Don’t give up on an addicted patient

You may be tempted to ignore the addiction or quickly pass the patient on to someone else. But if you follow this advice, you can provide real help.

Most interactions with patients “flow” purposefully forward like rivers, from initial recognition and diagnosis of the problem to treatment and, hopefully, resolution. However, it is rare that interactions with patients addicted to drugs flow so smoothly. In fact, most visits with these patients may feel like puddles in that, despite your best intentions, they have little structure and are not goal-oriented. Typically, visits with addicted patients turn into power struggles, and the clinician may leave the room feeling frustrated, angry, and disgusted.

Unfortunately, few clinicians receive formal, intensive training about the common, but complex and baffling, disease of addiction. Largely because of this lack of training, some research indicates that nine out of 10 primary-care clinicians fail to recognize addiction, even in patients who have classic symptoms.1

Of course, making this diagnosis is frequently a formidable task given how brief office visits have become. This article will focus on how to quickly recognize, diagnose, and refer the addicted patient. Also included are points to remember when your patient returns from rehabilitation. (Much of the material is from the textbook Management of the Addicted Patient in Primary Care, which will be published later this year.2)

Is it “real” or pseudoaddiction?

When to prescribe a drug can be the dilemma anytime you are dealing with a patient who may or may not be an addict and who may or may not be feigning an illness to get a prescription. To differentiate between those with the disease of addiction and those who truly need controlled substances for pain and/or anxiety, you first need to become familiar with these definitions:

Tolerance: The individual no longer responds to a drug — i.e., he needs more of the substance to get the same effect he used to get.

Dependence: The individual functions normally only in the presence of a drug; drug removal is usually accompanied by physical discomfort, or withdrawal. Anyone taking opioids or benzodiazepines for prolonged periods will become physically dependent, but this does not necessarily mean the person is an addict.

Addiction: The American Society of Addiction Medicine defines addiction as “a disease process characterized by the continued use of a specific psychoactive substance despite physical, psychological, or social harm.”

Pseudoaddiction: Addictlike behavior occurs when the individual is undertreated — i.e., the dosing schedule of a particular medication or the potency of the drug chosen is not adequate.

When the medication or medical problem is corrected, the behavior abates. Here’s an example: Two patients are physically dependent on opioids and complain of chronic back pain. Both went through detoxification and are no longer opioid-dependent. Now imagine that you are magically able to end the pain in their backs. The pseudoaddict would no longer have any interest in taking narcotic medications; to him, the pain was the primary issue and, now that the pain is gone, he no longer needs (or wants) the narcotics. The real addict, on the other hand, would still want the opioid because for him, the drug — not the pain — is the primary issue.

Differentiating pseudoaddiction from the real thing will become easier as you read on.

Recognition and diagnosis

Asking about past and present drug use should be part of every new patient history (you should also ask about alcohol, but this article concerns only other types of drug abuse). If your patient answers affirmatively that he or she either uses drugs or has done so in the past, move on to the “Three C” questions below as a quick way to screen for the presence of addiction:

Due to your (substance) use, have you ever experienced:

1. A loss of Control in any area of your life (e.g., forgetting important appointments, too tired to keep plans with spouse, continually late for work, etc.)
2. Compulsivity (i.e., using more of the drug than intended or for a considerable time)
3. A time when you kept using a drug despite adverse Consequences (e.g., arguments with loved ones, medical problems, work-related problems)?

If the patient answers “Yes” to any these, tell him that he may have a drug problem, and that you would like to assess further. To improve your ability to diagnose a substance-use disorder, become familiar with the criteria for abuse and dependence, both of which are detailed in the widely used Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).3

Another useful screening tool is the CAGE-AID (Altered to Include Drugs).4 If your patient responds that he has used drugs in the past (or present), ask the following:
1. Have you felt you ought to Cut down on your drug use?
2. Have people Annoyed you by criticizing your drug use?
3. Have you felt Guilty about your drug use?
4. Have you ever used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

Scoring: Responses are scored 0 for “No” and 1 for “Yes.” A score of 2 is clinically significant; however, primary-care clinicians may consider lowering the threshold to one positive answer to cast a wider net and identify more patients who may have substance-use disorders.5

Spotting behavioral clues

Some behavioral signs that may suggest addiction include (but are not limited to) the following:
• Numerous “lost” prescriptions
• Numerous requests for refills before the next refill date and/or calling at the end of the week for refills
• Asking for medication by name, stating that only one drug alleviates pain/anxiety (OxyContin, Xanax, Lortab, Soma, etc.), or feigning ignorance: “The only thing that has ever helped is…I can’t remember the name…It starts with a ‘Z’…Zantac? No…Xanax! That’s it…I think it’s Xanax.”
• Reciting either textbook symptoms or a vague history
• Inability to stabilize on a given dose or a constant need to escalate the dose
• Becoming angry/defensive or very anxious when you mention changing medication
• Exhibiting strong resistance to any other pharmacologic or nonpharmacologic treatment, such as a nonnarcotic medication, physical therapy, etc.
• Problems at home, work, or school
• Forgetfulness or difficulty sustaining attention
• Apathy, depression, irritability, or anxiety
• Paranoia

