TORONTO – All patients, regardless of presentation, should be screened for substance abuse, according to an expert, but barriers such as shame and fear often make an accurate assessment difficult.
“Using a warm, empathetic, nonjudgmental style can help,” Dr. Shelly F. Greenfield told an audience at this year’s American Psychiatric Association meeting.
More than 9% of the U.S. population aged 12 years or older use an illicit substance, including marijuana and opioids in the previous month, according to data from the 2013 National Survey on Drug Use and Health. Among the illicit drug users, more than 80% used marijuana. Nearly a quarter of people aged 12 or older were binge alcohol users, defined as having five or more alcoholic drinks on at least 1 day in the 30 days before the survey was conducted.
Dr. Shelly Greenfield
Early detection and intervention can help prevent more serious substance use issues that often co-occur with psychiatric comorbidities such as depression or anxiety, said Dr. Greenfield, an addiction psychiatrist with the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The overall goal, she said, is to “formulate the problem, educate the patient, and help him or her initiate appropriate interventions and treatment.”
Physicians should understand that there are very real barriers for many patients who may be unwilling to endorse signs of any substance use. “Some could have legal concerns, such as how revealing any information could impact child custody, for example,” Dr. Greenfield said. Often, patients will deny, minimize, or rationalize their use. Using open-ended interviewing techniques, such as those used in motivational interviewing, can help the clinician see how the patient is defining the problem. Questions that allow patients to frame actions in their own words can help avoid confrontation, reduce ambivalence, and prompt patients to consider a rationale for changing their behavior (Patient Educ. Couns. 2013;93:157-68).
For example, physicians could use a prompt such as, “I wonder if you could tell me about your pattern of use of alcohol in a typical week ...” This information could then be a starting point for discussing the patient’s drinking habits according to the Timeline Followback Method, where patients reconstruct the type, quantity, and frequency of their substance use over the course of their lives. However, some data have shown that the level of detailed recall diminishes the further back a patient is asked to recall (Addict. Behav. 2010;35:1138-43).
The key is to assess to what degree the patient has insight into the nature of his or her level of substance use, said Dr. Greenfield, also a professor of psychiatry at Harvard Medical School in Boston.
Other components that should be included in the assessment include full psychiatric, medical, family, and social and developmental histories, such as the person’s age at first use; consequences associated with the substance use; and a determination of whether the person already has had treatment for substance use. Also, it is helpful to know if there have been any periods of abstinence and how those periods were maintained, as well as what factors trigger relapse.
“The age of a person’s first substance use serves as a framework,” said Dr. Greenfield, noting that use before the age of 14 years often is associated with preceding psychiatric disorders. Although co-occurring substance use and psychiatric disorders such as depression are more likely to have a worse prognosis, Dr. Greenfield said integrated treatment can enhance outcomes for both.
A useful screening and assessment tool Dr. Greenfield noted is the Addiction Severity Index, which evaluates how substance use might be affecting seven key areas of a person’s life such as their relationships and employment. The assessment is free and available from the National Institute on Alcohol Abuse and Alcoholism. Other helpful screens include the Clinical Institute Withdrawal Assessment for Alcohol, and the Clinical Opiate Withdrawal Scale, both of which are also free and available online.
Augmenting substance use assessments with other mental health status exams and appropriate biomarkers, such as serum testing, can help create a more solid picture of a patient’s overall health.
Dr. Greenfield has no disclosures or conflicts of interest. She has received support for her research on substance abuse in women from the National Institute on Drug Abuse.
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