Awkward but Important Patient Conversations: Problematic Drug and Alcohol Use

Nov 26, 2019

This column will feature a series of focused overviews with practical suggestions for managing the manifold tricky needs of your patient population. This series started with a primer for addressing the sexual health questions of patients-paired with a healthy dose of required self-reflection (“Teach them to fish: Addressing the sexual health needs of patients and practice culture”). The series will continue with this dive into problematic substance use and next to coverage of other important but thorny issues including personality disorders, patient safety in the home (exposure to violence, abuse, or self-harm), cognitive impairment vis-à-vis medical decision-making, and the de-escalation of agitated, angry patients. There are other dozens of other difficult conversations, so please get in touch with suggestions.

This column will feature a series of focused overviews with practical suggestions for managing the manifold tricky needs of your patient population. This series started with a primer for addressing the sexual health questions of patients-paired with a healthy dose of required self-reflection (“Teach them to fish: Addressing the sexual health needs of patients and practice culture”). The series will continue with this dive into problematic substance use and next to coverage of other important but thorny issues including personality disorders, patient safety in the home (exposure to violence, abuse, or self-harm), cognitive impairment vis-à-vis medical decision-making, and the de-escalation of agitated, angry patients. There are other dozens of other difficult conversations, so please get in touch with suggestions.

DRUG AND ALCOHOL USE

Conversations about drug and alcohol use are complicated but overdue. Just last month, data from the 2018 National Survey on Drug Use and Health (NSDUH) were released. The NSDUH report is extrapolated from a survey of about 67,500 people from all 50 states and DC. The 2018 data reflect some positive trends including a decrease in new users of heroin and pain reliever misuse (Substance Abuse and Mental Health Services Administration, 2019). But there were also significant increases in daily marijuana use by young adults (18-25), especially among young pregnant women. Those same young people reported their marijuana use to be associated with opioid misuse, heavy alcohol use, and depression. Those risks are plain in the 2018 data, which show an increasing rate of serious mental illness, major depression, and suicidality in this age group (Substance Abuse and Mental Health Services Administration, 2019).

All told in 2018, 164.8 million people over the age of 12 (60.2%) reported using substances in the last month (i.e., tobacco, alcohol, or illicit drugs; Substance Abuse and Mental Health Services Administration, 2019). About 139.8 million Americans (age 12+) drank alcohol in the previous month, and  67.1 million of those respondents described themselves as binge drinkers. More than 2 million adolescents (1 in 11 of people ages 12 to 17) reported drinking alcohol in the past month, and half of them reported binge drinking. In total, there were 4.9 million alcohol users in 2018 (Substance Abuse and Mental Health Services Administration, 2019).

With respect to illicit drugs, about 20% of people (age 12+) reported using an illicit drug in the past year (which represents an increase from previous years) with marijuana users topping that chart; 16% of the respondents reported using marijuana in the previous year (Substance Abuse and Mental Health Services Administration, 2019). In addition, there were more than 3.1 million new marijuana users in the past year. Prescription pain reliever misuse was steady last year with 3.6% of the population (age 12+) reporting misuse in the past year, most (63.6%) with complaints of pain. Last year there were 1.9 million new misusers of prescription pain relievers, which is lower than in previous years (Substance Abuse and Mental Health Services Administration, 2019).

At the far other end of the substance use continuum, 20.3 million people (age 12+) met the criteria for substance or opiate use disorder (SUD/OUD) in the past year (Substance Abuse and Mental Health Services Administration, 2019). That includes 14.8 million with alcohol use disorder, 8.1 million people with illicit drug use disorder, 4.4 million people with marijuana use disorder and 2.0 million people with opioid use disorder, which is down from 2.1 million in 2017. Notably, of the 2 million people with OUD, only 400,000 were heroin users, and the remaining 1.7 million people were abusers of prescription pain relievers. All told last year, more than 21 million people reported the need for substance use treatment. That includes 1 in 26 adolescents, 1 in 7 young adults, and 1 in 14 adults (age 26+; Substance Abuse and Mental Health Services Administration, 2019).

