Quality Rounds
When You Suspect A Drug Problem
Patients who show signs of addiction and drug abuse are challenging. But with tools and training, physicians can help them.
By Scott D. Smith
It’s not easy for physicians to know what to do when they suspect a patient may be abusing alcohol, illicit drugs, or prescription medications. Take it from Ken Ripp, M.D., a family physician at the Raiter Clinic in Cloquet, Minnesota, who cites the example of a pregnant patient who recently tested positive for marijuana. Ripp wanted to give the woman a chance to save face. He suggested that perhaps she had inhaled some secondhand marijuana smoke and made it clear that exposure to marijuana was hazardous to the developing baby.
Although he tried to be nonjudgmental in his conversation with the woman, Ripp later received a call from a physician wondering why the patient was switching doctors so late in her pregnancy. “This one incident was enough to dissolve the doctor-patient relationship,” Ripp says of his attempt to address his patient’s marijuana use.
Encounters like this one illustrate the challenge physicians face when dealing with patients they suspect are abusing alcohol or other drugs. Although physicians may be well-intentioned, they often fail to deal effectively with addiction and, thus, miss opportunities to treat it.
Guidelines for Managing Substance Use Disorders in Primary Care
Assessment
- Use a standardized alcohol screening procedure (eg, CAGE*)
- Arrange detoxification or stabilization, if indicated
- Identify patients who should receive a brief intervention
- Identify patients with substance abuse or dependence who require a referral to specialty care
Brief Intervention
- Give feedback about screening results and health risks
- Inform about safer consumption limits
- Assess readiness for change
- Negotiate goals and strategies for change
- If unsuccessful, consider referral to specialty care
Care Management
- Document specific substance use at each visit by patient report
- Monitor and discuss biological indicators such as urine toxicology
- Encourage reduction or cessation of use at each visit
- Recommend self-help groups
- Coordinate treatment with other care providers
- Monitor progress and periodically assess for possible referral to specialty care
Source: Based on U.S. Veterans Health Affairs National Clinical Practice Guidelines (www.oqp.med.va.gov/cpt/cpg.htm)
*CAGE Questions
C – Have you ever felt you ought to Cut down on your drinking?
A – Have people ever Annoyed you by criticizing your drinking?
G – Have you ever felt bad or Guilty about your drinking?
E – Have you needed an Eye-opener or a drink in the morning to steady your nerves?
Alcoholism is likely if a patient answers yes to two or more questions.
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According to a 2000 survey of patients and primary care doctors by the National Center on Addiction and Substance Abuse at Columbia University, doctors provide less-than-optimal care in this area because of inadequate training in medical school on how to recognize drug abuse and addiction, hesitancy to discuss this touchy subject with patients, skepticism about the effectiveness of treatment, and time constraints because of short office visits. Of the 510 patients in treatment who participated in the survey, 43 percent said their doctors never diagnosed their problem. About 11 percent said their doctors knew of their problem but didn’t treat it. Of the 648 primary care physicians surveyed, only about one-third said they carefully screened for substance abuse. And 58 percent said they declined to discuss substance abuse with their patients because they thought those patients would lie about their use. That’s probably not an inaccurate belief, considering that about 85 percent of the patients surveyed agreed that patients would not be honest about their drug use.
This does not have to be the case, according to Scott McNairy, M.D., addiction fellowship training director at the Veterans Affairs Medical Center in Minneapolis. McNairy says that a primary care physician’s actions can have a significant, positive impact on patients with substance abuse problems. But he acknowledges that without tools and training, physicians often feel frustrated and helpless.
Uncovering the Problem
Whether physicians are prepared or not, it’s likely that they will encounter drug abuse among their patients, given that about 19 million Americans (or 8 percent) older than 12 years of age are illicit drug users, according to the 2004 National Survey on Drug Use and Health, and about the same number abuse alcohol, according to a 2002 U.S. Department of Health and Human Services epidemiologic survey. Yet, uncovering addiction remains challenging.
