Taking a Substance Abuse History and Effectively Intervening without losing your mind

1
Taking a Substance Abuse History and Effectively
Intervening (without losing your mind)

• Edward Via Virginia College of Osteopathic
  Medicine
• Addiction Medicine
• Block 9 2005
• Martha J Wunsch MD

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Learning Objectives

• List the elements of the complete substance abuse
  history.
• Identify the classes and patterns of substances
  used and abused by an individual patient.
• Identify effects of substance abuse in the
  physical, psychological, social, and legal areas
  of a patients life
• List the elements of a brief intervention using
  medical crisis as a lever for change.

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HPI The complete substance abuse history

• Determine what, how, when the patient is using
  which substances and prior substance abuse
  treatment history.
• Identify medical problems secondary to substance
  abuse.
• Define psychiatric history impacting upon
  substance abuse, including treatment, for a
  patient.
• Delineate family history of substance abuse.
• Determine social consequences of substance abuse.
• Determine legal consequences of substance abuse.

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Assessment and Plan

• Assessment
• Give patient your diagnosis Substance Abuse
  versus Substance Dependence
• Assess the patients Stage of Change
• Plan
• Brief intervention and referral
• Use FRAMES approach
• Summarize information from SA history
• Present patient with diagnosis
• Negotiate plan with patient
• Offer resources to patient and family

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Why?

• As with any diagnosis you will make
• Take a complete history
• Document how it is affecting the patients
  physical and psychological health
• Make a diagnosis and inform the patient and
  family (with their permission)
• Develop a treatment plan
• Because this is a chronic disease without cure,
  assist the patient in management

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Case John S

• Chief Complaint Blood pressure check
• 150/95, 160/105, 155/98
• HPI 50 year old male who comes with hypertension
  that is non-responsive to medical management.
• Wife has called you because she is concerned that
  he is drinking, to intoxication, after work each
  night and on weekends
• Wife says he has gotten his second DUI in two
  months
• Last year he developed alcohol withdrawal after
  his cholecystectomy requiring prolonged
  hospitalization in the Intensive Care Unit
• CAGE 2 (A and E)

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Delineate what, how, when the patient is using
substances..

• I am concerned that your drinking is a problem
  for your health, specifically your high blood
  pressure that is not getting better with
  medicine
• Can I ask you some questions that will help me
  decide how to best assist you?

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Stages of Change Model Readiness to change

• Helps use resources wisely
• Giving information versus long discussions
• Matching our intervention to readiness to change
  predicts in gt90 of cases
• Those who will engage in treatment
• Those who will leave treatment before completion
• Those who will be successful in treatment

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Behavior is more likely to change

• When an individual believes they have a problem
• When an individual feels they can be effective
• When they participate in setting goals
• When choices are developed that are limited (3)
  and specific

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Review of Readiness to Change/Stages of Change
Model

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Re-entry possible

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Precontemplation

• Patient generally says No, I dont take my blood
  pressure medicine every day like you told me
  toits not the drinking
• Not considering change
• No action in foreseeable future
• Underestimates benefit of change/Overestimates
  cost of change
• Cannot imagine why you want to discuss this with
  him/her!

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Contemplation

• Well, maybe my drinking is causing a problem
  with my blood pressure, if you say so
• Considering Change
• May take action in the next 6 months
• Benefits of changing behavior are clearer
• Costs of changing behavior are clearer
• VERY helpful to increase dissonance about current
  behavior and long term goals

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Preparation

• I need to stop drinking doc, I just dont know
  where to start. Ive tried before and not been
  successful
• Ready to change
• Action will probably occur in next month

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Action

• Hey doc, I went to an AA meeting! I havent had
  a drink in a month. It wasnt half bad. You know,
  I saw my neighbor Joe there. I didnt know he had
  a problem
• Learning new behavior
• Overt changes in last 6 months
• Patient is still at risk for use of substance

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Maintenance

• Patients will proudly share their progress with
  you
• Stable in new behavior
• Active in recovery community
• 6 months-5 years into new behavior

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Case John S No..I dont want to answer any
questions about my drinking

• Offer your support
• Id be glad to discuss this with you anytime
• Educate about safe drinking levels
• NIAAA guidelines
• Document in chart your concern about alcohol
  abuse and its effect on health problems
• State your concerns at every subsequent visit

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Yes.

• Why are you concerned doc? All my friends drink
  the way I do. I dont think its a problem

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Why do you think I drink too much, doc?

• Patient is willing to discuss this with you
• Patient may respond to a brief intervention
• Without further effort, you have enough
  information to conduct this brief intervention

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Brief Interventions

• Ask about drinking at periodic visits and when
  presenting problem indicates a concern
• Assess and state concern about level of drinking
• Advise to decrease drinking levels
• Assist with referral for further evaluation or to
  community based resources
• Re-inquire/Follow-up at subsequent visits

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Brief Interventions Work!

