24: Alcohol & Substance Use

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:

• 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.

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

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

• 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:

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

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

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

• The key choices are up to you.

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

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

The fundamental process strategies physicians should follow are as follows:

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

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

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

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

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

• 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) is a thoroughly studied screen. Studies show that substituting “alcohol or drug use” for “drinking” in the screen is effective. Any positive response should prompt a more thorough assessment. Two positive responses to the CAGE indicate a high likelihood of dependence.

A helpful tool that can be used to gather greater information about alcohol use patterns is the Alcohol Use Disorders Identification Test (AUDIT) (Appendix 24-A). The AUDIT is a 10-item instrument developed by the World Health Organization to screen for alcohol-related problems and to quantify severity. The NIAAA Clinician’s Guide also includes the AUDIT Questionnaire, with suggestions for its use and scoring in clinical practice.

Step Three: Advise and Assist

For patients whose pattern of use indicates that they are either at risk of alcohol or drug problems or who already meet criteria for abuse or dependence, the next steps include strategies to help patients reduce or eliminate drug use. As described below, interventions vary based on the extent of substance use and whether or not dependence symptoms are present. In delivering brief interventions the components we describe in this chapter can be remembered using the acronym FRAMES:

• Feedback is given to the individual about personal risk or impairment.

• Responsibility for change is placed on the patient.

• Advice to change is given by the provider.

• Menu of alternative self-help or treatment options is offered to the patient.

• Empathic style is used in counseling.

• Self-efficacy or optimistic empowerment is engendered in the patient.

Responding Effectively to Challenge, Resistance, & Ambivalence

We introduce the skill of “reflection”—paraphrasing the patient’s message or meaning—(Table 24-6) at this moment because quite frequently, as physicians ask screening and clarifying questions, patients show resistance and challenge. Physicians can improve the quality of the data as well as minimize tension by responding to irritation or resistance with reflections. This approach has been described extensively as “Reflective listening,” a key component of Motivational Interviewing.

Physicians who can gently reflect back the resistance, ambivalence, or challenge they receive from patients generate an atmosphere of alliance and partnership. Reflection shows a desire to fully understand the patient, demonstrating acceptance of the person and a willingness to listen. Reflection is neither aggressive nor defensive, and helps to minimize arguing, hostility, and negativity. Simple reflection gives the patient full choice over what to say next (whereas questions seek answers, and giving advice stakes out a position, as does agreement or disagreement, and statements of values). In fact, studies demonstrate that reflecting negative, resistant, or reluctant statements helps engage patients in dialogue (see Chapter 1).

Especially when the patient seems negative or hostile, reflection is not an intuitive response. Studies show that doctors usually respond by asking questions, giving advice, persuading or arguing the point, or shifting the interview focus. With practice and attentiveness, physicians can reflect back patients’ expressions of ambivalence, resistance, or challenge.

As this example illustrates, an empathic reflection that recognizes patients’ reasons for using substances can allow them to move forward and admit potential downsides to their pattern of use. Physicians can equally reflect patients’ statements about feeling, thinking, attribution, choice, action, or behavior. Reflection helps the physician by encouraging patients to share more of their perspectives, feelings, and thoughts; it thus engenders more trust and a feeling of safety in both persons. As patients who initially show disinterest, hostility, a sullen demeanor, or confusion reveal more of themselves, physicians become less judgmental and critical, more inclined to join patients and to support them. Patients who feel joined become better able to listen to their doctors, and have more strength to take responsibility for attempting change that might at first seem unimaginable. Reflection is useful in all interview stages, whether the physician seeks more information about drug use and its consequences, additional psychosocial information, or wishes to develop sensible management strategies for a patient.

Physical and laboratory examinations are useful adjuncts to structured interviewing. Odor of alcohol is alarming, and distinctly abnormal in medical encounters. If alcohol is easily smelled in the room, the blood alcohol level (BAL) is likely greater than 0.125 mg/dL, and a less dramatic odor indicates a BAL between 0.075 and 0.125 mg/dL. The nose is a good breath analyzer. Alcohol on the breath is a convincing sign, and always signals a serious alcohol disorder.

