INTRODUCTION

Substance abuse and substance dependence are commonly seen in medical settings and are frequently co-morbid with other medical and psychiatric disorders. Considerable social stigma exists toward patients with substance use disorders; healthcare providers frequently have negative attitudes toward these patients as well. Fortunately, you can master communication skills that will facilitate the establishment of therapeutic relationships and help motivate patients for treatment.

People with substance use disorders are heavily stigmatized. Clinicians, including mental health professionals, are not immune to negative attitudes about substance use disorders. Identification, assessment, and referral for treatment of are strongly influenced by clinician attitudes, which in turn are formed by life experiences, including personal, family or professional contact with substance use. Effective tools and strategies can help you recognize the physiologic and behavioral red flags of addiction and elicit a substance use history in a nonjudgmental manner, so you can make the appropriate diagnosis and develop a patient-specific plan for treatment and referral (http://drugabuse.gov/nidamed/).

This educational module on the clinical assessment of substance abuse disorders presents written text and instructional videos that demonstrate the knowledge, skills and attitudes needed in the screening, evaluation and referral of patients with substance use disorders. The video examples in this module focus on prescription drug abuse, a critical and increasing problem in clinical practice with serious morbidity. However, the strategies for screening and referral that we present are the similar for all substance use disorders.

For additional information on drug abuse and substance use disorders, please go to the National Institute on Drug Abuse's NIDAMED Web site http://www.drugabuse.gov/nidamed/ and the Substance Abuse and Mental Health Services Administrations website: https://www.samhsa.gov

MEDICAL MODEL OF SUBSTANCE ABUSE AND SUBSTANCE DEPENDENCE

Substance use disorders are complex chronic, relapsing and remitting diseases, resulting in significant morbidity and mortality. Substance abuse has an impact on many health conditions and can lead to major public health problems, including the transmission of HIV, hepatitis and tuberculosis, as well as incarceration. The relapse rates are very similar to those of other chronic medical disorders such as asthma, diabetes and hypertension.

Please click the video button on the left to watch Cliff, a Family Clinician, talking about his substance use and how he became addicted.




Please click the video buttons on the left to watch Michelle discuss how mental health issues led to addiction and Rhonda discuss the complex life circumstances that led to her addiction.


Substance use often begins in childhood or adolescence, when the brain is undergoing dramatic developmental changes. The prefrontal cortex enables us to assess situations, make sound decisions and keep our emotions and desires under control. Adolescents are at increased risk for poor decisions (such as trying drugs or continued abuse) because their prefrontal cortex is immature. The developing brain may also be particularly vulnerable to chemical changes caused by psychoactive drugs and, therefore, when adolescents and young adults experiment with substances, they may be at higher risk of continued abuse or dependence. Adolescents who use alcohol or other psychoactive drugs also frequently have academic and social problems, as well as encounters with the criminal justice system.

Continued use of psychoactive substances causes biochemical and structural changes in the brain that limit self-control and result in substance use disorders. Symptoms of substance abuse, dependence and withdrawal can mimic symptoms of major psychiatric disorders. Brain-imaging studies show changes in anatomy and physiology in areas known to be critical for judgment, decision making, learning, memory and behavior control ( http://www.drugabuse.gov/scienceofaddiction). Substance use disorders are a major co-factor in violent injury. Despite the neurochemical changes and the chronic and relapsing nature of these diseases, treatment is effective and recovery possible. http://www.drugabuse.gov/scienceofaddiction

Substance use disorders have a complex etiology. Genetics can account for 40 to 60 percent, in addition to biologic changes in brain function and pre-existing or secondary co-occurring psychiatric disorders. Family history, social experiences, and traumatic life events can also be important etiologic factors. Not all people who "experiment" with drugs or alcohol develop a substance use disorder.

Treatment enables people to regain control of their lives and counteract the powerful disruptive effects on the brain and behavior of substance abuse or dependence. You can make a difference by helping your patients access effective treatment. Treatment takes different forms depending on the drug of abuse. For example, medication assisted treatment (MAT) with methadone, buprenorphine or naltrexone plays a critical role in recovery for individuals with opioid or alcohol use disorders. Active treatment of co-existing psychiatric illness. Relapse is more likely in patients who do not adhere to MAT and/or psychiatric treatment. Relapse rates for treatment of substance use disorders are similar to those of other chronic illnesses, like asthma or diabetes. Thus, substance use disorders should be treated like any chronic illness, with relapse serving as a trigger for renewed intervention.

Diagnostic Criteria

To serve your patients well, you must know features that distinguish the substance use disorders from one another and from use that is not problematic. It is important take action when you are concerned, even if you cannot make a definitive diagnosis. Knowledge and skill can help us overcome our natural reluctance to broach this difficult issue with our patients.

The DSM V criteria for distinguishing substance use disorders, including substance abuse, dependence and substance-induced disorders, are delineated in the next sections. The symptoms that practicing clinicians witness are frequently only the tip of the iceberg. Any concern on your part may indicate a more serious problem. Therefore, take action as soon as your screening protocols or the presence of any "red flag" suggests substance use problems. Refer all patients with evidence of a substance use disorder for further evaluation and treatment by a substance abuse professional.