Increases in the use of drugs and alcohol reflect accessibility, growing psychosocial vulnerability, and changing social norms; but the few important reductions, including the slight reduction in opiate users, can be attributed to better drug and alcohol screening and brief interventions in medical settings.

Next page: Identifying problematic substance use.

IDENTIFYING PROBLEMATIC SUBSTANCE USE

The identification of problematic substance use is of paramount importance. Problematic drug or alcohol use is obviously related to risk of poor mental and physical health outcomes, and more specifically tied to increased risk of poor compliance and self-harm. The health risks are introduced by the drug itself and by the administration of the drug, but also in the impurities used to cut the drug. Fentanyl, for example, is often mixed with heroin and synthetic-mix-related overdose deaths have been increasing steadily since 2014 (Centers for Disease Control and Prevention, n.d.). There are related risks for poor diet, sleep, hygiene, problems with employment, housing, and involvement with the criminal justice system. The stakes are even higher for some specialty patients. For example, for rheumatology patients, the use of certain illicit drugs can trigger inflammatory responses and worsen underlying disease.

Given those stakes and the population prevalence of substance use and misuse, the US Preventative Services Task Force (2016) lists drug and alcohol misuse screening in the top 5 of recommended prevention activities and it is actually required for Level I Trauma Center Accreditation. There are a whole host of best-practice screening and intervention models and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model introduced by SAMHSA (2019) is the most widely-used approach to early intervention and treatment. The whole model is designed to motivate at-risk patients to change their behavior and to encourage patients with more serious drug or alcohol use disorders to accept a referral for more intensive treatment (Agerwala, McCance-Katz, 2012).  One large, prospective, uncontrolled trial of 459,599 patients reported that 23% of outpatients screen positive for problematic substance use (Madras, et al., 2009). Of those, only 3% of patients required the brief intervention, and only 4% required referral to specialty care, and the reported drug and alcohol use of the treatment participants decreased by as much as 68% in the next 6 months (Madras, et al., 2009). The Screening (S) component is obviously designed to identify unhealthy drug or alcohol use. One caution is to select the screening instrument carefully. Screening tools without validation may undermine the disclosure of substance use and related problems (Gryczynski, et al., 2019). You can find a whole list of very brief, free, empirically-validated screening instruments on this SAMHSA website. Research suggests that people do disclose problematic substance use on these questionnaires. In fact, one study reported that self- and interviewer-administered formats were both able to detect unhealthy substance use but the disclosure rate for prescription medication misuse was 50% higher with the self-administered format (Gryczynski, et al., 2017). These tools can be deployed in the waiting room, during patient intake or during consultation and take less than 5 minutes to complete. You can review the patient responses in real-time. The conversation that follows is even more important.

The Brief Intervention (BI) of SBIRT is a 5-30 minute conversation about substance use (using cognitive behavioral therapy and/or motivational interviewing) with an emphasis on providing patient education and improving motivation. Research suggests that the SBIRT model is most effective with patients with unhealthy alcohol or drug use who do not yet fall into the category of opiate or substance use disorder (OUD/SUD; Ober, et al., 2015).  The primary tool, Motivational Interviewing (MI), was developed for use by professionals in and outside the mental health field. There are five core principles: (1) reflective listening; (2) development of discrepancy between the goals/values and current behavior; (3) avoidance of argument and direct confrontation; (4) responding to resistance; and (5) patient self-efficacy and optimism (Miller & Rollnick, 1991). Becoming proficient (and maintaining proficiency) requires an investment of your time. Training in MI is readily available at professional conferences and online, and ongoing consultation and supervision are encouraged (and are demonstrated to substantially improve outcomes; Forsberg, Ernst, & Farbring, 2011). Used poorly, MI can sound shaming and condescending (e.g., “Why don’t you stop using drugs?” or “Why can’t you drink less?"). The biggest misstep physicians make is to wear a prescriptive ‘hat’ during this conversation. Instead, your goal (in as few as 5 minutes) is to help your patient articulate their ambivalence. Ask questions about the Pros *and* the Cons of problematic drug and alcohol use (“decisional balancing”). Point out the discrepancies between their prescribed or self-reported goals and their current status and enlist the patient as a collaborator in problem-solving. MI promotes behavior change and there are CPT codes to support reimbursement for the time you spend doing it.