Intoxication (slurred speech, incoordination, and/or emotional lability) in any encounter is worrisome, and means a high likelihood of drug or alcohol disorder, even in the emergency department. To underscore this important point, assume that the 10% of the population who are alcohol- or drug dependent are intoxicated once a week (it is often more than once), and assume that the 60% who are not abusers or dependent are intoxicated once yearly (it is often less than once). Thus, in a year, from a population of 100, 30 abstainers yield no episodes of intoxication, 60 users (not in trouble) yield 60, and 10 dependent people yield 520! Further, moderate users seldom become as intoxicated and are more likely to use in controlled environments (e.g., where someone else can drive). Intoxicated people in the emergency situation are not healthy users or drinkers who “have had one too many.”

Further, with respect to alcohol, if the odor of alcohol is apparent, and if the patient manifests no evidence of intoxication, tolerance to alcohol effect is present. Tolerance indicates brain adaptation to intoxicating alcohol levels, which is caused by heavy drinking, is inevitably toxic, and usually means that the patient is physically dependent on alcohol. Withdrawal symptoms (see Management of Withdrawal) indicate additional brain dysfunction, and are easier to discern than tolerance. The same reasoning holds for drugs other than alcohol, but our ability to quantify their use or blood levels, as well as our ability to detect intoxication (except for sedatives or opiates), is limited, so tolerance must be inferred less directly from the patient’s history.

Other physical and laboratory findings (see general medicine textbooks for the multitudinous possibilities) are poor screening tests, as they have either low sensitivity or specificity, or both. Once again, more data are available about alcohol than for other drugs. Alcohol has a broad range of toxic effects and an abnormality may prove useful in context. First, an unexplained finding may begin a fruitful investigative process. For example, despite a negative response to the alcohol screening question, the concerned physician of a young woman with palmar erythema continued the assessment, allowing the patient to reveal her alcohol problem. Second, in the presence of a clue, physical or laboratory findings substantially raise the posttest probability, and physicians should order appropriate tests, such as mean corpuscular volume (MCV) and liver enzymes (include alanine aminotransferase [ALT], aspartate aminotransferase [AST], and γ-glutamyl transpeptidase [GGT], the most sensitive to alcohol intake). For example, a 55-year-old man with chronic pulmonary disease was admitted for atrial fibrillation. His wife complained about his drinking, and an elevated MCV, AST, and ECG confirmed not only alcoholism but also “holiday heart” (alcohol-induced arrhythmia after binge drinking). Carbohydrate deficient transferring (CDT) is a more specific marker of heavy alcohol use and can be used to monitor abstinence for the patient needing ongoing treatment for a severe alcohol disorder (alcohol dependence).

Illicit drugs are readily detectable in urine; however, the ability to identify them varies with the technique used. Drugs that may not be included in routine panels include hydrocodone, oxycodone, methadone, buprenorphine, anabolic steroids, and short-acting designer drugs. Marijuana can be detected for up to 30 days in the urine of daily smokers (for 1–3 days in intermittent smokers), but all other illicit drugs are cleared within 72 hours; for example, a positive test for cocaine indicates use within the past 2–3 days. Simply being near a marijuana smoker never produces a positive urine test (it can be detected by mass spectroscopy, but levels are well below the cut-off levels of routine urine testing). Urine drug screening for recent alcohol use (last 48–72 hours) can be determined using the ethyl glucuronide/ethyl sulfate test. This test must be specifically ordered as it is not part of a routine panel of drugs tested. Further, ethyl glucuronide and ethyl sulfate are metabolites of alcohol that result from hepatic metabolism. This test will not be positive in urine that has been contaminated by ethanol-producing bacteria and so is considered to be specific for alcohol use.

