Q: Are certain methods of questioning and history-taking more likely to elicit helpful answers?
Ms. Becker: PCPs should use the “five As” (Ask, Advise, Assess, Assist, and Arrange) for screening and treatment. It’s important to establish a relationship with patients because if you ask straight out “Do you use drugs?” they will often say no. I generally begin with legal substances and lead with the question, “Do you smoke cigarettes?” If not, “Did you ever smoke?” I then ask about alcohol use. I might then move on to marijuana (the most commonly used illegal substance) and ask, “Have you ever used marijuana?” They may say they used long ago. I’ll follow up with “When was the last time?” Finally, I move on to other drugs. The nonmedical use of prescription drugs is the next most common form of abuse, followed by such harder substances as cocaine, heroin, methamphetamine, ecstasy, club drugs (also known as designer drugs), and inhalants. It’s unusual for people to have used just one.
Ms. Waters: The important thing to remember is that patients are responsive to medical advice about substance use because treating substance use problems as a medical disorder does not convey judgment. The federal government has invested substantially in a strategy called Screening, Brief Intervention, and Referral to Treatment (SBIRT).3 SBIRT programs in primary-care as well as emergency and trauma settings use evidence-based screening to identify patients who may be at risk for developing a substance use problem, in addition to identifying patients who are abusing or dependent on drugs. SBIRT uses a motivational interviewing approach, often in the form of a brief negotiated interview. I take a four-question approach to pre-screening: (1) When was the last time you had more than four drinks on one occasion? (a positive answer being within the past three months); (2) Do you smoke or use tobacco products? (3) Do you use marijuana, cocaine, or other drugs? and (4) Do you use any of your prescription drugs more than prescribed or take prescription drugs that were not prescribed to you? A positive answer to any of these questions warrants additional screening using such instruments as the Drug Abuse Screening Test (DAST).

Q: Can illicit drugs interact with each other or with medications?
Ms. Becker: Opiates, stimulants, hallucinogens, inhalants, etc., are powerful drugs that interact with prescribed medication. If SUD is the primary problem and you are unaware of it, you may end up prescribing drugs that interact with the illegal drug. For example, consider a patient with an anxiety disorder who self-medicates with an opiate. In attempting to treat the anxiety disorder, you may prescribe a medication synergistic with the opiate. On the other hand, if you are aware of the drug use, you can’t hold the patient hostage by saying, “I won’t treat you unless you stop using illegal drugs.” Or say a patient is depressed, has bronchitis, and is smoking five marijuana cigarettes a day. I relate the smoking to the bronchial condition and explain how it also makes the depression worse. 

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Q: When should the PCP refer to a specialist? What kind of specialist?
Ms. Waters: If a patient meets the diagnostic criteria for abuse or dependence or has a positive screen on an instrument such as the DAST, he or she should be referred for more specialized treatment. Generally, I recommend these patients see an American Society of Addiction Medicine-certified addictionologist for treatment planning. Withdrawal is terribly difficult. Moreover, it can be dangerous and should be carefully managed (whether as an inpatient or outpatient) by an expert. I also frequently refer patients to 12-step programs, psychotherapy, and social services. Coordinating services can be tricky, but taking the time to assist your patients can make a tremendous difference.
Ms. Becker: Every health-care provider should have resources to which he or she can refer for detoxification and treatment. There is a whole menu of options available (e.g., outpatient, inpatient, short-term inpatient). If I have an uninsured patient desperately trying to get treatment, I might refer him or her to Narcotics Anonymous or other community-based treatment, but I will also see that patient more frequently or have the patient check in by phone.