Ripp says although his clinic proactively screens for tobacco and alcohol use, physicians can be fooled by high-functioning individuals who hide their drinking or drug use. “There’s a rare [patient] that will say I smoke pot once a week, but most are not going to say I smoke meth three times a week,” Ripp says. “You can suspect it, but if the patient isn’t willing to come forward with the information, there is not too much we can address.”
To get patients to open up about their substance abuse, experts say physicians need to use a frank and direct, but nonjudgmental, approach that focuses on the health effects of alcohol, cigarettes, and illicit drugs. “I really believe that you can’t push, but you can lead, you can encourage, and build trust and the relationship,” says Peter Friedmann, M.D., an internist and associate professor of medicine at Brown Medical School in Providence, Rhode Island, who has researched addiction treatment in the primary care setting.
The doctor’s role, he says, is to figure out a person’s readiness to change, educate that person about the health risks of the behavior, and engage in some basic counseling to try to motivate the individual to stop harmful behaviors. McNairy adds that doctors should refer patients to an addiction specialist if the patient seems ready to accept such help.
One way to start the conversation is to ask patients’ permission to discuss sensitive subjects. When they agree, ask whether they smoke, drink, or use any mind-altering drugs. Primary care physicians typically do this at annual visits or after identifying a red flag such as anxiety, depression, insomnia, erectile dysfunction, trauma, or abnormal liver tests; or after a family member expresses concern.
To identify problematic alcohol use, physicians should screen systematically with the CAGE questionnaire, McNairy says. He adds that quantifying drinking habits is crucial. Current thinking is that men who consume 15 or more drinks per week or five or more drinks per day and women who drink eight or more per week or four or more drinks per day are at increased risk for alcohol-related problems. He says physicians should ask patients to keep track of the number of drinks they consume per day and the number of drinking days in the month. The physician can then use this to chart progress going forward (see “Guidelines for Managing Substance Use Disorders in Primary Care”).
Identifying other drug problems can be more of a challenge. One screening tool available to physicians is CAGE-AID, an adaptation of the CAGE screening that includes questions about abuse of other drugs. Two others are the Drug Abuse Screen Test and the Simple Screening Instrument for Alcohol and Other Drug Abuse. However, urine tests are the most reliable method of identifying or verifying drug use.
Jon Grant, M.D., a University of Minnesota psychiatrist, finds it useful to ask patients if they have certain behaviors they feel are out of control. This question may also reveal sexual and gambling addictions in addition to alcohol and other drug abuse, he says. Although patients are reluctant to talk about their problem at first, he says they often open up as the conversation goes on.
Treatment Options
For patients who acknowledge that they have a problem, McNairy suggests that physicians first try to negotiate with them to get them to cut back on their drug or alcohol use. In his practice, he offers patients a Plan A option. He lets his patients try their strategy first, which often is an attempt to cut down their drinking or use to accepted safe standards. But if they fail or lose control, McNairy wants a commitment that they will try his way, which often involves a trial period of abstinence lasting three to six months. If the patient has trouble achieving that goal, he may recommend community support such as Alcoholics Anonymous.
When such approaches fail, McNairy will refer a patient to either a residential or intensive outpatient treatment program. The classic Minnesota model for treatment is a 28-day inpatient/residential program based on adherence to the 12 steps to recovery used by Alcoholics Anonymous. But McNairy says outcomes research shows that intensive outpatient programs can work as well as inpatient programs as long as the patient stays with the program. Outpatient programs involve group and individual counseling, often with three- to six-hour psychoeducational sessions three to five days a week. He says the most effective psychoeducational treatment involves individual or group counseling sessions designed to help addicts replace old habits, ideas, and behaviors with healthier ones.