Treatment of alcohol or drug withdrawal is of special concern to the medical practitioner. Other urgent complications such as arrhythmia, alcohol or viral hepatitis, bleeding, gastritis, pancreatitis, skin abscess, sepsis, and overdose are covered in appropriate medical textbooks. Alcohol and opiate withdrawal are the most common withdrawal disorders, and physicians can manage many patients in outpatient settings if the withdrawal syndrome is mild in severity. Important parameters that patients should meet for adequate treatment in the outpatient setting include a commitment to abstaining from all mood-altering drugs during withdrawal (except as prescribed for withdrawal) and an expressed willingness to engage in continuing treatment. Homeless people or others not living with someone who can help monitor medication and symptoms in case of adverse events, those with significant polysubstance use, and those with important or unstable medical or psychiatric illness should not be treated as outpatients.

With regard to alcohol, when physical dependence develops, initial withdrawal symptoms of anxiety, sleep disorder, and tremor are mild, sometimes not attributed to alcohol, and easily relieved by drinking. As time passes, alcohol less reliably controls symptoms, and intoxication is fleeting, occurring only at high BAL (>250 mg/dL). Withdrawal is not an all-or-nothing state, and addicted patients experience symptoms whenever their BAL falls. The altered neurophysiology in the brain “perceives” a drop in BAL as disruptive to the new steady-state condition of addiction, and expresses the disruption through withdrawal symptoms. Soon, the person drinks steadily to alleviate withdrawal, but relief is brief. The range of BAL at which the individual feels “not sick” diminishes, and severe withdrawal, even delirium tremens, may develop despite a BAL of 300 mg/dL or more.

Outpatient treatment can be attempted in mild withdrawal. Physicians should hospitalize patients with clouded sensorium, fever, hyperventilation, a concomitant medical problem (e.g., hepatic failure, pancreatitis), or a history of alcohol withdrawal-related seizures, or if the patient has three risk factors for severe withdrawal (Table 24-7). Degree of tremor, anxiety, tachycardia, and stomach symptoms are poor predictors of need for inpatient care. When outpatient management is feasible, pharmacological support helps with symptom relief (Table 24-8) and must be integrated with patient education and referral options designed to help patients change entrenched behaviors. Medical withdrawal from alcohol should not be attempted on outpatients unless a responsible significant other has been identified who will stay with the patient and ensure that the medications for the patient are administered according to the physician’s instructions. If there is not such a support system, a patient should be admitted to the hospital or residential substance abuse treatment facility where 24 hour skilled staff are available.

With regard to opiate withdrawal, physicians can be helpful. Patients who use high doses of opiates, including those who have become addicted to prescription opioid analgesics and those who inject heroin, experience intolerable craving during withdrawal. Relatively few patients succeed in medical withdrawal from opioids without intensive follow-up treatment including use of an opioid antagonist medication, naltrexone (given orally or by injection), and ongoing psychosocial treatment to address the dysfunctional behaviors of the drug-abusing lifestyle. Except for physicians who have obtained a waiver from the Drug Enforcement Administration that permits them to provide office-based treatment of opioid dependence and who can then dispense or prescribe buprenorphine/naloxone as a withdrawal or maintenance treatment specifically for opioid dependence, doctors should never give any opiate drugs for treatment of withdrawal. Provision of opiates by well-meaning clinicians is never successful, and federal law prohibits the prescription of opiates for treatment of opioid dependence. People who are ready to stop abusing oral opioids (especially prescription pain medications) can also be treated with clonidine, benzodiazepines, and antiemetics for a few days to a week or two as outpatients if buprenorphine/naloxone treatment is not an option (see Table 24-9 for a suggested regimen). Patients should check with the physician face to face every 2–3 days until symptoms are minimal, and during the withdrawal process make initial contact with a professional treatment program. The patient will relapse unless support in coping with psychosocial aspects of dependence is available. We underscore this crucial point: treatment of withdrawal is not treatment of drug dependence.