Substance abuse specialists have the clinical knowledge, skills and tools to make an exhaustive diagnostic inquiry, make a diagnosis and provide appropriate treatment.

Substance Use Disorders and Substance Related Disorders

TThe Diagnostic and Statistical Manual of Mental Disorders, DSM-V, categorizes Substance Use Disorders and Substance-Induced Disorders, and specifies criteria for diagnosis: Abuse and dependence are maladaptive patterns of substance use leading to clinically significant impairment or distress, as manifested by persistent or recurrent social or interpersonal problems caused by substance use. Remember this phrase even if you never look at the DSM-V again. "Addiction" is a commonly used but nonspecific and sometimes stigmatizing term. We define "addiction" as a chronic, relapsing brain disease, characterized by compulsive drug seeking and use despite known harmful consequences. It may include physical dependence, marked by brain changes associated with daily substance use that produce noxious symptoms (e.g., gooseflesh, runny nose, hyper-alertness, sweating, tremor, confusion) when the person stops using (i.e., withdraws). Withdrawal is a powerful stimulus to use again, and the symptoms abate when use is restarted. It is important to note that physical dependence is not the same as addiction.

The DSM-V has shifted from the use of the term "addiction" to "substance use disorders" and has integrated the concepts of substance abuse and substance dependence. According to DSM-V, "substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress." Substance use disorders are identified when the recurrent use of substances results in functional or clinical impairment which includes impaired control, social impairment, risky use and tolerance. An individual must meet at least two out of 11 criteria over a 12-month period to be diagnosed with a substance use disorder. Presence of a mild disorder requires two to three symptoms, a moderate disorder requires the presence of four to five symptoms, and a severe disorder requires the presence of six or more symptoms. (https://www.amhc.org/1408-addictions/article/48502-the-diagnostic-criteria-for-substance-use-disorders-addiction)

Each of the nine-specific substance are addressed as a separate disorder, though most of the criteria are the same. Polysubstance use is no longer a diagnostic option. Additionally, DSM-V provides criteria of substance intoxication, substance withdrawal and substance-induced disorders.

As an example, the criteria for Opioid Use Disorder describe a "problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period." The 11 criteria:


1. Opioids are often taken in larger amount or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid or recover from its effects.
4. Craving or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect of opioids.
7. Important social, occupational or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by the following:
• A need for markedly increased amounts of opioid to achieve intoxication or desired effect
• A markedly diminished effect with continued use of the same amount of opioid
11. Withdrawal, as manifested by either of the following:
• The characteristic opioid withdrawal syndrome
• Opioids (or closely related substance) are taken to relieve or avoid withdrawal symptoms.

SCREENING FOR SUBSTANCE USE DISORDERS

Clinicians often do not identify substance use disorders. To avoid this, screen all new patients and periodically reevaluate established patients. In one primary care study, clinicians reported a prevalence of substance abuse disorders of less than one percent of their patients despite an estimated substance abuse prevalence of two to nine percent (SAMHSA, 2008). Lack of knowledge of clinical screening techniques and referral resources increases clinician reluctance to evaluate patients for substance use disorders.

An appropriate clinical interview includes questions about substance use and the sequelae of use across medical, psychiatric, personal, legal and social domains. Pay close attention to high-risk or under-recognized patients, including pregnant women, young and older adolescents, older adults, indigenous people, healthcare providers, noncompliant patients, those with a history of trauma and/or of major psychiatric disorders, and individuals with a history of criminal justice involvement. (https://www.samhsa.gov/sites/default/files/topics/tribal_affairs/ai-an-data-handout.pdf)

Many high-risk patients have co-morbid medical or psychiatric disorders, such as those with chronic pain, gastrointestinal complaints (abdominal pain), systemic infections including Hepatitis B and C, HIV/AIDS, other STDs, bacterial endocarditis, pulmonary disease, obesity, cardiovascular and cerebral vascular disease, sexual and/or other trauma including motor vehicle accidents, gunshot wounds and psychiatric symptoms including depression, anxiety and insomnia. (http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse)

All non-hospice patients with chronic opioid use should be evaluated for substance use and disorders. The assessment and management of chronic pain presents complex challenges to the clinician. Some patients will come to you after being treated with ongoing opioids and will feel they cannot function without the medication. It is important to remember that pain is a subjective sensation that is very real for the patient. Many factors influence the processing of pain signals and the sensation of pain, including past life experiences, personality traits, fear and anxiety, the meaning of the pain, depression, "secondary gains," etc., in addition to any pathology that may be present. The factors that contribute to a patient's perception of pain may need to be evaluated over several visits, sometimes with the help of a pain professional or psychiatrist.

If any of the known medical, psychiatric, familial, social, school or employment, or legal "red flags" are present, as noted in the next section, you will need to do a more detailed evaluation to evaluate the presence of a substance use disorder and the patient's readiness to accept treatment.

