1. The Primary Clinician, Nursing Staff, or SUD Counselor should observe whether the client exhibits current symptoms of severe alcohol withdrawal using the Identifying Alcohol Withdrawal guide or whether the client has recently (within the past six hours to four days) stopped drinking and has a history of requiring hospitalization for severe alcohol withdrawal, seizures, or delirium tremens.

   1. If there is any uncertainty about the need for withdrawal management, consult with a Prescribing Provider.
2. If the client exhibits these symptoms, an urgent referral can be made to a withdrawal management facility or to the closest emergency room.
3. A SUD Counselor or Primary Clinician should create a follow-up plan to assess ongoing need for services after the client’s return from withdrawal management.

1. Score and document an Alcohol Use Disorders Identification Test (AUDIT-C) for alcohol use.

   1. See the Alcohol Screening Documentation worksheet for instructions.
2. If the AUDIT-C score is greater than or equal to 3 (women) or 4 (men), conduct an AUD diagnostic assessment.

IF THE AUDIT-C SCORE IS LESS THAN 3, then proceed with the established mental health care treatment plan and reassess annually.

1. Use the Diagnostic Criteria Checklist to assess whether the client meets the DSM-5 criteria for AUD.
2. If the client meets the DSM-5 criteria, place AUD in the diagnosis list field as a secondary diagnosis to the primary mental health diagnosis in the electronic health record (EHR). (Treatment for AUD must be documented as secondary to the mental health diagnosis.)

IF THE CLIENT DOES NOT MEET THE DSM-5 CRITERIA, SKIP AHEAD TO THE BRIEF INTERVENTION, PROCEED WITH THE ESTABLISHED MENTAL HEALTH CARE TREATMENT PLAN, AND REASSESS ANNUALLY.

1. The Primary Clinician should

   • document COD-alcohol care addressing alcohol in the treatment plan in the EHR as an intervention relevant to the primary mental health diagnosis.
   • document COD-alcohol care addressing alcohol in the treatment plan.
     • Under the primary mental health diagnosis, list the following objective: “Support clients’ mental wellness and reduced mental health symptoms through reduced alcohol consumption.”
       • Under this objective, add the following intervention: “Staff to assist client to reduce alcohol use through offering medications and counseling for co-occurring alcohol use disorder in an effort to reduce mental health symptoms and improve wellness and recovery.”
2. Inform the Prescribing Provider, Nursing Staff, and SUD Counselor about the updated treatment plan.

1. Conduct a comprehensive assessment using the Supplemental COD Assessment worksheet.
2. Use the supplemental assessment to

   1. inform the treatment plan
   2. determine readiness for treatment or medication. If the client is not ready for treatment or medication, deliver a brief intervention to discuss the risks to health and revisit the discussion annually or as initiated by the client.

1. A Prescriber orders an AUD lab set during visits with the client.
2. A Nurse administers a urine drug screen for opioids, oxycodone, methadone, and buprenorphine. If the client is of childbearing age, the Nurse administers a pregnancy test prior to the client being prescribed a new order of naltrexone (oral or long-acting injection). Lab collection can take place during the initial visit or any subsequent visit. Use the Lab Collection Instructions for detailed instructions on how to collect labs.

Special Circumstances

• When a urine screen or pregnancy test is not feasible to obtain prior to prescribing or administering naltrexone, do not withhold naltrexone if recent opioid abstinence can be confirmed through other means, such as the client’s reliable self-report, in combination with reviewing of the Prescription Drug Monitoring Program (PDMP) report and finding it negative for opioids, verifying the client’s tolerability of recently administered doses of naltrexone, and/or verifying with any available collateral.
• For AUD medications other than naltrexone, laboratory testing prior to prescribing the medication is not required, as the risks of withholding these medications outweigh the risks of providing them.

1. Conduct a brief intervention.

   1. For instructions, use the Conduct a Brief Intervention guide.
   2. Determine readiness for treatment or medication. If the client is not ready for treatment or medication, deliver a brief intervention to discuss risks to health and revisit the discussion annually or as initiated by the client.
2. Document discussion in session notes, including the brief intervention and discussed treatment options.

The SUD Counselor shares clinical support options with the client:

1. Review SUD counseling options with the client.
2. Review your clinic’s Substance Use Treatment Services resources available outside the mental health clinic with the client.

TIP: Note that mental health and substance use treatment services often are siloed. Building relationships with providers in the substance use treatment system will facilitate this process.

3. Discuss logistics of referral if the client is interested in services outside the mental health clinic.
4. Determine whether the client would like to attend SUD counseling at the mental health clinic or in a SUD treatment facility.

   1. Provide SUD counseling services that the client is interested in or
   2. communicate client interest in treatment to SUD treatment facility or counselor by telephone, by email, or in person.
5. Document discussion, counseling services, and client needs in EHR notes.