Patients who are both alcohol and benzodiazepine dependent or who are opioid and benzodiazepine dependent or those who are prescribed benzodiazepines from their physician are not candidates for outpatient medical withdrawal. Their medication needs are likely to be significantly higher than for a patient dependent on alcohol or opioids alone. The use of high doses of benzodiazepines during medical withdrawal procedures can be medically dangerous and such patients should be referred for inpatient treatment.

Early intervention is more important than certainty about diagnosis. Physicians should always share their concern when they perceive a potential problem with drugs or alcohol. Effectiveness is more dependent on intervening early with the style and skills we discuss, rather than waiting to get the diagnosis exactly correct. Habits and addictive cycles are complex and entrenched, so starting earlier with effective brief interventions is better than waiting. The strategies described below are drawn from the National Institute on Drug Use (NIDA) and NIAAA Clinician’s Guides for brief interventions for alcohol drug problems in primary care settings as well as the Motivational Interviewing treatment model of Miller and Rollnick.

Assess Patients’ Current Readiness to Reduce Substance Use

As we move from data gathering to sharing information and planning, we like to begin with an assessment of interest in changing alcohol or drug use. An inquiry regarding current readiness level can also open a useful dialogue that can serve to increase motivation. For example:

As this example illustrates, it is helpful to listen carefully for what patients report as their specific reasons for change. Miller and Rollnick refer to this as “change talk.” Whereas a physician is typically most concerned about the impact of alcohol or drug use on health, often patients are more concerned about other issues that nevertheless are important sources of motivation to reduce use, as in the example here in which the patient is more concerned about the financial cost of drug use. Listening for change talk is an important strategy for physicians to use, allowing patients to make the case for change in their own words. As shown above, the physician responds with reflection or a request for elaboration.

Support Autonomy

Patients must make commitments and decisions in an atmosphere that genuinely tolerates and respects the full expression of ambivalence, resistance, and uncertainty, with respect to both facts and feelings. Physicians create such an atmosphere when they show they are listening to patients’ perspectives without judgment by simply reflecting what they hear, and by reminding patients that they are in charge of all the important decisions, and free to take whatever action (or inaction) they choose. That is, physicians recognize patients’ autonomy, while simultaneously offering their own expertise, clear recommendations, and support. A more explicit autonomy supportive statement (to Jim, above) could have been:

True dialogue is difficult in conversations that involve substantial differentials in perspectives, expertise, and/or power. Patients tend either to defend a point of view or to be passive and silent. Clinicians can encourage dialogue by consciously employing a format of “tell, ask, tell, ask,” which supports taking turns and results in a dialogue. Briefly provide (i.e., “tell”) advice or information, and then “ask” patients what they think about it, or how it feels to hear it, or what they intend to do about it. Keeping the “telling” brief helps clarity, and “asking” allows the patient to choose a “change-enhancing” or “change-obstructing” response. The manner in which patients respond to the “ask” also suggests which next steps will likely be helpful. Generally, “change-enhancing” responses include statements of agreement, commitment, or optimism, and these suggest that exploring the facts might be helpful. Generally, “change-obstructing” responses, such as statements of disagreement, reservation, pessimism, defensiveness, noncommittal statements, and all questions that do not ask for clarification of meaning, suggest that the clinician should reflect back the response as the next step in the conversation. Reflection invites patients to look inside themselves, and encourages motivation and attention to discrepancy between patients’ current situation and stated goals. Both “asking” and making reflections foster exploration and choice.

Dialogue about Information

Tell information about what is known about drug problems in an impersonal “objective” or “scientific” way. Here are some examples:

• “Research shows that treatment helps,” or

• “Steady drug use changes brain function,” or

• “Having a high tolerance for alcohol means that a person is deprived of the early warning system that tells him to stop drinking before the alcohol level gets so high as to be dangerous,” or

• “95% of men drink less than 35 drinks per week,” or

• “Many people are terrified to imagine stopping drug use,” or

• “Being sick in the morning until after a drink means a person’s brain has become hooked on alcohol,” or

• “Men with any close relative with drinking problems have an almost 50% chance of developing serious problems themselves,” or

• “Guidelines from extensive research show that drinking more than 14 drinks a week is risky.”