When screening for substance use disorders, include questions about both alcohol and drug use. Many patients use more than one substance and you will need to explore each one. Ask specifically about tobacco (cigarettes, cigars, smokeless tobacco), alcohol (beer, wine, liquor), marijuana, cocaine/crack, methamphetamines, other stimulants, opioids (heroin and prescription pain medications), PCP, inhalants and other prescriptions, especially benzodiazepines. (http://drugabuse.gov/nidamed/http://drugabuse.gov/nidamed/, Isaacson, 2005; Parran, 1997, http://www.nida.nih.gov/DrugPages/DrugsofAbuse.html) There are validated tools to assist with screening. For example, the NIDA Modified Alcohol, Smoking and Substance Involvement Screening Test (NMASSIST) provides screening questions covering all drugs of abuse (specifically separating out prescription drugs from similar street drugs). (https://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/additional-screening-resources)

Please click the video-button on the left to play Dr. Parran's Comment on screening.

It can be difficult to introduce the subject, and we are often tempted to soft-pedal our questions. Studies show that "subtle" screening is not better than direct questioning (www.nida.nih.gov/DrugPages/DrugsofAbuse.html). Effective screening strategies include simple structured questionnaires, such as the CAGE-AID, adapted from the widely used CAGE questions for alcohol dependence (Pulford, 2007, Clark, 2008).

With adult patients, start with a question about use: “ Do you use, or have you ever experimented with alcohol or other substances? ” If “yes”, or if the answer is equivocal, follow with the CAGE questionnaire: Have you ever felt a need to Cut Down on or Control your use of alcohol or other drugs? Have friends/family made comments to you about your use of alcohol or other drugs … have those comments ever Annoyed you? Have you ever felt bashful, embarrassed or Guilty about things you have said/done when using alcohol or other drugs that you would not have said/done otherwise? Do you ever use Eye-openers (drinking or using in the morning to “get going” or settle your nerves)?

Please click the video-button on the left to play Dr. Parran's Comment on patients' positive responses to these questions.

If any answer is positive, initiate a "Brief Intervention" (described below), because the patient's responses to the questions will help you structure your brief intervention conversation.

In your follow-up, define patterns of use for each substance including the quantity, duration of use, frequency of use during that time, route of administration, effect of use, strategies used to acquire substances and cost. Explore periods of abstinence and triggers to use substances along with associated physical symptoms (Clark, 2008). It can be helpful to ask the patient about his/her perspectives and observations about their use and consequences.

It's also important to identify those patients at lower risk for substance use disorders. The NIAA has defined criteria for low-risk alcohol use. For women, low-risk drinking is defined as no more than three drinks on any single day and no more than seven drinks per week. For men, it is defined as no more than four drinks on any single day and no more than 14 drinks per week. For patients who are using substances, but appear to be at low risk of a substance use disorder, give them information about these safe limits for alcohol use, and acknowledge that the only reasonable advice about other drug use is not to use illicit substances and not to exceed amounts prescribed for any psychoactive prescription drugs. Continue to screen these patients periodically to verify that they have not developed a substance use disorder.

Red Flags for Substance Use Disorders

Patients are often reluctant to reveal substance use disorders. They may fear negative judgments, be embarrassed about their inability to control their lives, or be in denial about the extent of the problem. Patients effectively avoid disclosure in a variety of subtle or not-so-subtle ways. Their methods include not listening to questions, minimizing use or consequences of use, changing the topic, discouraging inquiry with irritation, anxiety or other behaviors, blocking facts from their own consciousness, and outright lying.

Please click the video buttons on the left to see what Reno and Rhonda have to say about interactions with their doctors.

There may be signals that raise concern about a patient's substance use in an interview, during the physical exam, in prior records or in statements from significant others, office staff or hospital staff. These "red flags" should be an indication to follow up with the same diligence and persistence as you would after a positive drug screen or disclosure of heavy substance use.

Some common red flags:

• Physical findings: Alcohol on the breath, ascites, an enlarged liver, nasal ulcers or a perforated septum, excoriated skin (from scratching), track marks, skin abscesses, obesity or anorexia, abnormal gait, tremor, slurred speech, change in pupil size, injuries, chronic pain, blackouts, accidental overdoses, withdrawal symptoms, other liver or gastrointestinal problems, premature labor and vague somatic complaints. For more information about specific medical consequences of substance use, please see http://www.nida.nih.gov/consequences/.
  
  
• Psychiatric symptoms: Depression, anxiety, flashbacks, insomnia, suicidal behavior, paranoia, irritability, vagueness, hallucinations, memory and concentration problems, and defensiveness about questions relating to substance use.
  
  
• Social Problems: Isolation/withdrawal, loss of previous friendships, marital difficulty including intimate-partner violence and loss of interest in prior activities (e.g., sports, hobbies).
  
  
• Education and employment history: School failure or poor grades, job losses, and frequent job changes.
  
  
• Legal problems: DUI, involvement in assault as either perpetrator or victim, other violent behaviors, stealing, drug possession and prostitution.
  
  
• Family history: May be positive for substance use or mental disorders, as well as developmental problems in children.