The Primary Clinician, Peer Support Specialist, and/or SUD Counselor share peer and family support options with the client:

1. Go over the Peer and Family Support resource with the client.
2. Review the peer support options available within the county mental health clinic setting with the client.
3. Determine whether the client would like to engage with peer support or whether the client would like to engage with family and whether the family would like to engage in providing support.
4. Discuss the logistics of in-clinic and referral options for peer support. Facilitate warm connections and hand-offs because navigating between systems can be challenging for people with a COD. (Note that clinic-specific resource lists should include COD-specific resources.)
5. Document discussion, services, referrals, and client needs in the EHR.

1. Review the range of options that are appropriate for a client, also known as Choice Talk.
2. Compare the pros and cons of treatment options, also known as Option Talk.
3. Reach decisions that reflect client preferences as informed by the experience and expertise of their health care team. This step involves supporting the client in their consideration of preferences and helping the client come to an agreement regarding their treatment plan. This is known as Decision Talk.
4. The Primary Clinician should update the treatment plan to reflect decisions made.

TIP: Some shared decisionmaking conversations, such as the Option Talk and the Decision Talk, may take place only between the client and the Prescriber. Some may take place between the client and any Counselor, Clinician, Peer Support Specialist, or other staff member.

1. Conduct a medication evaluation with the client using the Medications for Alcohol Use Disorder in Mental Health Settings guide.
2. Obtain relevant labs (if indicated within the Medications for Alcohol Use Disorder in Mental Health Settings guide).
3. Consult with an AUD medication specialist for support as needed.

If the client is not a good candidate for AUD medication, continue to develop a treatment plan without medication.

1. The Treatment Team collaborates to develop a treatment plan.

   TIP:

   • Schedule in-person/virtual meetings. It can be difficult to coordinate schedules, but it’s the best way to facilitate communication and collaboration.
   • Set aside a regular time to meet.
   • Think about who you usually collaborate with and how you can broaden that group to include people you don’t ordinarily work with.
2. The Treatment Team communicates the plan to the client.
3. The Treatment Team documents updates to the treatment plan.

   1. See the Treatment Planning and Documentation Guidelines document.

It’s vital that documentation of AUD treatment in the treatment plan follows specific language. An example is provided below. This can be adapted to fit individual clients.

Under the primary mental health diagnosis, list the following objective:
“Support clients’ mental wellness and reduced mental health symptoms through reduced alcohol consumption, based on client self-report.”

Under this objective, add the following intervention:
“Staff to assist client in reducing alcohol use as evidenced by the client's report of reduced consumption of alcohol through offering (or prescribing, if prescribed) medications for co-occurring alcohol use disorder and through offering (or providing, if the client agrees to participate) counseling for co-occurring alcohol use disorder in an effort to reduce mental health symptoms and improve wellness and recovery.”

TIP: Make sure your documentation is consistent with your clinic’s documentation and billing policies.

1. Discuss medication options for AUD with the client, including a review of the risks and benefits.
2. Prescribe the identified medications and educate the client about the expected benefits and potential adverse effects.

   1. For a detailed description of the AUD medication prescription process, use the Medications for Alcohol Use Disorder in Mental Health Settings guide and the Incorporating Alcohol Pharmacotherapies guide.
3. Consult with an AUD medication specialist for support, if needed.

TIP: Medication should continue to be provided even if the client continues using alcohol.

If the treatment plan does not include pharmacotherapy for AUD, skip to Workflow Task 14.

1. Follow the instructions in the Medications for Alcohol Use Disorder in Mental Health Settings guide.
2. Use the following resources as needed:

   1. Highlights of Prescribing Long-Acting Injectable Naltrexone
   2. Long-Acting Injectable Naltrexone Video 1
   3. Long-Acting Injectable Naltrexone Video 2
3. Consult with an AUD medication specialist for support, if needed.

1. The Primary Clinician or SUD counselor provides evidence-based psychotherapy for COD-alcohol and mental health diagnosis.
2. The SUD Counselor works with the rest of the Treatment Team and supervisory staff to establish COD-alcohol groups and individual counseling for COD-alcohol.
3. Conduct COD-alcohol group therapy using the following resources when necessary:

   1. Building Recovery by Improving Goals, Habits, and Thoughts
   2. COD Treatment Workbook
   3. Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) KIT
   4. SUD Group Therapy: A Treatment Improvement Protocol

1. The Primary Clinician and/or SUD Counselor updates the treatment plan.
2. The Psychiatrist or Nursing Staff updates the medication treatment plan.
3. The Treatment Team should collaborate to discuss the psychosocial and medication treatment plans and how these work together to support the client.