And finally, for the relatively fewer patients with a higher-risk problem, the Referral to Treatment (RT) of SBIRT is a warm hand-off to a community behavioral health provider. Referrals to community behavioral healthcare providers can be stymied by lengthy waitlists or unreasonable out-of-pocket costs. Consider inviting an addictions counselor, case manager or psychologist to your office for some training (for the benefit of all parties) and ask them for recommendations. Barring that, you should bookmark this site, The National Council for Behavioral Health. They are the parent organization for community addictions (and mental health) treatment providers around the country. Enter a zip code and you have a list of local specialty providers.

PROBLEMATIC SUBSTANCE USE IN AMONG HEALTHCARE PROFESSIONALS

And here is one important closing note for readers. One of the most stigmatized areas of need is problematic substance use among healthcare professionals. More than 10% of physicians will develop a substance use disorder during their careers, a rate that exceeds the general population (Berge, Seppala, & Schipper, 2009). The unique vulnerabilities of healthcare professionals are obvious to people *in* the field and that is the reason that peer identification and intervention programs are so vital. The outcome data for treated physicians are unequivocal, most physicians successfully return to practice after treatment with monitoring systems in place. An adage about ‘healing ourselves first’ comes to mind.

 

CITATIONS
Agerwala, S. M., & McCance-Katz, E. F. (2012). Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. Journal of psychoactive drugs, 44(4), 307–317. doi:10.1080/02791072.2012.720169

Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical dependency and the physician. Mayo Clinic proceedings, 84(7), 625–631. doi:10.1016/S0025-6196(11)60751-9

Centers for Disease Control and Prevention. CDC Wonder. http://wonder.cdc.gov/. September 2019.

Forsberg, L. , Ernst, D. & Farbring, C. Å. (2011), Learning motivational interviewing in a real‐life setting: A randomised controlled trial in the Swedish Prison Service. Criminal Behaviour and Mental Health, 21(3), 177-188. doi:10.1002/cbm.792

Gryczynski, J., McNeely, J., Wu, L., Subramaniam, G., Svikis, D., Cathers, ., Sharma, G., King,
J., Jelstrom, E., Nordeck, C., Sharma, A., Mitchell, S., O’Grady, K., & Schwartz, R. (2017). Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care. Journal of General Internal Medicine 32 (9), p. 990-96.

Gryczynski, M., Schwartz, K., Dušek, M., O'Grady, B., Oros, & Hosler (2019). Disclosure of
Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research Interviews. Journal of Adolescent Health, 64 (4), p. 541-43.

Madras B.K., Compton W.M., Avula D., Stegbauer, T., Stein, J.B. & Clark, H.W (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend, 99, 280-295. doi: 10.1016/j.drugalcdep.2008.08.003

Miller W.R., Rollnick S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford.

Ober, A. J., Watkins, K. E., Hunter, S. B., Lamp, K., Lind, M., & Setodji, C. M. (2015). An organizational readiness intervention and randomized controlled trial to test strategies for implementing substance use disorder treatment into primary care: SUMMIT study protocol. Implementation science : IS, 10, 66. doi:10.1186/s13012-015-0256-7

Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health [HHS Publication No. PEP19 5068, NSDUH Series H 54]. Retrieved from https://www.samhsa.gov/data/

U.S. Preventive Services Task Force (2016). Draft Update Summary: Illicit Drug Use, Including
Nonmedical Use of Prescription Drugs: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryDraft/drug-use-in-adolescents-and-adults-including-pregnant-women-screening on September 24, 2019.

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