Clinician Attitudes

Clinicians who have had difficult professional or personal experiences with substance use disorders may expect these difficulties to repeat with each patient. They may believe the patients will betray their trust and manipulate them with drug-seeking behavior. These early experiences can lead to persistent negative attitudes, including cynicism and hopelessness, resulting in inadequate screening for substance use disorders and lack of empathy. Negative clinician-patient interactions decrease patients' willingness to discuss use and accept referrals for treatment (Pulford, 2007).

You can enhance your care of patients with substance use disorders by reflecting on your own attitudes, discussing them with colleagues, increasing your knowledge about the medical nature of the disease and the effects of substance use disorders on patients' lives and by practicing discussions about diagnosis and treatment with patients who are fearful and discouraged. Very few of us had models for empathic relationships with patients who are abusing substances. If we don't feel that we have the tools to help them, the encounters will inevitably be frustrating for us, and that can become a self-fulfilling prophecy. The skills described in this module can help you move past previous difficult experiences and have more success in the future.

Significant societal stigma still exists toward patients with substance use disorders despite significant advances in scientific knowledge, diagnosis, and treatment (Leshner, 1997; Clark, 2008). As we have noted, addiction is comparable to other chronic medical conditions with similar rates of relapse such as diabetes, asthma or hypertension.

 

Please click the video button on the left to hear Dr. Parran's comments about the benefits of honing skills in these challenging relationships.

 

Negative clinician attitudes can be manifested in the way clinicians ask and respond to questions about substance use, e.g., "You don't use drugs, do you?" or in responding "Good" when a patient initially denies use. Anger toward patients, especially when they are noncompliant or relapsing, will only drive a wedge between the patient and clinician and exacerbate noncompliance.

Addressing patients' drug-seeking behaviors respectfully and directly, in an empathic manner, while setting appropriate limits on requests for prescription drugs, will increase the possibility of engaging patients in treatment. Patients' behaviors may continue to be frustrating, but a positive attitude and belief in the possibility of recovery can energize patients. After all, many patients do recover, though it may be a long process and take several interventions. You can visualize frustrations as challenges to overcome, and feel compassion for patients' struggles. Learning and using effective communication strategies and setting relationship limits in a respectful and straightforward manner create a healing relationship. Your hope and respect give your patients both hope and a new measure of dignity. If patients feel that you won't give up on them, they may be less likely to give up on themselves.

Respond to irritability and suspicion of screening by reflecting what you hear:

“Many people are concerned about these questions.”  “I hear some concern or irritation in your voice.” “I’m feeling a bit confused by your responses. Help me better understand what you are saying.”

When patients express irritation with your reflections or your limit-setting, or at their own shortcomings, here are some helpful responses for you to consider.

“I hear your frustration that I will not prescribe more oxycodone for you” “I understand your frustration.  Patients in recovery tell me that my firm limits were helpful in getting them into treatment; I hope that will be the case for you.” “I hear your sense of hopelessness now, and I’ve heard so many people turn that around when they get into treatment.”  “I know you feel bad about failing to carry out the plan. But let’s look at some of the details together and see if we can learn something that will help you succeed the next time.”

Physical Examination

Prognosis for recovery is better if diagnosis and intervention are made early in the course of the disease. Some physical findings may be present in early stages of substance use disorders. Others, particularly the "classic" physical findings occur only in later stages.

Injuries from accidents, or from altercations in the home or on the streets, may appear early in the course of substance use disorders, and they are always cause for active intervention.

Other early clues include alcohol on the breath; signs of intoxication such as abnormal gait, slurred speech, sedation, dilated or constricted pupils, excoriated skin (from scratching), track marks, and skin abscesses; and behavioral symptoms such as irritability, vagueness, paranoia, and poor concentration.

The earlier a diagnosis is made, the better the prognosis. However, use over periods of years produces physical findings that make diagnosis much easier. Some examples of physical symptoms and findings that ensue after persistent use include the following:

• Malnutrition, including cachexia, but also obesity
  
  
• Systemic infections including cellulitis, sexually-transmitted diseases, HIV, hepatitis B and C, tuberculosis, and bacterial endocarditis
  
  
• Elevated blood pressure, tachycardia, chest pain, transient ischemic attacks, restlessness, sweating, and tremor—from withdrawal
  
  
• Physical damage from administering a drug that involve chronic sinus/nasal problems, worsening bronchitis from marijuana or cocaine smoking, or "track marks" from injection drug use
  
  
• The myriad systemic effects of alcoholism, including delirium, liver enlargement or failure, ascites, anemia, thrombocytopenia and bleeding, seizures, trauma, myopathy, and cardiomyopathy
  
  
• In pregnant women, abruptio placenta, premature birth, low gestational size, and neonatal withdrawal syndrome

Intervention may seem more difficult in later stages of the disease process, but many patients have suffered enough by that time and are more ready to accept the diagnosis and referral for treatment with experienced professionals. Be clear about availability and efficacy of treatment, even after many years of destructive use; be respectful and compassionate; and be persistent with later-stage patients.

