It probably comes as no surprise that substance abuse and dependence are major problems within the United States (and across the world). For example 22.5 million persons aged 12 years and older exhibit substance abuse or dependence. Additionally, emergency department visits related to prescription medications (opoids) nearly doubled between 2004 and 2009. What may come as a surprise, however, is that fewer than 20 percent of primary care physicians are completely prepared to deal with these problems, and more than 50 percent of patients with substance misuse disorders said that their primary care physicians did nothing to address these issues. In an article titled “A Primary Care Approach to Substance Misuse,”
Dr. Brad Shapiro and colleagues provide a useful framework for how primary care physicians can address substance misuse issues.
However obvious this advice may sound, it’s imperative that a primary care physician screens a patient for substance misuse disorders. A good screening test may be the Drug Abuse Screening Test-10. Based on results of such screening, patients fall into 3 categories: hazardous use, substance abuse and substance dependence.
Hazardous use. In a hierarchy of danger, hazardous use is the lowest rung. People who exhibit hazardous use are at greater risk for developing substance abuse and substance dependence. Hazardous use invites potential consequences, and even the infrequent use of certain illicit drugs can be very hazardous. For example, a puff of marijuana may have limited (but not negligible) consequences whereas shooting up heroin even once can be highly hazardous. Physicians should show good judgment when counseling patients who exhibit hazardous use, and if counseling is called for, the physician should never confront or push a patient to change. Instead the physician should elicit the patient’s own reasons to change using a “motivational interviewing” approach.
Substance abuse. Substance abuse is more serious than hazardous use. A person has substance abuse issues if use of a drug resulted in consequences. For example, if you smoked some pot, had a car accident and were arrested, you have a substance abuse problem. Often repercussions related to substance abuse serve as strong motivators for change, and these patients may be willing make lifestyle changes. With patients who have substance abuse issues, a primary care physician should advise abstinence. If that doesn’t work, harm-reduction strategies such as clean needles or avoidance of driving while intoxicated may help. If a person with substance abuse problems can’t cut back or quit, substance dependence is likely.
Substance dependence. Substance abuse is a disease replete with its own ICD 9 code. Substance dependence is a lifelong disease that remits and relapses. It requires involved treatment such as counseling and drug-specific pharmacotherapy (buprenorphine, naltrexone and methadone). For best outcomes, families should get in on the treatment. Although some treatments can be provided in an outpatient setting, many people with substance dependence need to be referred to a drug treatment program.
Primary care physicians are on the front lines of clinical medicine. Even if they can’t treat a problem, they must be able to recognize the problem and refer a patient to the proper specialist or treatment facility. We trust our primary care physicians to recognize all our health problems including substance dependence which is an illness like any other. No primary care physician is unprepared to treat diabetes or hypertension but apparently a majority can’t deal with heroin or cocaine dependence. Furthermore, a primary care physician is obligated to follow up with a patient who exhibits hazardous use, substance abuse or substance dependence. In the end, illicit drug misuse mediates a whole host of psychiatric and psychosocial issues such as mental illness or intimate partner violence, which are just as dangerous as its somatic effects.
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