Everything Primary Care Physicians Have Always Wanted to Know about Patients with Substance Use Disorders (SUDs) But Were Afraid to Ask
Elizabeth Wells, PhD
University of Washington School of Social Work
I don’t work on a day-to-day basis with primary care physicians (PCPs). Setting about to compose this column, my main point of reference is my own PCP. She is a family practice doc who works on a primary care team in a large HMO. Each time I go to see her, she spends between 10 and 20 minutes with me, so I imagined that she does not have a lot of time to read pages and pages. I decided to give her a bulleted list rather than a lengthy diatribe. Here are the top 8 messages I think she should hear:
1. They (patients with SUDs) are not, by definition, bad people.
- Don’t allow cultural stereotypes about people who use substances to color your perceptions.
- Addiction isn’t a moral failing; it is an illness like others you treat.
- While addiction may be associated, for some people, with illegal actions, people with SUDS need help from you with their illness.
- If your patient thinks you will judge her because of her use, she may not share important diagnostic information.
2. The most important thing you can do is ask patients what, and how much, they are using.
- If you are wishy-washy about asking questions, you communicate that you don’t want to know.
- Ask what your patient drinks or uses.
- Ask how often your patient drinks or uses.
- Ask how much is used on each occasion.
- Repeat these questions over time to evaluate how things are going.
3. Just as there are diagnostic tests for physical illnesses, there are research-based screening and assessment instruments for substance use and SUDs.
4. Substance use has likely altered your patient’s brain in ways that makes it difficult for him/her to discontinue use.
- Long-term use of alcohol or drugs creates changes in the brain.
- These changes may affect your patient’s thinking or lead to intense cravings.
- Given this, stopping or reducing use is going to require more than will power.
- Talking to your patients about changing their substance use behavior can best be done in a non-judgmental way using motivational interviewing skills.
(See Family Practice Management at http://www.aafp.org/fpm/2011/0500/p21.html
5. Treatment for SUD is effective.
6. Once a patient screens positive for a substance use problem, a “warm hand-off” from the PCP to a trained SUD treatment clinician is critical for active follow-through.
- If you determine your patient has a SUD and is interested in treatment, it is important to refer him/her to a clinician with time and training to address the SUD.
- If simply given a name and phone number, most patients will not follow through.
- You should have a relationship with an addiction specialist who can talk to the patient immediately after you complete your screening.
7. SUD is often accompanied by other psychiatric disorders or physical health problems. Knowledge of patients’ substance use can aid in treatment of these other problems.
- Now that you know about your patient’s substance use, you can determine whether it is linked to the patient’s other physical or mental health problems.
- When you talk to your patient about these problems, provide information about how substance use might be affecting their health.
8. SUD is usually a chronic, rather than acute, condition; PCPs can improve outcome by providing ongoing monitoring and redirecting to treatment if necessary.
- Think about SUD like you do other chronic health conditions, such as diabetes or high blood pressure.
- Slips and relapses often occur.
- Your ongoing relationship with your patient makes you the ideal person to monitor substance use and refer to specialty care as needed.
- A study of patients entering SUD treatment in a managed care health plan over 9 years, found those who had yearly primary care and specialty SUD or psychiatric services when needed had twice odds of SUD remission at follow-up as those without 1.
- Chi, F.W., Parthasarathy, S., Mertens, J.R., & Weisner, C.M., (2011). Continuing care and long-term substance use outcomes in managed care: Early evidence for a primary care-based model. Psychiatric Services, 62(10), 1194-1200.
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