For more information about specific medical consequences of substance use, please see http://www.nida.nih.gov/consequences/

Laboratory Evaluation

While no specific laboratory test establishes an unequivocal diagnosis of substance use disorder, blood alcohol levels may confirm tolerance or detection of another drug may confirm the origin of coma or confusion. Routine laboratory screening including liver function tests, complete blood count (anemia from chronic gastritis or a slightly high Mean Corpuscular Volume [MCV] with excessive alcohol consumption), and vitamin B12 and folate levels occasionally are the "red flags" that stimulate further diagnostic inquiry.

Blood alcohol levels, breathalyzer test results, urine drug screens and, less commonly, hair and saliva analysis can be used to assess patients for possible alcohol and other drug use. A drug screen may be useful in evaluating an adolescent with school problems or in accidents, domestic violence or other trauma situations. Performing urine and blood screens in some situations (e.g., school, employment) may be controversial, so it is advisable to obtain the patient's (and/or parents') permission before initiating such screens. Failure to do so can damage the clinician-patient relationship and cause legal consequences for the clinician.

Blood, urine and saliva studies add a crucially important dimension to the effectiveness of treatment programs. Testing adds structure and limits that are critical aspects of helping patients regain self-control and self-respect.

VIDEO: Initial Visit

 

THE BRIEF INTERVENTION

When clinical screening indicates a potential substance use disorder, you need to assess the patient's readiness to change and conduct a brief intervention to facilitate treatment engagement. It is critical to convey to patients that treatment works and recovery is possible.

In a brief intervention, you tell the patient your diagnosis in a matter-of-fact and non-confrontational way. You offer educational materials and choices about next steps, emphasize that any change is up to the patient and convey confidence in the patient's ability to change his or her behaviors. You help the patient work out appropriate and manageable next steps toward following your recommendations. You should encourage the patient to regularly report progress toward his or her established goals (Clark, 2008).

Prior to discussing treatment options, check patients' readiness to change their behavior (see specific skills below). Inquire directly about patients' interest in changing and about their confidence in accomplishing change. You then make definite treatment recommendations, tailoring your conversation based on the patient's apparent readiness to take action. Acknowledge that the patient is the one who decides what to do and, in fact, does all the real work.

Most clinicians find that telling patients of a diagnosis of a substance use disorder is a difficult task, an uncomfortable example of "giving bad news." The discomfort can arise from an incomplete understanding of the pathophysiology of substance use disorders, from previous negative experiences with substance abusing patients, from negative judgments about the patient's behaviors (impulsivity or criminal activity) and from a lack of practice with skills for this special type of clinician-patient interaction. The following guidelines present ideas about the content of recommendations, the process of giving them and some "how-to's" and skills for responding to patients' reactions, as well as information that may assist you in examining your own biases.

All intervention dialogue with patients should be direct, empathic, and nonjudgmental in order to present information without alienating patients who may be ashamed, in denial, ambivalent or resistant to change. The use of shame, guilt, threats, confrontation, arguments and arbitrary treatment plans is counterproductive and should be avoided. Express optimism about recovery and willingness to continue to work collaboratively with your patients (Clark, 2008). NIDA Info-Facts for "Understanding Drug Abuse and Addiction" are available at http://www.nida.nih.gov/infofacts/understand.html

Explicitly and clearly recommend that patients with mild substance abuse disorders abstain from all illicit drugs. You can do this while acknowledging that this is the patient's decision. You might say "You will make your own choices about your substance use. I recommend that you stop using completely because of the risk to your health."

Patients with a co-morbid psychiatric disorder will need help finding a qualified psychiatrist to prescribe and supervise the taking of any appropriate psychoactive drug. It is particularly helpful if the psychiatrist is associated with a licensed substance use disorder treatment program. Coordination of care is essential. Do not prescribe any psychoactive drugs for patients, unless they are active in a treatment program, and then only with specific guidance from that program. If you prescribe unilaterally, your prescriptions may not be effective, and they are likely to worsen patients' problems. Be clear about your medical concerns and offer specific information connecting the patient's substance use and medical issues. Provide patients with written information from the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) about drug abuse disorders and steps they can take. It is important to convey that you believe they need the help of substance abuse professionals and that you would like to refer them to local treatment programs.

Recommendations for patients who have progressed to moderate or severe substance use disorders are essentially the same as for mild substance use disorders: abstinence and participation in a licensed treatment programs. Office counseling is rarely useful for patients who are not participating in other treatment activities, and it unwittingly contributes to prolonging or worsening the substance use disorder. You may wish to follow up and support such patients, but leave the treatment to professionals. It is important to covey to patients that you are not abandoning them as their primary care provider. You might say, "I will continue to care for your diabetes and high blood pressure, but I'm not qualified to help you with your substance use. In order to have the best treatment, you need to see a specialist." This is no different from referring patients with heart disease to a cardiologist while you continue to see them for primary care.