As researchers have gained understanding of the neurobiology behind addiction, they have been developing drugs to counteract cravings and address the physical aspect of dependency. Disulfiram (Antabuse), naltrexone (ReVia, Vivitrol), and acamprosate (Campral) have been approved by the FDA for treatment of alcohol dependence. In trials, naltrexone and acamprosate combined with counseling were shown to be more effective than counseling alone at preventing short-term relapses of drinking, according to a review in the November 2005 American Family Physician by researchers at the Veterans Affairs Medical Center in Lebanon, Pennsylvania.
Led by Steven Williams, Ph.D., the investigators did a systematic review of 11 double-blind, placebo-controlled trials and found that naltrexone reduces short-term relapse rates in alcoholics when combined with psychosocial treatment. (An article on the research is available on the American Academy of Family Physicians’ Web site at http://www.aafp.org/afp/20051101/1775.html.)
They also found a poor compliance rate with self-administration among patients who were prescribed disulfiram, which has long been available in the primary care setting. One study showed a 46-percent dropout rate with oral disulfiram because of the drug’s side effects (nausea, vomiting, headache); others found that the drug wasn’t effective in increasing abstinence or preventing relapse. But when studied with monitored dispensing—in the clinic three times weekly—the clinics’ results were much better.
Currently, there are no FDA-approved drugs for treating addiction to stimulants such as cocaine and methamphetamine. However, the National Institute on Drug Abuse (NIDA) has been testing drugs approved for other conditions to see if they might reduce cravings for cocaine. In 2004, NIDA was sponsoring human studies of 21 FDA-approved medicines, which accounted for about two-thirds of all the potential drugs being tested to address cocaine cravings, said Frank Vocci, director of NIDA’s pharmacotherapy division, in an August 2004 Associated Press story.
The drugs being studied include topiramate, disulfiram, amantidine, baclofen, naltrexone, and modafinil. So far, investigators at Yale University School of Medicine in New Haven, Connecticut, have tested disulfiram in 121 outpatients for 12 weeks. They found the drug decreased the incidence of cocaine use from 2.5 days a week to 0.5 days a week on average. Cocaine use on disulfiram results in an unpleasant or dysphoric experience rather than the expected euphoria.
Building Physician Confidence
Although the anti-craving drugs do benefit some patients, they’re still not widely used by primary care physicians. Al Heaton, director of pharmacy at Blue Cross and Blue Shield of Minnesota, says physicians don’t often prescribe these drugs, even though Blue Cross covers them, because of the side effects and because physicians are “pretty realistic about how effective they are.”
Raiter Clinic’s Ripp, for example, says the patients for whom he has prescribed naltrexone haven’t reported it making a significant difference after 12 weeks, the typical amount of time for which the drug is prescribed. As for disulfiram, patients just stop taking it because of its side effects, he says. “These drugs are OK, but they aren’t whizbang drugs.” Furthermore, he says, many of these drugs, which carry price tags of $100 or more a month, cost too much for patients who are already down and out because of their addictions.
James Van Vooren, M.D., a family physician who practices at Bethesda Clinic in St. Paul, says he doesn’t prescribe the drugs because he doesn’t have the skill or time to adequately manage patients on them. “To be effective, these drugs need to used in combination with a treatment program,” he says, adding that he refers patients who are candidates for medication to addiction specialists.
The VA’s McNairy stresses that medications need to be viewed as adjunctive to other therapies and care management. “No medication will replace the hard work of behavioral and lifestyle changes or recovery programs and support,” he says.
Brown’s Friedmann compares the status of addiction treatment today with that of depression treatment before the introduction of drugs such as Prozac. After those drugs came on the market, primary care doctors were more likely to screen for and treat depression, he says. He expects the same will happen with addiction as more effective pharmaceutical treatments become available—something he expects to see happen within the next 15 years. “Once docs have a pill they can use, they will be much more likely to get involved in managing these disorders,” he says. MM
Scott Smith is a staff writer for Minnesota Medicine.