Next, ask what patients think of this information, and how it might apply to their situation.

Tell information about the patient’s situation as a fact, a number, or score, rather than a conclusion:

• “Three of your liver tests are abnormal,” rather than “alcohol has damaged your liver,” or

• “Your alcohol level when you arrived in the emergency room was 0.160,” rather than “You were drinking heavily before you came into the emergency room,” or

• “You have a serious infection in your arm,” rather than “You got this infection because you were injecting,” or

• “You mentioned three important things—that your relationship with your wife is going poorly, that you are having a lot of stomach trouble, and that you lost your license to drive,” rather than “Alcohol is wrecking your marriage, your career, and your body,” or

• “You are very shaky and sick to your stomach until you can get another pill,” rather than “You are addicted to tranquilizers,” or

• “You have quit drinking several times,” rather than “Your relapses show you are addicted.”

Next, ask what the patient thinks of this information. Think about whether the patient’s response to the “ask” is “change-obstructing” or “change-enhancing.”

Dialogue about Recommendations; Tell Advice Clearly, but not Harshly

Then, after discussing relevant information, tell advice tentatively, as part of a search for a suitable and attainable action option before the next visit. “Wagging one’s finger,” actually or figuratively, tends to push patients into a corner, it highlights any feelings of shame or stigma, and it inhibits discussion. Physicians who display a posture of “I know what is right for you,” without regard to cautions that apply to science (today’s truth is tomorrow’s fiction, and every case is unique), make patients defensive, and encourage arguments.

Useful advice has two other characteristics. First, give an objective rationale derived from a broader database than this case; and second, make your advice consistent with your assessment of your patient’s willingness to consider it. The following specific examples illustrate these ideas.

• “The option that I recommend, based on data in the medical literature, and my experience with experts who have advised me about similar patients, is that you stop drinking all alcohol. Of course, no one can be certain that this is the right thing for you to do, or that it will work for you,” or

• “Most people find that talking with people in Alcoholics Anonymous (AA) is helpful. AA might or might not be right for you. I recommend you go there.”

Ask what the patient thinks of the advice. Commanding or ordering instead of checking the result of giving advice ensures poor adherence, as patients will not do things that they do not choose to do. If clinicians push ahead and try persuading patients in spite of reluctance, they foster continued ambivalence, raise resistance to change, and begin an enervating downward spiral in which both participants become further demoralized and discouraged.

Here is another example of how this discussion might proceed.

(Jim’s response might surprise you)

Confirm Results of Dialogue

Finally, physicians need to be explicit that agreement has been reached on a specific plan. Check with patients that they are indeed committed to the plan and confident that they can carry it out. Set a specific timetable to follow up.

Helping To Maintain Change Over Time

At the follow-up visit, it is important to ask about any behavior change that the patient may have agreed to in the interim, even if the patient indicates that they are not yet ready to cut back on alcohol or drug use at the present time. For example, if the patient agreed to track how much they are drinking or to consider pros and cons of cutting back (as in the example above), continue the dialogue to help continue building patient motivation for change.

Many patients come to physicians having already made changes in drinking and drug use. These patients will benefit from thoughtful physician follow-up regarding those changes. Begin by acknowledging that change is difficult, and support any positive change, or efforts to change. Listen to patients’ perspectives on their situation, and encourage reflection about both goals and strategies. Reaffirm your willingness to assist and talk, address any coexisting psychiatric disorders, and renegotiate the goals and plans when appropriate.

Pharmacotherapies for Alcohol Use Disorders

Currently there are three medications approved by the US Food and Drug Administration for the treatment of alcohol dependence (severe alcohol use disorder). These include disulfiram (DIS), naltrexone (both oral and injectable formulations) and acamprosate. All can be useful treatments in selected patients in the context of an office-based practice.

