Physicians are well aware of the harm that the use of drugs and alcohol brings to their patients and families. The prevalence of substance use disorders exceeds 20% in ambulatory practices and is even higher in hospitalized patients. Those affected include everyone from adolescents, teachers, and shipyard workers to doctors themselves. Physicians report that conversations with patients about drinking can be stressful and conflict laden, and that many patients are unmotivated to change their behavior. Physicians’ negative feelings sometimes derive from their own family experiences or from encounters with intoxicated patients who can be hostile, uncooperative, and occasionally violent. These dynamics, combined with the sense that substance abuse may not really be a “medical” issue, tend to keep physicians from addressing alcohol and substance use disorders in their patients.

Evidence from many sources provides reason for optimism, however, and shows that clinicians who take a few moments to thoughtfully structure their interventions with patients can reduce harm, lower medical care costs, lessen morbidity for patients and families, strengthen patients’ family and social relationships, and enhance patient self-esteem and emotional stability. Indeed the recovery rate from substance abuse, 30–40% of treated patients, exceeds that from most other chronic illnesses. Recovering patients often credit their clinicians with being a primary factor in their recovery and with literally saving their lives. For physicians, participating in the identification and treatment of substance abuse can be as gratifying as helping patients recover from leukemia or pneumonia.

Primary care medicine is increasing its role in addressing alcohol and drug problems, since the majority of individuals with alcohol or drug abuse usually avoid seeking care from specialized chemical dependence programs. Two important recent developments are significant in this regard. The first is a push for early identification and treatment of alcohol and drug abuse before those problems become severe. The Screening, Brief Intervention and Referral to Treatment (SBIRT) model is a public health approach promoted by the National Institutes of Health to encourage universal primary care screening and intervention when needed. This screening now qualifies for Medicare reimbursement. The second important movement is the increasing recognition that alcohol and drug use problems are often chronic relapsing conditions and need to be managed medically, with ongoing monitoring in primary care settings and referral when needed to specialized chemical dependency services. Physicians have a key role to play in this process. In this chapter, we will discuss identification and management of substance use problems, and how physicians’ interactions with patients can enhance their coping with these problems.

Chemical dependence (nontobacco-related addictive disease) is a chronic, progressive illness affecting 24.8% of Americans at some time in their lives (lifetime prevalence) and approximately 6.5% of Americans at any given point in time. Heavy drug or alcohol abuse precipitates a vicious cycle of increased use associated with behavioral and social problems. Heavy drinkers are at elevated risk for hypertension, gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis of the liver, and several cancers. The insidious development of tolerance to intoxication, cognitive deficits from high doses, and dysphoria leads to social impairment. Relationship problems are exaggerated when friends and family resent the (apparently) voluntary nature of overindulgence. Addicts can become adept at ignoring reality and suppressing negative feelings. Lengthy periods spent in brain-altered states result in the dramatic neurophysiologic changes of addiction and withdrawal. Further, emotional isolation may develop when those suffering from addiction make excuses for their behavior, direct blame onto others, and show hostility when sensible limits are discussed. Physicians have an important role to play in mitigating these adverse consequences.

Drug and alcohol problems exist on a continuum (Table 24-1). At times, diagnosis may be elusive because of scant or imprecise information. Nevertheless, experts agree on an evidence-based classification system that is useful in guiding physician actions. Patients on the severely afflicted end of the continuum, with the prototype syndrome formerly known as alcohol or drug dependence, but now diagnostically classified as severe alcohol or drug use disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) (often called alcoholism or drug addiction, respectively), suffer medical and social consequences from uncontrolled use. A striking 5–10% of adults develop this syndrome. Physical dependence and withdrawal syndromes imply drug dependence virtually 100% of the time.

People toward the center of the continuum, with problems of modest severity, have mild-moderate drug or alcohol use disorder (alcohol or drug abuse), a maladaptive pattern which leads to impairment or distress. Note that what distinguishes the patient with a mild-moderate substance use disorder (drug abuse) from the patient with severe drug abuse disorder (drug dependence) is not the nature of the problems, but the frequency, persistence, and pervasiveness of the problems. Thus, both drug abuse and drug dependence may include health problems (e.g., stroke from cocaine use, hypertension from alcohol use, oversedation from benzodiazepines), legal problems (e.g., arrests for DUI or violence), family dysfunction, and performance problems at school or work.