In the most common clinical situations, you should not prescribe medications that substance using patients can abuse. Instead of prescribing, respectfully and calmly say "no" and continue recommending that the patient take advantage of specialist treatment. No matter how persuasive (or demanding) patients are or how much you think a small dose of "x" might ease their suffering, we cannot emphasize enough this caveat. Patients who have a substance use disorder and require narcotic medication for pain management following surgery or trauma should be managed collaboratively by their surgeon/trauma clinician and an addiction treatment professional. The patient always needs to be an integral part of the treatment team.

Content of a Brief Intervention

This section delineates the principles and rationale for a brief intervention, along with sample dialogue for handling patients' denial and their normal resistance to changing their behavior that has progressed to the point that it controls their lives. Depending on severity, you will support positive lifestyle choices, recommend abstinence from illicit drug use, recommend that psychoactive prescription drugs be taken only as prescribed, and suggest referral to professional treatment.

All intervention dialogue with patients should be

• direct
• empathic
• nonjudgmental

When talking about next steps, present information without alienating patients who may be ashamed, in denial, ambivalent, or resistant to change. The use of shame, guilt, threats, confrontation, arguments, and arbitrary treatment plans is counterproductive and should be avoided. Express optimism about recovery and willingness to continue to work collaboratively with your patients. (18)
NIDA Info-Facts for "Understanding Drug Abuse and Addiction" are available at http://www.nida.nih.gov/infofacts/understand.html

Non-problem use:
For patients who are using substances but appear to be at low risk of a substance use disorder, give them information about safe limits for alcohol use, and acknowledge that the only reasonable advice about other drug use is not to use illicit substances and not to exceed amounts prescribed for any psychoactive prescription drugs. Continue to screen patients periodically to verify that they have not developed a substance use disorder.

Substance use disorders:
Explicitly and clearly recommend that patients with substance abuse or dependence abstain from all illicit drugs. For patients with a co-morbid psychiatric disorder, help the patient find a qualified psychiatrist to prescribe and supervise the taking of any appropriate psychoactive drugs—it is particularly helpful if the psychiatrist is associated with a substance use disorder treatment program. Coordination of care is essential. Do not prescribe any psychoactive drugs for patients, unless they are active in a treatment program, and then only with specific guidance from that program; otherwise your prescriptions may not be effective, and they are likely to worsen patients’ problems. Articulate your medical concerns and be specific about the patient’s substance use and the related medical issues. Provide patients with written information from the National Institute on Drug Abuse (NIDA) about drug abuse disorders and steps they can take. It is important to convey that you believe they need the help of substance abuse professionals and that you would like to refer them to local treatment programs.

Substance dependence:
Recommendations for patients who have progressed to dependence are essentially the same as for substance abuse––abstinence and participation in local treatment programs. Office counseling is rarely useful for patients who are not participating in other treatment activities and it unwittingly contributes to prolonging or worsening the dependent state. You may wish to follow up and support such patients, but leave the treatment to professionals.  

Under normal clinical situations, you should not prescribe medications that drug-dependent patients can abuse. Instead of prescribing, respectfully and calmly say "no" and continue recommending that the patient take advantage of specialist treatment. No matter how persuasive (or demanding) patients are, or how much you think a small dose of “x” might ease their suffering, we cannot emphasize enough this caveat . Patients who are drug dependent and require narcotic medication for pain management following surgery or trauma should be managed collaboratively, by their surgeon/trauma clinician, dentist, and addiction treatment professional. The patient always needs to be an integral part of the treatment team.

VIDEO: Second Visit

 

Determining Readiness to Change

When clinical screening indicates a potential substance use disorder, take steps to determine the patient's willingness to accept the diagnosis and accept further exploration, intervention and referral for treatment. Prior to discussing treatment options, check patients' readiness to change their behavior. Inquire directly about patients' interest in changing and about their confidence in accomplishing change.

Researchers have found that patients go through a series of predictable stages in the process of changing unhealthy behaviors. Stages of change include: precontemplation, contemplation, preparation, action, and maintenance. (http://www.niaaa.nih.gov) It is important to understand what stage your patient is in, since your counseling will need to address the patient's particular needs and expectations relevant to that stage. Briefly, in Precontemplation, the patient is content with the behavior and doesn't see the need to change. In Contemplation, the patient understands that there are benefits of the behavior, but also risks and current negative consequences, and is thinking about changing the behavior. In Preparation, the patient has decided that it is best to change the behavior, begins to gather information on what it will take to change, and plans concrete actions necessary to change. In Action, the patient undertakes the necessary behavior, social, and environmental changes necessary. In Maintenance, the patient practices the many behaviors necessary to substitute for the previous unhealthy behaviors and to avoid restarting the previous behaviors. In Relapse, the patient restarts the previous unhealthy behaviors and usually returns to the contemplation stage.

Please click the buttons "Contemplation", "Action", and "Relapse" in the graphic on the left to play video examples showing interviews of Ms. Anderson in these stages. Below are videos of actual patients illustrating maintanance.

 

Please click the video buttons on the left to listen to Reno, George, and Cliff talk about how they remain in the stage of maintenance.