Disulfiram is an aldehyde dehydrogenase inhibitor that inhibits the metabolism of acetaldehyde, a metabolite of alcohol, leading to a noxious reaction that includes flushing, palpitations, and headaches when alcohol is ingested following DIS administration. Disulfiram has been reportedly associated with nonadherence rates of 80% in a veteran sample with alcoholism and without intervention to assist with compliance. However, in this study fewer drinking days were reported in those who did adhere to DIS treatment, and there was a significant relationship between adherence and complete abstinence. Disulfiram is a medication that requires complete abstinence from alcohol. It is best reserved for those who have either failed other alcohol pharmacotherapies or for highly motivated individuals for whom complete abstinence is a requirement. Disulfiram is also contraindicated in pregnancy, in those with significant liver disease, esophageal varices, a history of gastrointestinal bleeding, or in those with psychosis, impulse control problems, or suicidality. A once daily dose of DIS 250 mg will inhibit aldehyde dehydrogenases within 12 hours to a degree at which a DIS/alcohol reaction will be observed should alcohol be ingested. The aldehyde dehydrogenase enzymes are fully inhibited in 3 days. Further, patients must generate new enzymes that metabolize alcohol before they can drink again without experiencing the DIS/alcohol reaction, and this will require at least 6 days following the last dose of DIS.

Naltrexone is a mu-opioid antagonist medication that is approved as a treatment for both opioid dependence and alcohol dependence. Naltrexone is thought to decrease craving for alcohol because it blocks some of the pleasant and reinforcing effects of alcohol by preventing the stimulation of opioid receptors and the reduction of dopamine release in the ventral tegmental area (VTA). Naltrexone is given at a dose of 50 mg orally daily, and there is also an injectable form of the medication given once monthly at a dose of 380 mg. The most common side effects with naltrexone treatment are stomach upset and headache. The medication can be started at a lower dose (12.5-25 mg/day) if this is a concern. Naltrexone has been associated with hepatotoxicity in some, usually at doses much higher than those approved by the FDA, but this has led to recommendations of baseline liver function tests and follow-up tests approximately every 3 months. Because naltrexone is an opioid antagonist, it should not be used in those who will need opioid medications for pain relief or who are already receiving treatment with opioid pain relievers.

Acamprosate is an anticraving medication which stabilizes excitatory glutamatergic neurotransmission that is altered during withdrawal from alcohol and is also FDA approved for the treatment of alcohol dependence. Like DIS and naltrexone, it has no abuse liability, and no sedative/hypnotic or muscle relaxant properties. One difficulty for some patients is the need to take this medication three times daily making adherence a difficulty in some cases. Acamprosate is renally cleared and can be an option for patients with alcohol use disorders complicated by serious liver disease or for patients who are likely to need ongoing opioid pain medications. Because DIS, naltrexone, and acamprosate are not controlled substances and have no mood-altering effects, these medications are easily prescribed by primary care clinicians who can provide medical care for alcohol use disorders in addition to other medical illnesses.

Pharmacotherapies for Opioid Dependence

There are two pharmacotherapies available for the treatment of opioid dependence which can be prescribed by primary care providers. The first is naltrexone, the opioid antagonist drug that blocks mu-opioid receptors and thereby blocks the effects of an opioid drug with agonist effects that might be ingested by a patient with opioid dependence. The dose of naltrexone to be used in the treatment of opioid dependence is the same as for alcohol dependence treatment—50 mg daily. Similarly, injectable naltrexone has been approved as a once monthly injection for treatment of opioid dependence at a dose of 380 mg. As in the treatment of alcohol dependence, the same provisos regarding side effects and potential adverse events are present for the opioid-dependent population who should be made aware of the risks/benefits of naltrexone treatment. It is important to know that naltrexone can precipitate opiate withdrawal in a patient who is physically dependent on opioids and who ingests this medication. Therefore, it is important to document last dose of opioid, no current use (which can be verified by urine toxicology screening), and resolution of opiate withdrawal symptoms and their temporal relationship to the first dose of naltrexone to be given. In general, once a patient has been completely tapered from the opioid they have been using and no longer have significant withdrawal symptoms, naltrexone can be started. Naltrexone can be started at a dose as low as 12.5–25 mg daily for those who experience gastrointestinal upset with this medication, and this can be continued for several days before increasing to the standard dose of 50 mg daily.