At the milder end of the continuum, conceptualization of alcohol and drug use problems has been broadened to include patterns of substance use that do not meet strict diagnostic criteria but which put patients at risk for adverse health consequences. These patients have been described as “at-risk,” or “hazardous” users. These people use too much, but have not developed important negative consequences. Physicians should intervene with them on the basis of the quantity of intake. In contrast, intervention with patients with “abuse” or “dependence” is made because of negative consequences and high quantity of use. Most, but not all people who experience serious life consequences use very excessive amounts, but the decision about how vigorous to be with interventions is made on the severity of problems, not on the amount consumed. Data about both amounts and consequences should be sought, but the full meaning of the data about amounts cannot be established until the physician obtains a clear picture of adverse consequences or lack thereof.

Regarding alcohol, expert consensus is that moderate drinking is defined by quantity of intake (not more than 14 drinks per week for men and 7 for women), a social setting for drinking, and amount consumed at one time (not more than 4 drinks per occasion for men and 3 for women). Drinking above these limits is called “at risk” or “hazardous,” and is likely to cause harm, according to long-term studies. “At-risk” drinking is very common. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 3 out of 10 adults in the United States drink at levels that put them at risk for physical and mental health problems.

“At-risk” prescription drug use includes patients on mood-altering drugs or medications with abuse liability or prescription pain medications for more than 3 months. The majority of patients using long-term sedative drugs to manage insomnia, anxiety, depression, and other disorders, as well as those using narcotics to treat chronic pain, develop neither problems nor dependence. Similar to drinkers and users of illicit drugs, however, 10–20% do experience problems such as falls, oversedation, drug interactions, drug overdoses, or symptoms of dependence, such as taking more medication than prescribed. Therefore, physicians need to be alert to potential problems arising from long-term medication use. In addition, of course, physicians need to be alert to the possibility that patients may be using medications for other than as indicated, for example, use of pain medications to enhance mood, or obtaining medications from more than one physician.

Although the brain effects of addictive drugs vary in neurochemical mechanisms, timing, intensity, and potential toxicity, the severe substance use disorder is similar across the various drug classes and specific drugs. Addictions to alcohol, heroin, cocaine, methamphetamine, benzodiazepines, and other abused substances are variants of the underlying disease of substance dependence. Any differences in strategies for managing abuse of these various substances stem from the legal and social consequences of obtaining and using the particular drug, and its potential medical complications. Consequently, screening, assessment, and management of drug addictions other than alcohol are similar to strategies for alcohol-use disorders. A caveat to these general principles relates to prescription drug abuse, which may involve physicians’ interpersonal and intrapersonal vulnerabilities, beliefs, and prescribing preferences and habits.

Promoting Behavior Change

Several methods for promoting behavior change in patients with substance use problems have emerged from research. A key first step is screening all patients for hazardous alcohol or drug use patterns or substance use disorders. For those with indications of hazardous substance use or abuse, several approaches may be utilized depending on the severity of the problem. These include brief intervention, motivational interviewing, shared decision making, relationship-centered care, and autonomy support (see Chapter 19 for a full discussion on behavior change). The fundamental principles derived from this research are as follows:

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  Generally speaking, the physician takes responsibility for calibrating and adjusting interventions so that patients can hear information and feedback that create or amplify differences between the way life is now and the goals and values patients espouse. Using an empathic and caring style, the physician shows that discrepancies between the actual and the potential might be minimized if patients change their alcohol and drug use patterns.

  
  
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  Patients will not change until they are ready, and ambivalence about change and/or resistance to change is normal.

  
  
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  Physicians can best promote change by maintaining an empathic and relationship-centered style. Taking a strongly persuasive stand usually fails to promote change.

  
  
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  Only the patient can take responsibility for change and effect change. Physicians can promote change by providing information (both feedback about the patient’s health and information about resources), by showing attentiveness and listening carefully to the patient’s ideas about both the pros and the cons of possible changes, and by helping boost the patient’s self-confidence about change.

The fundamental content messages physicians should include in interviews are as follows:

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  I am concerned that your drug use may be hurting you and others you care about.

  
  
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  Most people use a lot less than you, or abstain.

  
  
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  For better health, you should curb (or cease) your drug use.

  
  
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  The key choices are up to you.

  
  
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  I will give you my best advice, which is based on expert consensus and my experience with other patients with similar problems.

  
  
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  I want to collaborate with you, even if progress is slow or intermittent.

The fundamental process strategies physicians should follow are as follows:

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  Maintain dialogue when giving information and recommendations; use a tell, ask, tell strategy.