Asking two questions about patients' conviction and confidence helps you ascertain their motivational readiness.  Conviction assesses what patients believe about the importance of taking action, and confidence assesses what patients believe about their present ability to adopt or change a behavior (despite obstacles or barriers.)  The latter is often referred to as their degree of "self-efficacy."

Ask patients to help you understand where they stand by using a numerical rating scale.

"On a scale of 0–10, how convinced are you that quitting cocaine is important?"

Not only will patients' answers to readiness questions alert you to material not usually made explicit, but also many patients respond with more dialogue and useful information about the past and the present. This is true even when patients protest that they do not like to use number scales.

Asking why the number the patient chose is not LOWER than the one the patient named may provide a helpful continuation of the dialogue. You may wish to incorporate this tactic in your Brief Intervention (below), perhaps saying,

"So you are at a “6” about thinking you need to quit cocaine.I wonder why you did not name a lower score?”

Asking about lower scores encourages patients to speak (and to hear themselves speak) about change in positive terms.  You can then move more smoothly to talking about next steps.

Frame your confidence question as follows:

"Let's suppose for a moment that you were a 10, completely convinced that you should cut down or quit. On a 0 to 10 scale, how confident are you that you would be able to entirely abstain for the next four weeks?"

If the patient chooses a low number, you might ask, "What would it take for you to get your confidence level higher, say to an 8?"  The patient may then suggest strategies that develop a greater sense of self-efficacy and hope.

The Narcotic Contract

Prescribing opioids for chronic non-malignant pain is complex and may not be appropriate for primary care. If you choose to do this, it is helpful to be explicit about the circumstances under which you will prescribe narcotics. Asking your patient to sign a narcotic contract can be very helpful.

The NIDA Centers of Excellence for Clinician Information (CoE) https://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/other-opioid-prescribing-resources provide, amongst many other valuable resources, an example of a narcotic contract on page eight to nine of https://www.drugabuse.gov/sites/default/files/files/SamplePatientAgreementForms.pdf

In the video below, you can observe Dr. Parran discussing a narcotic contract with a patient.

EXAMPLE VIDEO: Narcotic Contract

 

Dealing with Resistant Patient Behaviors

Behavior change is difficult for everyone. Patients' resistance to accepting a substance use diagnosis or treatment is frustrating and often contributes to clinicians' irritation and defensiveness. Trying to help patients who do not appear to want help is exhausting and discouraging. Some patients are prepared to accept their diagnosis and a treatment referral in dialogue with a respectful clinician. Some are not - at least at first. If we seek to understand patients' resistance to change, we can develop an effective treatment alliance. During ongoing conversations, we can use our understanding of the nature of resistance to augment patients' intrinsic motivation and hopefulness and thus shepherd patients towards recovery

Patients suffering from substance use disorders often experience emotional isolation, irrational fears, discouragement and hopelessness, accompanied by an overwhelming inner certainty that they are worthless and undeserving persons. This may be manifested by:

• Estrangement from family
• Loss of friends who are not part of a substance-using subculture
• Daily life restricted to obtaining the substance, or to finding the means to obtain it
• Large amounts of time recovering from the effects of use
• Criminal behaviors such as shoplifting, burglary or other types of stealing
• Daily small and large lies about feelings and about actions
• Negative interactions with healthcare personnel, particularly around episodes of intoxication or injury
• Begging, pleading, or wheedling for their substance of choice, or any substitute that might stem the urge or craving—from doctors, pharmacists, dealers, and other users
• Destructive episodes of uncontained anger or impulsivity, resulting in violence to friends, family, or strangers such as pedestrians, people in other vehicles, or healthcare personnel
• Repetitively and abjectly poor performance of social roles such as parent, spouse or partner, worker, or citizen
  
  

The psychological mechanism of denial, intrinsic to the disease process, may play a key role in the patient’s inability to recognize the problem and seek treatment. Sporadic or binge users of psychoactive drugs can have even more difficulty saying, "I can stop anytime."

Shame and guilt based on reactions from friends and family can contribute to patients' resistance. When patients imagine their clinicians' negative response to discovering their involvement with substance use, their shame, guilt and need to stay hidden increase. A co-morbid psychiatric disorder can limit patients' ability to accept a diagnosis or participate in treatment. Substance-induced cognitive impairment can impede patients' understanding of the need for treatment and ability to follow through with treatment.

In concert with the patient and his or her family, develop a differential diagnosis as to why a patient is resistant to treatment. Remain open to addressing the patient's concerns and resistances without confrontation, and develop skills and strategies that effectively communicate your expertise and your concern (Lipari, 2017). (DocCom Modules 9, 13, 14 and 29)

In the following example, the clinician addresses denial directly and uses "reflection" in a genuine attempt to understand and hear the patient's perspective. While the patient does not appear to be ready to discuss treatment, the clinician lays the groundwork for a therapeutic relationship and increases the chance that the patient will be open to further conversation in later visits. Note that the physician does not argue with the patient's assessment while clearly expressing concern about the diagnosis and confidence in their clinical expertise.