• Alcohol consumption decreases at 12 month
  follow-up
• 20-50 after 1-2 short visits in primary care
• 80-90 in alcoholics requesting care
• Efficient available means to document that you
  have addressed alcohol abuse
• Increased effectiveness with supportive, non-
  confrontative, clinician attributes
• Fleming, Barry, Manwell et al 1997 Fleming and
  Graham 2001
• Project MATCH 1997

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John S Brief Intervention

• State your concern based on information you
  already have obtained
• Medical Alcohol elevates blood pressure
• Medical Patient required medication to manage
  withdrawal after surgery reflecting development
  of physiological tolerance to alcohol
• Legal Two DUIs
• Social Wife is concerned about his drinking

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I can stop drinking anytime

• Issue a challenge to patient to stop drinking for
  30 days, return for a blood pressure check.
• Offer educational materials
• Re-visit concern about drinking patterns at
  subsequent visits

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Substance Abuse History

• Age at first use
• Youngermore likely to be problematic
• Determine if regular use ( ie 2-3 times/week)
• More often indicative of problem
• How the substance was used
• For drugs, escalation from oral to nasal to
  intravenous will occur as tolerance to desired
  effects occurs
• Daily versus weekend drinking
• Use in last 30 days
• Current problem versus past
• Indicative of escalation of problem
• Why have you decided this may be a problem now?

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• Tolerance Ask about withdrawal symptoms after
  stopping drinking
• Shakes and anxiety, hospitalizations, medications
  given for treatment as an out patient
• Blackouts Ask if there is ever a time when they
  cannot remember what happened after drinking
• Periods of abstinence
• After you began drinking, has there been a time
  when you stopped?
• Previous treatment
• AA attendance, using community resources, long
  term or residential treatment setting, detox
  admissions

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Treatment History

• Ever attend an Alcoholics Anonymous meeting?
• Residential Treatment at a psychiatric hospital
  or substance abuse treatment center
• In Virginia, ever receive treatment at a
  Community Service Board for substance abuse?

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Medical History

• Trauma/Injuries while drinking
• Seizures
• Frequent Infections
• Vomiting, hematemesis, black/bloody stools
• Sexually Transmitted Diseases
• Hepatitis (alcoholic, Hepatitis B or C)
• Exacerbation of chronic diseases
• Diabetes Mellitus
• Hypertension

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Psychiatric History

• Current symptoms
• Treatment for depression
• Treatment for anxiety
• Diagnosis of a personality disorder
• History of suicide attempts or suicidal ideation
• Temporal association with drinking/drug use
• Admissions to psychiatric hospital

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Family History/Childhood History

• Helpful to use a genogram
• Ask about substance abuse and psychiatric history
• Ask about brothers, sisters, parents and
  grandparents
• If applicable, ask about children of the patient
• Ask WHICH substances have been a problem for
  which relative
• Dont forget to ask about prescription drug abuse
• If comfortable, ask about childhood abuse

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Social History

• Current living arrangement
• Intact stable network helpful
• Lack of others abusing drugs and alcohol in
  environment helpful
• Marital status
• If divorced or separated inquire if related to
  substance abuse in patients opinion
• Educational attainment
• Employment status
• Legal history
• DUI, DIP, possession/distribution of illegal
  substances, incarceration

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Back to our caseage on onset of problems

• Began drinking at age 15 years
• Weekend drinking to intoxication by age 17
• Drinking every day by mid-20s
• Had had periods when he drank less when things
  were going well but drank every week
• Last 5 years have been a real struggledoc I
  want to drink less

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Substance abuse in last 30 days

• What do you drink?
• 1 pints of vodka each day
• Occasionally more (up to 2/day) on the weekends
• How much do you drink at a sitting?
• Drink after work, continuously until he falls
  asleep
• Drinks all weekend long
• How often to you drink to intoxication?
• Never really feel drunk, just dont feel the
  shakes unless he cannot get to a drink by 5 pm

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Substance Abuse History

• Tolerance Patient has noted to you that he never
  really feels any high from drinking. He drinks
  to avoid being ill.
• Blackouts
• Wife tells him that he says thingshe doesnt
  remember.
• Took his grandchild fishing one weekend afternoon
  and has no memory of this

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Substance Abuse History

• Periods of Abstinence
• Drank much less for two years in late 30s
• Links this to death of father from drinking
• Was given some medicine by his family doctor
  during that time that seemed to help him drink
  less (?Antabuse)
• Previous treatment None

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Medical History

• Cholecystectomy with prolonged hospitalization
  for alcohol withdrawal
• Was counseled to decrease/stop drinking by his
  surgeon after that hospitalization
• Fell from ladder while working--but was not
  drinking during that daybut notes his balance is
  not very good
• Suffers from indigestion and heartburn,
  especially on Monday mornings

