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.
CASE ILLUSTRATION
Jim is a 50-year-old factory worker with high blood pressure. He has a follow-up visit with the doctor who has been his primary care physician for the past decade. He mentions that he recently received his second “driving under the influence” (DUI) citation and considers it unfair. His probation officer ordered Jim to undergo alcohol counseling at the local alcohol treatment center. Jim has no interest in counseling but he thinks he must attend to keep his driver’s license, needed to get to his job.
Jim cannot remember his father, but knows he had serious drinking problems and left the family when Jim was 4 years old.
Jim began drinking as a teenager and got up to a 12-pack of beer per day. He cut back once he got out of his twenties, since “that was going nowhere” but still drinks four to six beers daily—at his club or playing pool or cards with his buddies, and up to two six-packs per day on the weekend. (Based on his self-report and national survey data, only 3% of American men drink more than Jim.)
You have asked Jim the CAGE questions (Table 24-4) in the past, and at that time he said that when he was a lot younger he needed to cut down, and he drank eye-openers in the morning, again in the distant past. He said he was not annoyed because of criticism of his drinking, and that he never felt guilty or remorseful after drinking. Now, as you ask questions, he seems irritated.
You decide to begin your assessment of Jim’s current situation by asking him the CAGE questions again. You ask about cutting down:
Jim: Look, doc, my father may have been alcoholic, and many of my buddies drink a lot more than me, but I’m not an alcoholic, and I can take it or leave it.
Rather than confronting him with the considerable evidence already available that indicates his situation qualifies as at least alcohol abuse and possibly dependence, you decide to use an empathic style and reflect his apparent feeling state as well as the content of his declaration.
Doctor: Jim, I see this is a sensitive topic, as it is for most people, and I get it that you are convinced that drinking is not a problem for you.
Jim: I quit several times when my wife complained, no problem. But 2 years ago she took the kids and left, saying that they couldn’t live with me unless I quit drinking. I don’t understand women!
You have important new data about drinking and about Jim’s life, and Jim feels understood rather than interrogated.
On repeated checks over the past couple of years, Jim has had an elevated MCV, but the rest of his complete blood count, metabolic panel, and liver function panel are repeatedly normal. He tells you his blood alcohol concentration was 0.22 (220 mg/dL, 0.08%, is now the “legal limit” in all US states) when he was cited.
Your physical examination shows Jim’s blood pressure is controlled, and you find no evidence for new medical problems or active withdrawal from alcohol. You agree to continue his lisinopril:
Doctor: We have talked about alcohol quite a bit today, Jim. On a scale of 0–10, how interested are you in quitting drinking at this time, where 0 means not at all and 10 means quitting is a top priority?
Jim: I’m quitting until I get my license back, no problem.
Doctor: You feel you are in full control of your alcohol intake.
Jim: I’m fine, doc, and thanks for checking.
Doctor: I am pleased that you are ready to quit now, and I know you have been successful in the past. Also, I’m concerned, because I think you may have an alcohol use disorder that will require your attention even after you get the license back . . What are your thoughts about that?