The second medication that can be used in primary care for the treatment of opioid dependence is buprenorphine or buprenorphine/naloxone. Buprenorphine is an opioid partial agonist medication that can be prescribed to treat opioid addiction, including addiction to prescription opioid pain medications or to heroin. Because buprenorphine is an opioid partial agonist, it has lesser effects on respiration at high doses, making it safer in an overdose situation. The exception to this is when buprenorphine is combined with other central nervous system sedative drugs, such as benzodiazepines, where serious adverse events and even death can occur. In addition, because buprenorphine is a partial agonist, it is thought to have less reinforcing effects than those of full mu-opioid agonists. Because of this, the FDA listed buprenorphine and buprenorphine products on Schedule III, making it possible for physicians to prescribe this medication from office-based practices to treat opioid dependence. However, only qualified physicians who have received a waiver from the Drug Enforcement Administration allowing them to prescribe such medications approved by the FDA to treat opioid dependence may prescribe buprenorphine. This usually requires a training of 8 hours in assessment and treatment of substance use disorders with a focus on opioid dependence, co-occurring mental illness, use of buprenorphine in clinical practice, and treatment of special populations with opioid dependence with buprenorphine. These trainings are available through the Center for Substance Abuse Treatment/SAMHSA (see www.pcssb.org, www.pcssmat.org or www.samhsa.gov) for physicians. The formulation of buprenorphine to be used in treatment of opioid dependence is buprenorphine/naloxone. Buprenorphine and buprenorphine/naloxone are taken sublingually. The addition of naloxone to the buprenorphine tablet is meant to discourage diversion of the drug to injected use. Naloxone, an opioid antagonist, is not active when ingested sublingually, but if buprenorphine/naloxone were to be injected by an opioid-dependent person who had recent opioid use, the naloxone would precipitate opiate withdrawal. Buprenorphine/naloxone is effective at clinical doses in the range of 12/3–16/4 mg sublingually daily and the upper dose approved by the FDA is buprenorphine/naloxone 24/6 mg. Buprenorphine/naloxone induction is required to start treatment in an opioid-dependent person. The patient must come to the office in mild–moderate opiate withdrawal before the medication can be initiated. The reason for this is that buprenorphine has a very high affinity for mu-opioid receptors and will displace other opioids that are occupying the mu-receptors. However, as a partial mu-opioid receptor agonist, buprenorphine will not provide the agonist effects that the patient is accustomed to and so can precipitate opiate withdrawal in a patient who has recently ingested opioids. Determining when to start buprenorphine is not difficult when a rating scale of opiate withdrawal severity is used (see www.pcssb.org—Clinical Guidances or www.samhsa.gov) and the patient receives rapid relief from opiate withdrawal once the first dose of buprenorphine is administered. All opioid-dependent patients will need ongoing psychosocial therapy and support from family/concerned others. Referral to Narcotics Anonymous groups can also be useful for support. It is important to be aware that prescribing buprenorphine/naloxone alone is not sufficient to treat opioid dependence. Further, although buprenorphine/naloxone can be used for medical withdrawal (see Table 24-9), maintenance treatment for at least 6 months to 1 year or as long as the patient is benefitting from the treatment is recommended to prevent relapse. It is also worth noting that methadone cannot be used to treat opioid dependence/addiction from office-based settings; rather this medication can only be given from federally regulated narcotic treatment programs for the treatment of opioid dependence. In determining which medication might be the best choice for patients with opioid dependence, it is best to discuss their expectations of treatment: Are they willing to be medically withdrawn from opioids? Are they concerned about taking a medication that produces physical dependence? Is their goal to be free of medications that are mood-altering? If the answers to these questions are “no,” then buprenorphine/naloxone might be the better medication choice. If the answers to the questions are “yes,” then naltrexone might be the better choice.

