Doctors: How to Assess Alcohol and Substance Abuse

Doctors: How to Assess Alcohol and Substance Abuse

The football season we enjoyed in past months reminds me of the important role family practitioners play in what can be a dangerous game.

Family practitioners are on the sidelines in identifying early intervention as well as
prescribing treatment for alcohol and substance abuse. However, demanding schedules, calls and interruptions, limited time with a patient can all intercept an opportunity to identify
substance abuse.

According to national surveys, nearly a third of Americans consume
more than the FDA-recommended two drinks a day for men and one for women. These people have stable jobs and families, and most of them do not qualify for a diagnosis of alcohol
dependence. They rarely think of themselves as having a problem. Yet this group is so large that it probably accounts for most of the problems caused by alcohol—including family conflict, accidents, injuries and poor health.

Here are some suggested ways to make the best use of your “game time.”

Practice and Warm-up
Plan to routinely speak to patients in a relaxed and nonchalant way about substance use, by referring to their answers to the questions about substance use on their medical record.

The CAGE is a four-question screening instrument commonly used in family practice medical records but you can enhance that intervention by commenting on their responses and making a “metacomment”
about their response to questions such as “we know that asking about alcohol and drug use is the biggest gift we can share with you to preserve and care for your health in my practice” or “thank you for your responses to the CAGE, we know that our concern for how you use alcohol and drugs goes a long way in protecting your health.”

Patients who abuse drugs and alcohol rarely confide in others about their use. Instead, they register vague physical complaints, and come in with high blood pressure and frequent minor injuries. These complaints offer an opportunity to ask patients about their use. A closed question such as “do
you use alcohol, marijuana or illicit drugs?” will elicit an automatic “no.” Open-ended questions such as “are there times when you get concerned about your alcohol, marijuana or illicit drug use?”
or “are friends and family, or other people besides me, concerned that this injury is related to drug
use?” can elicit more information. Keep in mind that a common personality feature is opposition to advice or suggestions, so statements that challenge the patient’s internal opposition to what you have to say can be helpful.

Hail Mary
An opener for the end run occurs when patients begin to offer information about their use. William Miller, researcher and distinguished professor with the University of New Mexico School of Addictions Research tells us that individuals with addictions are as forthcoming and honest about the amount of
their use as other patient populations. However, they do tend to minimize the effects of that use more than other populations. You may find that they can honestly admit to six drinks per night but will minimize how this alcohol affects them.

While identifying the amount of alcohol or drug
use is helpful to understanding patient medical risk, questions that identify how the drug impacts their job, family, energy level and mood will be more useful and engage them in talking about the problem.

Punt
Take a chance with the information the patient has provided to share your concern that both of you need further information to identify what to do about the drug use. Suggesting that the patient go seek treatment may result in them leaving the office, failing to follow up with your recommendation or avoiding visits for health care. Instead, ask the patient to obtain a consultation and suggest that you schedule another appointment in the near future, after they have completed a consultation. Remind your patient that their health and decisions about their health are important to you and require
careful consideration.

Ask the patient to sign a release of information with the behavioral health provider they choose so that the provider shares information with you before the patient returns to your office for the follow up
appointment. The behavioral health provider will provide an assessment of the level of care, models for treatment and resources.

The partnership of behavioral health provider working with the return visit to your office to discuss addiction treatment will go a long way to engage the patient in seeing treatment.