MD : Hmmmm. You are doubtful about my diagnosis of a substance use disorder. Patient: I really don’t think I have a problem. I know I can stop at any time! MD: You are pretty certain that the relationship problems and health issues we have discussed do not come from your drug use. Patient: Well, I’m always stressed out with my crazy family, and my horrible boss. I just need to chill out now and then. MD: I hear that even if drug use caused some of the problems, you need drugs to help you chill out. Have I got that right? Patient: I’m thinking you are way off, doc. MD: You know, as we speak, I get more worried about your health. I could be mistaken, but what you have told me about your situation and the way you are looking at it as we talk sounds like what I have heard from others affected by substance use before they got well. In medicine, we understand that this process is common, and we even have a name for it—“denial”. Perhaps I am wrong, but I am deeply concerned, and worry that the disease of substance abuse has taken control of your life. What do you think?  Patient: Thanks for your concern. What about my rash? it is really killing me. MD: I’ll recommend an effective, simple treatment for your skin. How can you and I work together to look out for your overall health, now and into the future?

EXAMPLE VIDEO: Resistant Patients

 

TREATMENT OF SUBSTANCE USE DISORDERS

Treatment for substance use disorders requires specialist care from certified counselors or licensed comprehensive community programs supplemented by mutual help groups, e.g. 12-step programs. You should understand the core principles of treatment, so you can best advise your patients.

Primary care clinicians play a key role in identifying high-risk patients and providing appropriate prevention counseling. When appropriate, family members should be engaged as well. Primary care clinicians also play an essential role in referring patients for treatment. Convey to patients that substance use disorders are chronic, relapsing diseases that can be successfully treated and managed and that recovery is a long-term process.

Effective treatment needs to be individualized, and it includes psychosocial and pharmacological interventions. Treatment recommendations need to be staged based on patients' immediate treatment needs, e.g. brief intervention identifying the diagnoses for the patient, detoxification to manage withdrawal symptoms, residential or outpatient treatment, and adjunctive 12-step programs.

Initial and brief interventions include discussions of the results of screening, advice about the need to change substance use behaviors, evaluation of patients' readiness to make change, negotiation of goals, scheduling of follow-up visits and referral for specialized substance use disorder treatment. Assessment and treatment for co-morbid psychiatric disorders are essential components of substance abuse treatment.

Please click the video button on the left to watch George discuss his treatment.


NIDA Treatment Guidelines

The National Institute on Drug Abuse (NIDA) recommends a set of overarching principles that characterize effective substance use disorder treatments. http://www.drugabuse.gov/infofacts/Treatmeth.html

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.
   
   
2. Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible.
   
   
3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational, and legal problems.
   
   
4. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual's age, gender, ethnicity, and culture.
   
   
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.
   
   
6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding non-drug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community.
   
   
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Buprenorphine and methadone are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate dependent patients and some patients with co-occurring alcohol dependence. (See https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction. For patients with mental disorders, both behavioral treatments and medications can be critically important.
   
   
8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive and psychiatric disorders often occur together, patients presenting for either condition should be assessed for the other disorder and treated accordingly
   
   
9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help patients achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.
   
   
10. Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase both treatment entry and retention rates and the success of drug treatment interventions.
    
    
11. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring.
    
    
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases; and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.
    
    
13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

RELEVANT BEHAVIORS

ASK:

1. Screen all patients for past and present substance use.
2. If any use, ask "CAGE" questions for alcohol/drugs.
3. Ask about frequency of use.
4. Ask about method of administration.
5. Ask patients for their perspective on the current and potential consequences of drug use.
6. Ask patients how they acquire their substances, including how they can afford them.
7. Ask about past quit attempts, or attempts to cut down. Include withdrawal symptoms, how long abstinent, etc.
8. Ask about current mood and any past mental health problems.
9. Ask patients if they are open to hearing that they might have a substance abuse problem and might need specific help for this.
10. Assess patients' conviction and confidence about their willingness to quit using.
11. Conduct interviews in a non-judgmental way. (ie: Do not say, "This is really a will-power problem and you need to just quit!" or make other statements that might induce judgment or shame.)

TELL (Brief Intervention):

1. Tell patients that you are concerned that they have a substance abuse problem and need help to manage it. Talk about the potential negative impact of substance use on patients’ health, family, employment, mental health and well-being.
2. Recommend assistance / treatment, and speak succinctly about options: stop on their own, join a 12 step program, go to an addiction specialist, be referred to a treatment center.
3. If patients are on prescription narcotics, negotiate a treatment contract with them.
4. Inform patients about the role of drug and alcohol testing in treatment monitoring.
5. Communicate that individual needs vary, and that treatment usually includes psychological, social, vocational, and biological interventions.
6. Make a supportive statement like, "Recovery is usually a long-term process and it may take years to return to full functioning."
7. Offer to communicate with patients' families.
8. State your willingness to provide continuing care to patients who abuse substances.

ASK:

1. Ask patients if they are ready to accept a referral to treatment.
2. Ask patients about their reactions to the discussion.
3. Ask patients about their questions and concerns.

REFERENCES

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