  
  
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  Make clear recommendations, but do not try to persuade patients.

  
  
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  State explicitly that you will advise, but that the patient decides.

  
  
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  Establish the patient’s commitment to any plans on which you agree.

  
  
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  Never argue with patients and do not try to overcome resistance, reluctance, rebellion, or rationalization. Use reflection to respond to these manifestations of ambivalence.

  
  
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  Support the patient’s self-confidence.

Two key steps can assist physicians in doing a better job with substance-abusing patients. The first is to intervene as soon as any clue suggests that an alcohol or drug use problem might be present; do not wait until the evidence is glaring or a patient’s health has begun to suffer. Physicians can better limit serious consequences of substance use by broadening their focus from the detection of dependence or addiction to include the detection of hazardous or risky patterns of use.

The second key step is to conduct those interventions using techniques specifically structured to promote behavior change, as described below. We will discuss first the process of deciding which patients require interventions, and then discuss principles, content, and strategies of effective physician–patient interactions.

Studies show that “brief interventions” can be structured for “at-risk” users as well as those who have developed mild, moderate, or severe substance use disorders. Adjusting interventions to problem severity is helpful, and consequently we suggest simple strategies that separate healthy users from potentially problematic ones and help clinicians assess severity. Subsequent sections advise physicians what to do in each case. In the steps below, we incorporate the National Institute on Alcoholism’s Clinician’s Guide: Helping Patients Who Drink Too Much, which is a very useful reference and includes procedures also relevant to screening and treatment of drug use. These steps can be recalled using the “4 A’s”—Ask, Assess, Advise, and Assist.

Step One: Ask about Alcohol and Drug Use

Step one is to ask about alcohol and drug use. Prescreen every new patient with two questions: “Do you sometimes drink beer, wine, or other alcoholic beverages?” and “When was your last use of marijuana or other drugs?” If the answer is “No,” “Never,” or “Years ago,” leave this topic. If patients belong to an abstinent subgroup with past problems, they often disclose this spontaneously.

For patients who report any alcohol use, ask the National Institute on Alcohol and Alcoholism recommended single question about hazardous drinking (Table 24-2). If positive (five or more drinks in a day for men; four or more in a day for women), quantify the drinking behavior. Determine a weekly average by asking: “On average, how many days a week do you have a drink?” and “On a typical day, how many drinks do you have?” Drinking above “safe limits” (Table 24-3) means the person is at least an “at-risk” user.

The National Institute on Drug Abuse has developed a similar stepped screening approach. The first step is to ask patients which drugs they have used in their lifetime (including major categories of illegal drugs as well as prescription psychotropics other than as prescribed); and of these, which if any have been used in the past 3 months.

Step Two: Assess for Substance Use Disorders and Substance-Related Problems

For patients who drink alcohol over recommended limits or who report drug use in the past 3 months, the next step is to determine if patients meet criteria for a substance use disorder. See Table 24-1 for a summary of diagnostic criteria.

If any dependence screen is positive, or if intake exceeds safe limits, or if another clue from examination or the family suggests a drinking or drug problem, the clinician needs more detail to clarify the extent of the problems. A search for characteristic negative consequences is warranted and not time consuming if thoughtfully structured. The physician decides when to conduct this inquiry based on priorities for the present encounter; however, because alcohol and drug use produces many symptoms and affects many other illness conditions, at least a brief inventory when the issue initially surfaces is imperative. Asking patients about the symptoms in Table 24-4 as they relate to alcohol use provides ample data for the primary assessment, and the NIAAA Clinician’s Guide organizes this inquiry very well. Protocols for drug use assessment are less well developed than those for alcohol. Patients can be assessed further by inquiring how much money they spend a week on drugs, the frequency of use, consequences of use, and how many days or weeks they have abstained in the past 12 months.

Interviews with others, including family, nurses, or social workers, enlarge the inquiry if the patient furnishes insufficient data. Records from other physicians or hospitals may contain unanticipated information that helps determine a diagnosis. Obtaining a thorough evaluation allows the physician to discuss impressions in a compassionate manner. In fact, experimental data show that thoughtful diagnostic conversation itself produces beneficial therapeutic effects. Additional assessment approaches, including laboratory testing, are described below.

The CAGE test (Table 24-5

Related posts:

1: The Medical Interview 8: Global Health and Behavioral Medicine 19: Behavior Change 27: Attention Deficit Hyperactivity Disorder 37: Errors in Medical Practice 40: Palliative Care, Hospice, & Care of the Dying

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