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.
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 higher in hospitalized patients, and involves everyone from adolescents, teachers, and shipyard workers to doctors themselves. Physicians report that conversations with patients about drinking are stressful and conflict laden, and that patients are unmotivated to change their behavior. Physicians' negative feelings derive from family experiences or from encounters with intoxicated patients who are hostile, uncooperative, and often violent. Anyone entangled in the web of substance abuse is likely to act irresponsibly—driving while intoxicated, attempting suicide, engaging in high-risk sexual behavior, and sharing, dealing, and stealing illegal drugs—despite legal, moral, and family sanctions. These dynamics, combined with the sense that substance abuse may not really be a "medical" issue, tend to keep physicians from speaking up and prevent them from helping their patients.
Evidence from many sources provides reason for optimism, however, and shows that doctors who take a few moments to thoughtfully structure their interventions with patients succeed in reducing harm. In so doing, physicians not only lower medical care costs and morbidity for patients and their family members, but also strengthen family and social relationships, self-esteem, and emotional stability. Indeed the recovery rate from substance abuse, 30–40% of treated patients, exceeds that from most 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 reversal of substance abuse can be as gratifying as helping patients recover from leukemia or pneumonia. Of course, caring for patients with these problems is more like helping patients with depression, anxiety, elevated cholesterol, or arthritis than patients with acute problems that respond to surgery. In this chapter, we will discuss identification and management of substance-use problems, and how Jim's success in coping with his problems will be affected by his physician's interactions with him.
No person is immune to nervous tissue actions of alcohol and other drugs, and no one seeks to develop substance-use problems. People modulate use according to feedback from internal states such as shame or hangover, and external cues such as reprimands, criticism, and sanctions. They succeed or fail in limiting use because of the interplay of genetic, physiologic, psychological, and social/cultural factors.
Case Illustration (Contd.)