma and illustrate its effect on human health (especially mental health) and the measures that can be taken to eliminate it. You will be introduced to international standards and regulations on mental health and human rights. In addition, this module will help individuals appreciate the impact that stigmatizing attitudes, words, or other behaviors can have on patient outcomes. This module will assist individuals in paying closer attention to the rights of patients/clients so as to provide better quality service in their practice.

    Competencies covered in this module:

    • Being aware of and being able to address stigma

    • Promoting and protecting the human rights of those you serve

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  • Module 2: Lesson 1: Policies and Legislation


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    Learning Objectives:

    Upon completion of the first lesson of Module 2, students should be able to:


    • Understand stigma and its potential impact, as well as the practical strategies to address it
    • Develop awareness of how physician/clinician attitudes toward patients with substance use disorders can impact recognition, diagnosis, and treatment of patients
    • Provide care in a way that respects the dignity of the person and is culturally sensitive and appropriate
    • Provide care that is free from discrimination on the basis of race, color, sex, language, religion, political or other opinion, nationality, ethnicity, indigenous or social origin, property, birth, age, or other status
    • Minimize stigma, marginalization, and discrimination, and promote the social inclusion of people with mental, neurological, and substance use disorders by fostering strong links with the employment, educational, social (including housing), and other relevant sectors. 

    • Required Learning Resources and Activities

    • Additional Learning Options

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  • Module 2: Lesson 2: International and National Standards

    Learning Objectives:

    Upon completion of the second lesson of module 2, students should be able to:

    • Understand international and national standards, legislation, and policies on mental health and human rights
    • Pay special attention to confidentiality, as well as the right of the patient to privacy
    • Ensure that the patient (or their designated decision-maker) understands the proposed treatment and provides free and informed consent to treatment
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  • Module 3: Substance Use Disorders and Primary Health Care

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    This module will introduce you to best practices for managing tobacco, alcohol, and other substance use at the primary care level. It provides insight into the various risks and physical effects associated with substance use and how they can be prevented. It introduces skills and techniques for effective diagnosis of tobacco use and related diseases. The links between tobacco use and Chronic Obstructive Pulmonary Disease (COPD), as well as tobacco use and cancer, will be elaborated upon. There will be an introduction to screening for alcohol intoxication as well as an overview of current treatment and referral strategies.

    Competencies covered in this module:

    • Understand various best practices for the medical management of tobacco, alcohol, and other substance use disorders in primary care

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  • Module 3: Lesson 1: Tobacco Specific Information and Approaches

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    Learning Objectives:

    Upon completion of the first lesson of Module 3, students should be able to:

    • Know the effectiveness of tobacco cessation interventions
    • Be familiar with quick, in-practice resources to support tobacco cessation interventions
    • Understand the personal health disease risks (cardiovascular, respiratory and cancer) associated with tobacco use
    • Understand the general benefits of quitting smoking
    • Understand the symptoms of tobacco withdrawal and the methods of dealing with those symptoms
    • Understand the health consequences of involuntary (second hand) exposure to tobacco smoke
    • Understand the link between tobacco and Chronic Obstructive Pulmonary Disorder (COPD) and be familiar with best practices for the management of COPD
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  • Module 3: Lesson 2: General Approaches to Address Alcohol and Other Substance Use Disorders in Primary Care

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    Learning Objectives:

    Upon completion of the second lesson of Module 3, students should be able to:

    • Understand the general approaches to address alcohol, tobacco and other substance use in primary care
    • Take a thorough medical history, including the history of the presenting complaint(s), past history and family history (as relevant), and know the red flags for substance use disorders
    • Recognize the symptoms of acute intoxication for a substance and treat or refer accordingly. Assess the person for substance withdrawal symptoms and treat or refer accordingly
    • Be familiar with the evidence-based model of brief intervention in primary care for other psycho-active substances
    • Required Learning Resources and Activities

    • Additional Learning Options

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  • Module 3: Lesson 3: Alcohol Use Disorder Specific Information

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    Learning Objectives:

    Upon completion of the third lesson of Module 3, students should be able to:

    • Understand the impact of alcohol on overall health
    • Understand the specific effects of alcohol on the liver
    • Assess the person for alcohol withdrawal symptoms and treat or refer accordingly
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  • Module 4: Using the ASSIST Package for the Assessment and Brief Intervention for Substance Use

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    In this module you will apply the foundational knowledge you have developed in the previous three modules and learn how to screen and treat alcohol and substance use disorders in your practice. Specifically, you will use the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) developed by the World Health Organization. The ASSIST package was developed by a number of international substance abuse researchers to provide substance abuse screening and brief interventions in primary and general medical care worldwide.

    Competencies covered in this module:

    • Understand how to effectively screen for substance use disorders using the ASSIST package
    • Be able to deliver an effective brief intervention to address substance abuse
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  • Module 4: Lesson 1: Ability to Screen Effectively and Quickly for Substance Use Disorders

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    Learning Objectives:

    Upon completion of the first lesson of Module 4, students should be able to:

    • Acquire the interviewing skills necessary to screen for substance disorders using the ASSIST Screening Tool
    • Demonstrate skills for evaluating patients’ stage of change, readiness to accept the diagnosis, and readiness to undertake behavior change
    • Clearly and supportively recommend treatment to patients with substance use disorders
    • Acquire the skills required for addiction prevention counseling
    • Demonstrate the skills that help set respectful limits on patient requests for prescription medication
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  • Module 5: Monitoring, Follow-Up, Comorbidities, and General Well-Being

