Communication Commentary: Substance-Related and Addictive Disorders: Substance Use Disorder

Research suggests that physicians frequently do not inquire sufficiently about substance use when taking a patient’s medical history. In addition, data suggest that patients routinely under-report the degree to which they use alcohol, cigarettes, over-the-counter medications, and other substances of abuse (2, 3). A complete and accurate understanding of substance use is essential in the diagnosis and treatment of all general medical and psychiatric conditions. Thus, ensuring that patients provide accurate information and become engaged in the joint venture of understanding the effect of substance use on their health and quality of life is vital. The three main themes that have emerged as critical to the identification and quantification of substance use for patients include the following: 1) the importance of trust and open communication in the doctor-patient relationship, particularly regarding sensitive issues; 2) the recognition that substance use and abuse may play an integral role in many disorders physicians treat, even when these disorders are not the presenting condition; and 3) treating physicians may be crucial for both identifying substance abuse in their patients and/or reducing their patients’ risk for development of a substance abuse disorder (3).

The National Institute on Drug Abuse (NIDA) Centers of Excellence for Physician Information Program has developed teaching tools for medical students, residents, practicing physicians, and medical educators to improve the effectiveness of screening tools and interview techniques for identifying substance use disorders in patients assessed. Among the tools are curricula, screening tools, educational videos, and general suggestions regarding taking a substance use history and inquiring about other sensitive subjects and high-risk behaviors. Some of these patient assessment measures were developed jointly with APA as “emerging measures” for further research and evaluation (3). These assessment tools were designed to be administered at the initial patient interview and to monitor treatment progress. One of these measures is the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The test was initially developed by the World Health Organization, and APA adapted this screening assessment from the NIDA Modified ASSIST (2) as well as the NIDA Quick Screen (4) to be used as potentially useful tools to help patients and their caregivers identify and quantify their substance use.

Establishing a Therapeutic Alliance

Research shows that the quality of the physician-patient relationship is important in treatment engagement, adherence, and improvement in many medical disorders (5–7). This is particularly relevant when the treatment is more complex, when the disorder is more chronic, and when adherence is crucial to health outcomes. Schneider and colleagues (8) found that better physician-patient relationships were associated with higher adherence to antiretroviral therapy in patients with HIV infection. Of the seven physician-patient relationship quality measures assessed, six were statistically related to better medication adherence. These included four generic measures (general communication, overall satisfaction, willingness to recommend the physician, and trust in the physician), an HIV-specific communication scale that focused on physician-patient communication about sexual behaviors and substance abuse, and one measure of adherence dialogue that focused on how physicians communicate with their patients about antiretroviral medications.

In the context of substance use disorders, trust in the physician seems to be particularly relevant to improving honest reporting of substance use and engaging in treatment. Studies also suggest that self-report screening tools are helpful in identifying areas for further inquiry in terms of addictive and high-risk behaviors (2–4).

Experience often improves physician comfort with interviewing, asking difficult questions, and engaging patients. In addition, educational interventions with physicians are demonstrated to improve physician-patient interactions and health-related outcomes (9–12).

Clinical Vignette

Mr. Brown stepped into the office, giving Dr. Joshi a firm and confident handshake and flashing a too-broad smile. Dr. Joshi returned the smile warmly, and they sat down.

“So, Doc,” Mr. Brown started. “Dr. Miller, my primary care doctor, said that you could help. He thinks that anxiety is adding to my blood pressure problems.”

Dr. Joshi nodded empathically and inquired, “And what do you think?”

“Well, I have been stressed a lot. I mean, there have been layoffs at work and I am worried I could be next,” Mr. Brown said.

Dr. Joshi inquired about the patient’s social, developmental, and family history, psychiatric history, and medication use. Anxiety and depression were noted in family members, and Mr. Brown’s grandfather had been an alcoholic. Mr. Brown had never been in psychiatric treatment, although he and his wife had gone to couples therapy approximately 6 months ago for several sessions when they were having marital disagreements “about money and raising the kids.” Mr. Brown had two children, ages 15 and 17 years, who were in their “rebellious” stages, but “they are pretty good kids overall. Their grades are good, and they want to go to college. I just hope I can afford it…,” Mr. Brown’s voice trailed off.

Dr. Joshi nodded compassionately. “It sounds like it has been a very hard year for you. I’m sorry to hear that.” She paused briefly and then added, “You know, each of us manages stress in different ways. Some of us get depressed and withdrawn, some drink a bit more, and some find that they are cranky or not sleeping very well. Let’s review which of those you have been experiencing.”

Dr. Joshi began with open-ended questions and then asked specific questions. Mr. Brown had completed the ASSIST screening measure (2) in the waiting room, and Dr. Joshi asked if they may review it together.

Mr. Brown looked somewhat embarrassed, but he agreed.

“Okay,” Dr. Joshi noted matter-of-factly. “It seems that stress may be affecting your drinking. Alcohol can help you feel less stressed and worried. As you may know, however, drinking can backfire by becoming another problem. Drinking can also interfere with restful sleep,” Dr. Joshi explained. “You noted that you have been drinking more than usual lately.”

Mr. Brown nodded affirmatively. “My wife thinks I have a problem, and she has been nagging a lot about it. But I think she is overreacting. She tends to do that.”

“Thank you for telling me that,” Dr. Joshi mused, smiling appreciatively. “I hope this also means that you will feel comfortable being honest about your answers to the specific questions about your drinking. I’ll try not to nag,” Dr. Joshi said, smiling again. This time, Mr. Brown’s smile was wide and genuine.

Dr. Joshi took a detailed substance use history, and she determined that drinking was becoming impairing for Mr. Brown. He was falling asleep with a beer in his hand in front of the TV every night, and his kids said that he embarrassed them when they had friends over. He did not drink in the morning, but he admitted that he was not as sharp as he used to be. He was anxious and self-deprecating.

“My confidence is shot,” Mr. Brown concluded. “Maybe that’s why I take one,” he said. Dr. Joshi looked briefly puzzled. “You know. That’s why I take a shot—of booze. Sorry, bad joke on my part,” Mr. Brown said.

Both Mr. Brown and Dr. Joshi smiled at this attempt at humor with mutual understanding. Mr. Brown agreed to try Alcoholics Anonymous in the coming week. He set reasonable goals for himself, and he made a follow-up appointment.

“You aren’t going to tell my wife, are you? I just can’t deal with her saying ‘I told you so.’”

“No,” Dr. Joshi confirmed. “This is confidential.”

“Whew! Well, thanks, Doc. I feel better already. Wish me good luck!”

“Good luck,” Dr. Joshi replied warmly, as they shook hands—with less gusto and more sincerity than the handshake when they met.

Tips for Enhancing Engagement With Individuals Who Have Substance Use Disorders

Substance use disorders tend to have an insidious onset, and substance users often are not fully cognizant of the degree to which substances are negatively affecting their behavior and functioning (2, 3). In addition, physicians who have experienced negative effects from substance use in their own families may have special challenges in terms of empathic engagement of these patients (3). Physicians need to anticipate these challenges and utilize engagement techniques that will assist their patients in honestly reporting their substance use and in optimizing their motivation to engage in treatment. The physician must be aware of the probability of underreporting or lack of follow-through with agreed-upon treatments. Establishing a collaborative mutual partnership in which the therapist and patient work together to set goals and complete treatment tasks is particularly important in the crafting of successful treatment of substance use disorders. A few tips are provided below to enhance the treatment alliance between the physician and the patient for whom substance use may be impairing.