If a patient exhibits any of these signs, screen further using DSM-IV-TR criteria. Physical examination findings suggestive of addiction or its complications should also be assessed.6

A urine drug screen should be a standard part of the intake process. Remember these facts about urine testing:
• It takes approximately five half-lives for most substances to leave the body. Whenever possible, urine collection should be observed. If that’s not possible, assess the temperature of the sample immediately after collection.
• Be certain that laboratories are testing for alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and synthetic opioids, since these substances are not necessarily part of a routine urine drug panel.
• Patients may be less likely to use drugs if they know they will be screened on a regular or random basis.7

Positive screen: what to do next

If your patient responds positively on a screen and you believe he is abusing drugs, you might say, “After reviewing your case, there are some things I’d like to follow up with you,” or “Your answers to the questions I asked are similar to the answers of people who may be having a problem with drugs.” The following are some possible approaches based on severity of the problem and possible risk:

1. Follow up immediately with further questions during the same appointment (using DSM-IV-TR criteria to diagnose a substance-use disorder).
2. Schedule another visit for further questioning if the screening results are inconclusive.
3. Immediately refer to a detoxification unit and/or substance-abuse treatment center for further evaluation or to community resources, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).

Once a diagnosis of drug abuse is made, the part of the patient’s medical record that makes any reference to his substance use is protected beyond that of existing standard state and federal law and cannot be released without his consent. The records can only be released to an attorney with a court order (not with a subpoena). Be aware that any action you take to address the patient’s substance use, whether passing on information for a referral or prescribing medications (e.g., naltrexone, disulfiram [Antabuse]), is confidential under federal law.

When the patient returns from treatment (or is attending a 12-step program, such as the ones endorsed by AA and NA), it is extremely important to praise him for his efforts and offer ongoing support and encouragement. If the patient’s family members are not attending Al-Anon (a 12-step program for families and friends of someone with a substance addiction), recommend that they do. Brief cognitive-behavioral techniques, which the primary-care clinician can administer, are also useful for creating boundaries and adding structure to your visits (for further discussion, see sidebar “Examples of cognitive-behavioral techniques”).

The written agreement

During active addiction, it is normal for patients to be dishonest and manipulative. However, once in recovery, trust can be built. An important part of creating an atmosphere of trust, whether your patient accepts or declines treatment, is to have a written agreement that stipulates the boundaries of your new postdiagnosis relationship. Some of the points that should be covered in this agreement include:

1. There will be random urine tests.
2. The patient is to be completely honest about any alcohol or other drug use.
3. The patient will not be prescribed any narcotic, benzodiazepine, or other potentially addictive medication.

Actively addicted or recovering patients who have valid chronic pain or a severe anxiety disorder should see a pain specialist or psychiatrist. If none is available in your area and you decide to manage the medication for these patients, be sure to write up a medication agreement.

4. A medication agreement should set clear boundaries and consequences of medication use and misuse.

If your patient is unable to adhere to this agreement, you will likely need to refer him elsewhere. Continuing to see a patient who is actively abusing substances with your knowledge may be detrimental to you, your practice, and, ultimately, to the patient. While this may be a difficult decision, it can help the patient move closer to choosing appropriate treatment.

While addicted patients may be difficult and challenging, you can make a real difference in their lives. Your empathy, support, gentle confrontation, encouragement, and limit- setting can serve as the foundation that the patient so desperately needs to start leading a productive, drug-free life.

Dr. Heidi Pomm is director of behavioral science in the Family Medicine Residency Program, St. Vincent’s Medical Center, Jacksonville, Fla. Dr. Raymond Pomm is medical director of the Florida Impaired Practitioners Program in Fernandina Beach.

References

1. The National Center for Addiction and Substance Abuse (CASA). Missed Opportunity: The CASA National Survey of Primary Care Physicians and Patients 2000. New York, N.Y.: Columbia University; 2000.

2. Pomm HA, Pomm RM. Management of the Addicted Patient in Primary Care. New York, N.Y.: Springer. In press.

3. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, D.C.: American Psychiatric Association; 2000.

4. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94: 135-140.

5. National Library of Medicine. Guide to Substance Abuse Services for Primary Care Clinicians: Treatment Improvement Protocol (TIP) Series 24; Available at: www.ncbi.nlm.nih.gov/books/bv.fcgi. Accessed January 3, 2007.

7. Jacobs WS, Repetto M, Vinson S, et al. Random urine testing as an intervention for drug addiction. Psychiatr Ann. 2004;34:781-785.

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