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Psychiatric History

• Sleeping poorly, very anxious in the afternoon
  before his first drink.
• Cites feeling very sad and down because he
  knows his wife is upset about his drinking.
• Never attempted or thought about suicide
• Never received outpatient counseling and no
  admissions

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Family/childhood history

• Father, grandfather, paternal uncle were heavy
  drinkers
• Mother asked father to leave and raised children
  alone because of his drinking problems
• History of physical abuse by father
• Two brothers (one alcoholic, one drinks socially)
  
• No history of psychiatric disease in family

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Social History

• Married for 30 years with two children
• Supported his family throughout drinking career
• Feels that his wife is about to leave because of
  alcohol
• Daughter without substance abuse problems
• Son with prescription drug abuse, currently
  incarcerated, divorced from wife who is
  prescription drug abuser
• Have custody of grandson because of sons
  problems
• 8th grade education, works as painter EVERY day
• Legal DUI X 2

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Diagnosis

• Substance Dependence A maladaptive pattern of
  substance use leading to impairment or distress
  with
• Three or more of the following in the same 12
  month time period
• Tolerance increased amounts for same effects
• Withdrawal characteristic syndrome or use to
  avoid
• Taken in larger amounts than intended
• Persistent desire to cut down on use
• Great deal of time spent procuring, using,
  recovering
• Important social, job, recreational activities
  given up
• Use in spite of physical or psychological
  problems caused by alcohol

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Diagnosis

• Substance abuse A maladaptive pattern of
  substance use leading to impairment or distress
  with
• One or more of the following in the same 12 month
  time period
• Failure to fulfill major role obligations at
  work, school, or home
• Recurrent use in situations that are hazardous
• Recurrent substance-related legal problems
• Continued substance use despite
  social/interpersonal problems exacerbated by use
  of the substance

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Diagnosis?

• Tolerance?
• Physiological Withdrawal?
• Giving up important roles and responsibilities?
• Continued use in spite of physical and
  psychological problems?
• Legal consequences for use?
• Continued use in spite of relationship problems?
• Taken in larger amounts than intended?
• Persistent efforts to cut down?

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Assessment

• Alcohol Dependence
• Assess for Withdrawal Potential
• Evaluate for autonomic instability
• History of previous withdrawal ( YES!)
• Referral for hospitalization
• Discuss plan with patient and family

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Talking with patients FRAMES

• Feedback
• Responsibility
• Advice
• Menu
• Empathy
• Self-Efficacy

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FRAMES

• FEEDBACK about personal risk or impairment
• According to individual status
• For each patient, list specific consequences of
  substance abuse
• Not drinking while driving
• Avoiding alcohol during pregnancy
• Not lecturing
• Not generalities

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Feedback

• List medical and social problems that are related
  to alcohol dependence and benefits of changing
  behavior
• Help decrease blood pressure
• Avoid further legal consequences
• Improve relationship with wife
• Providing alcohol/drug free environment for
  grandson

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FRAMES

• Emphasis on personal RESPONSIBILITY for change
  and freedom of choice
• Its up to you, youre free to decide to change
• No one else can decide for you or force you to
  change
• Youre the one who has to do it if its going to
  happen

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FRAMES

• Clear ADVICE to change and the need to change and
  decrease consumption
• Supportive and concerned manner
• Not authoritarian
• Avoidance of arguments

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FRAMES

• Offer a MENU of alternative change options
• Encourage patient to develop these options
• Three choices maximum
• Patient chooses more appealing or suitable option
  and is more willing to follow through on change

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Menu of options

• Issue a challenge to stop drinking completely for
  30 days
• Attempt to decrease consume to a safe level
• Try medication and accept referral for treatment

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Menu of Options

• Medical Management
• Disulfram (Antabuse) 250-500 mg/day
• Causes discomfort with drinking due to blockade
  at alcohol dehydrogenase
• Must evaluate Liver Function first
• Must see patient weekly to monitor progress
• Naltrexone (Revia) 25-50 mg/day
• Blockade at the opioid receptor
• Felt to interrupt the reward pathway for some
  individuals

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Menu of Options

• Psychological and social support
• Encourage patient to attend AA meetings
• Have a list of meetings in your office
• Help patient identify treatment options and make
  a referral
• Call mental health hot line for insured
  patients
• Community Service Board/public programs
• Encourage family to attend Alanon
• If patient goes to treatment, ask for release

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FRAMES

• Clinician EMPATHY is effective
• Acceptance
• Careful listening and reflection
• Empathetic, warm, reflective, supportive style is
  linked to better outcomes
• Remember that the patients time frame for change
  may not fit yours!

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FRAMES

• Facilitate patient SELF-EFFICACY or optimism
• Help patient recognize barriers to change
• Establish a sense of discrepancy, or cognitive
  dissonance, between the persons current
  situation or goals
• Reinforce the patients expectation that they
  will be able to change