Many addiction specialists agree that these drugs can be helpful for patients who commit to abstinence, and cannot remain sober. Because patients may imagine that these medications will provide a miraculous cure, the physician should promote this additional step toward abstinence, and also steer the patient toward an improved recovery regimen. The primary care physician should refuse to prescribe unless the patient undertakes additional action steps, for example, toward more involvement with addiction professionals or self-help groups. It is always a good idea to provide a listing of local resources, including specialized substance abuse treatment programs and self-help group meetings in the local geographic vicinity, for patients and family to take with them.

Referral to Specialized Treatment

Substance abuse treatment programs provide patients with specialized care, and physicians should refer any patients who do not make progress on changing substance use patterns in the primary care setting. Whether patients are making progress is more important to the need for referral than the apparent level of problem or the specific diagnosis of at-risk use, abusive use, or dependent use. Substance-dependent patients may benefit from access to medical withdrawal services and multidisciplinary counseling opportunities. Treatment programs can also help patients initiate contact with community-based self-help organizations, halfway houses, and intensive counseling, sometimes in an inpatient setting. Programs with co-occurring disorders treatment capabilities (i.e., the ability to provide treatment for both substance use disorders and other mental disorders) are able to serve patients with additional psychiatric problems known to occur frequently in those with substance use problems, more comprehensively than any physician’s office. Physicians in these specialized treatment programs will be more familiar with, and so better prepared to treat, more complex patients with co-occurring substance use disorders complicated by mental illness. Findings from the 2009 National Survey on Drug Use and Health underscore the need for such programs as referral centers for the primary care physician who has identified a patient with multiple disorders. This survey reported rates of mental illness in those with substance use disorders to be 43% (versus a rate of mental illness in those without substance use disorders of 18%), and the rate of substance use disorders in those with mental illness was 16.5–26% depending on the severity of the mental illness (those without mental illness have an overall rate of substance use disorders of 6.5%).

Patients will often resist following through on a referral for specialized treatment. A helpful strategy is to confirm the patient’s intention and commitment to follow through, as discussed in the sections above on making choices, supporting autonomy, and giving advice. An additional strategy is to emphasize your need for a second opinion from a specialist, just as might be the case with referral to a cardiologist. Set up the appointment before the patient leaves the office. Tell the patient you will send a referral letter summarizing your views and asking for advice from the specialist. Let the patient know that you will speak with the specialist after the assessment, and that you would like to participate in the treatment plan. It may also be helpful to indicate that outpatient treatment programs often have flexible options in the services they offer—for example, intensive or less intensive services, day or evening programs—and to encourage patients to get an appointment with a program even if they are not sure that they are ready for abstinence.

Many communities have programs for patients with special needs, such as adolescents, women, abusers of particular drugs (methadone treatment for opioid dependence/severe opioid use disorder with evidence of physical dependence on opioids is the best-known example), and patients with severe psychiatric problems. Self-help alternatives to AA and other mutual help groups exist in many communities; Rational Recovery is one example, and Women for Sobriety is another. These resources are available to help primary care providers obtain all of the treatment needed by a patient with substance use problems, in addition to any other medical illnesses that might be present. The primary care clinician can then be the provider to coordinate all of the interventions and treatment resources needed by these patients.

The Alcohol Use Disorders Identification Test (AUDIT)

SCORING THE AUDIT

Record the score for each response in the blank box at the end of each line, then total these numbers. The maximum possible total is 40. Total scores of 8 or more for men up to the age of 60 years or 4 or more for women, adolescents, and men over the age of 60 years are considered positive screens. For patients with totals near the cut-points, clinicians may wish to examine individual responses to questions and clarify them during the clinical examination.

Note: The AUDIT’s sensitivity and specificity for detecting heavy drinking and alcohol use disorders varies across different populations. Lowering the cut-points increases sensitivity (the proportion of “true positive” cases), whereas increasing the number of false positives. Thus, it may be easier to use a cut-point of 4 for all patients, recognizing that more false positives may be identified among men.