I am thrilled to have a guest post today from friend and NP Colleague, Kim Setser
Opening her own practice – Substance Abuse screening is so important and Kim can guide providers and patients on appropriate screening and treatment referral

November of 2014, an idea and dream became a reality for two nurses from Del Rio,
TN. While on a girls’ day out, the discussion of opening a clinic in our home town came up as we
passed by a small clinic in Lake Lure, NC. The town of Del Rio has not had a medical clinic in
many years, and most cannot remember ever having a doctor there although there were some
in the early 1900’s. The most recent medical provider was a midwife, Etta “Granny” Nichols,
who was trained by her father, who had been trained by his father, a local physician.
The Del Rio Community Center became the first home for the free clinic, which quickly
evolved into a come one-come all clinic when those with insurance started asking if they could
also be seen there. We began the credentialing process, and I found a job that was more
flexible with the schedule and would allow us to grow the clinic into what we thought would be
a part time clinic at most.

In the Spring of 2015, I heard about a grant from the Department of Mental Health
which was being offered to nurse practitioners in Tennessee. Knowing how much the
community and our clinic could use the money, but not really knowing what was involved, I
applied for the grant, along with several others in the state. Imagine our surprise when we
heard we had been chosen for this award which would not only help us get established
financially, but would help us learn how to help those in our community with alcohol and
substance abuse problems.

Why is the State doing this? According to a randomized study, 1175 patients with an
average age of 38 years old revealed that after a single brief intervention, a person was more
likely to be abstinent for cocaine and heroin. Among those who screened positive, the follow up
rate was 82% and cocaine levels in hair samples decreased by 29 % for those in the intervention
group and only 4% in those who did not receive a brief intervention.

According to the Tennessee Department of Health and Substance Abuse Services, almost 5% of
Tennesseeans have used pain relievers in the past year for non-medical purposes, and more
than 70% of those people got them from a friend or relative. Young adults in Tennessee age 18-
25 are using prescription opioids at a rate 30 percent higher than the national average.
When it comes to alcohol use and abuse, there are many health concerns that we need
to bring awareness to, including medication interactions. We often miss those who are less
obvious but may be well on their way to alcoholism. For example, the gentleman who used to
have a drink of wine every night with his wife, but now she has passed away and he is drinking
several glasses a night,or maybe he is drinking more now in an attempt to treat his depression
and loneliness. These are the ones this program hopes to help, by screening and intervening

No matter where we practice, it’s often difficult to address alcoholism and drug abuse
with our patients as it’s obviously an uncomfortable subject. During the interview for the grant,
the interviewer asked me what I thought would be our biggest obstacle to implementing the
program in Del Rio. I knew those in the area where we practice are very sensitive when it
comes to asking their social history, especially if it involves alcohol or drugs, and it has proven
to be true at least in my experience.

What’s involved in the process? With every new patient who comes into the clinic, we
include a questionnaire in the new patient packet, or the nurse will administer the questions at
check in. The questions are:

1. In the last year, have you had 4 or more drinks in one day (women) or 5(men). One
drink is equivalent to 12 oz beer, 5 oz wine or 1.5 oz liquor (one shot).

2. How many times in the last year have you used a recreational or prescription drug
for non-medical reasons? Recreational drugs include methamphetamines (speed,
crystal meth), marijuana, inhalants, Valium, barbiturates, cocaine, ecstasy, LSD,
mushrooms, or narcotics (heroin).
3. If a female responds by indicating she has more than 4 drinks a day or a male has
more than 5, the staff administers the AUDIT questionnaire which has ten questions.
Each question has five answer choices with points for each response indicated on
the form. If the patient scores 8 or more, the motivational interview takes place and
we offer referral to treatment.

4. If a female or male responds to the pre-screen drug question indicating he/she used
drugs recreationally during the previous year, the intake staff administers the DAST-
10 which has ten questions. Each positive response receives one point. If they score
1-2 points, we monitor the patient and re-assess later. If a patient scores 3-5, we
perform the motivational interview and for 6 to 8 points, they receive a motivational
interview and/or referral to treatment.

How are our results? As expected, we feel patients are not always forthcoming or
truthful with their answers. We have screened approximately 500 patients over the age
of 16 and have only had 5 positive screens. Four were for alchohol and none wanted
treatment, although they did feel they had a problem but prefer to deal with it on their
own. The one positive for illicit drugs had been in jail for related charges and had
already been through treatment and was doing well. I do not feel these numbers
accurately depict our population, but in a small community where everyone knows
everyone else and almost everyone is a relative, it can be difficult to break that wall of
shame and to ask for help.

How has this benefited the community? By asking the questions, we bring
awareness to the problem. We are able to share with the patients that we are
concerned and that we do have referral resources available if they choose to open up to
us at a later time and accept our help. We provide a non-judgemental atmosphere, and
want to help those who are ultimately our friends and neighbors in our small close-knit
community. We do appreciate the opportunity to share this information with other
providers and if you would like more information on obtaining the forms or training on
the process for your staff, please feel free to contact me (Kim Setser, FNP) or the nurse
(Tina Reece, RN) at Mountain Health Clinic, 260 Highway 107 South, Del Rio, TN, 423-