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    This module will further outline the complexities of substance use disorders and the tendency of these disorders to co-occur with other health conditions. Substance use may be related to mental illness, HIV status, or malnutrition, and can have serious implications for women’s reproductive health. Both mental and physical co-morbidities may increase the levels of dysfunction, leading to more complicated treatment and management. You will learn how psychoactive substances are related to HIV status, general health status, and lifestyle, as well as various mental illnesses. You will receive instruction on how to treat and manage patients with co-occurring depression and substance use disorders as well as manage the reproductive health of female patients with past or current substance misuse and their infants. You will also learn how to continue treatment and to mobilize community support for individuals with substance use disorders. You will learn what formal and informal supports are currently in your community as well as how to involve and inform families and caregivers how to best support their loved ones. In your clinical practice, you will learn how to continually monitor the health and well-being of these at-risk individuals.

    Competencies covered in this module:

    • Be able to provide general care, monitoring and follow-up, taking into consideration general health status, common co-morbidities and issues faced by those with substance use disorders
    • Understand co-morbidities associated with alcohol abuse including: HIV, depression, psychosis and reproduction implications such as fetal alcohol spectrum disorders
    • Address special reproductive health issues for women using substances or receiving pharmacological treatments for co-morbidities
    • Understand the importance of promoting healthy lifestyles and the general well-being of those with substance use disorders and/or mental health conditions
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  • Module 5: Lesson 1: Mental Health Comorbidities

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    Learning Objectives:

    Upon completion of the first lesson of Module 5, students should be able to:

    • Recognize and observe evidence of SEVERE self-injury such as signs of poisoning or intoxication or signs/symptoms requiring urgent medical treatment such as: bleeding from a self-inflicted wound, loss of consciousness, or extreme lethargy
    • Ask about self-harm or suicidal thoughts and care for people in those situations, including offering or activating psychosocial support
    • Know how to maintain regular contact and follow-up with patients as needed
    • Required Learning Resources and Activities

    • Additional Learning Options

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  • Module 5: Lesson 2: Substance Use and HIV

    Learning Objectives:

    Upon completion of the second lesson of Module 5, students should be able to:

    • Understand how substance use (including alcohol and tobacco) interacts with HIV
    • Be aware of the relationship between alcohol use and HIV including the increased risk of HIV infection in those who consume alcohol
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  • Module 5: Lesson 3: Substance Use and Pregnancy

    Learning Objectives:

    Upon completion of the third lesson of Module 5, students should be able to:

    • Understand the links between alcohol and other substance use and reproduction, and be able to discuss pregnancy planning and contraception methods with men, and with women of childbearing age
    • Assess the potential risks of medications and substance use on the fetus or baby when providing care to a pregnant or breastfeeding woman
    • Ensure that the babies being breastfed by women on medications are monitored for adverse effects or withdrawal, and undergo comprehensive examinations if required
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  • Module 5: Lesson 4: Substance Use Follow-Up, Self-Help, Well-Being, and the Community

    Learning Objectives:

    Upon completion of the fourth lesson of Module 5, students should be able to:

    • Know when to refer patients
    • Know how, at follow-up, to reassess the person’s expectations of treatment, clinical status, understanding of treatment and adherence to the treatment and correct any misconceptions
    • Continually monitor for treatment effects and outcomes, drug interactions with substances (alcohol and illicit drugs) and medicines (both naturopathic and traditional) and adjust accordingly
    • Encourage involvement in self-help and family support groups, where available
    • Learn to identify and mobilize possible sources of social and community support in the local area, including educational, housing and vocational supports
    • Encourage self-monitoring of symptoms and explain when to seek care immediately
    • Know when it is appropriate to involve the carer or family member in the person’s care
    • Use family and community resources to contact people who have not returned for regular follow-up. (Keeping in mind Modules 1 and 2)
    • Promote autonomy and independent living in the community and discourage institutionalization
    • Assist the patient in acquiring healthy lifestyles, which can improve mental health and help manage substance use disorder triggers such as stress
    • Perform a general healthy weight assessment (BMI, weight and height)
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  • Module 6: Communication with People Seeking Care, Their Caregivers and Family

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    The final module of this course focuses on communication. With the stigma surrounding many of the topics discussed in this training, it is important that primary care providers are sensitive, nonjudgmental, and able to communicate in a language that their patients understand. Effective communication builds trust and rapport between patients and their health care providers and provides the opportunity to dispel myths and common misconceptions held by patients and their families. This in turn can strengthen both the community at large and the social support for those affected, as well as increase the patients’ acceptance and adherence to treatment.

    Competency covered in this module:

    • Communicate effectively with those to whom you provide care, their family and caregivers
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  • Module 6: Lesson 1:

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    Learning Objectives:

    Upon completion of this module, students should be able to:

    • Use simple and clear language
    • Ask the person for his or her own understanding of the condition
    • Provide information to the person on their health status in terms that they can understand
    • Understand that you must be friendly, respectful and nonjudgmental at all times
    • Ensure that communication is clear, empathic, and sensitive to age, gender, culture and language differences
    • Gain the consent of the person to keep carers informed about the person’s health status, including issues related to assessment, treatment, follow-up, and any potential side effects
    • Anticipate the typical families' reaction to knowledge of substance use issues in a family member
    • Respond to the disclosure of private and distressing information (e.g. regarding sexual assault or self-harm) with sensitivity
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  • Final Exam, Activities and Course Evaluation

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