Effective Engagement of Patients About Their Alcohol and Other Drug Use

This article appears in the May–June issue of Minnesota Medicine, published by the Minnesota Medical Association, and is posted with permission.

By Lew P. Zeidner, PhD and CEO of EOSIS

There is growing public health awareness that even moderate use of alcohol and other drugs has a profound association with both mortality and morbidity. A recent report by the U.S. surgeon general talked about similarities between the grow­ing awareness of the health consequences of tobacco use in the 1960s and current evidence of the impacts of alcohol use. The opiate and related fentanyl crises also trigger frequent news head­lines. All of this while our communities scramble to make THC-related products more readily available. Every provider is faced with the need to find effective and efficient ways to address the role of alcohol and other drugs in the lives of their patients while maintaining a positive relationship with patients and effectively managing time in their office practice.

Identifying patients with substance use disorders or their pre­cursors would be less arduous if there were a laboratory test or other objective diagnostic measure for providers to use, reducing the requirement for clinical judgment. While measures of the medical consequences of more advanced stages of substance use disorders are clear, early intervention and prevention of advanced disease requires a different form of diagnostic.

Unlike acute or chronic physical pain that leads to easy discus­sions with a provider, moderate use and initial stages of substance use are often associated with the reduction of physical or psychic pain and not seen as disturbing symptoms. Later, early hints of problems with alcohol and other drugs are associated with shame and fear and therefore resistance to disclosure and discussions with physicians.

As with most diseases, prevention and early intervention with alcohol and other drug use disorders leads to less suffering, fewer psychosocial challenges, and better outcomes. This article will seek to provide guidance related to methodologies for effective early intervention with patients.

A review of a large number of substance use histories from those suffering with a disorder shows that patients report three primary drivers of initial alcohol and other drug use.

• First, reduction in social anxiety and an ability to be more engaged socially is common. Reduced inhibitions in social con­texts allows many people to initially feel less isolated and more accepted by peers and colleagues.
• Second, reduction of disturbing thoughts and feelings triggered by life’s stresses or historic emotional traumas. Often people will reflect on “needing a drink” at the end of a difficult day or challenging interaction.
• Third, reduction of physical pain caused by injury or other medical conditions. Recent disclosures and movies about the sales of OxyContin showed the impact that drugs that are per­ceived to manage pain can have on addiction.

Although each of these reasons for using alcohol and other drugs initially reflects “normal behavior” in our majority culture, when it intersects with genetic factors, other mental health condi­tions, and different levels of life stress it can lead to disordered use. While initially effective in addressing life challenges (as noted above), alcohol and other drugs lose their effectiveness over time and become associated with growing challenges in multiple aspects of a patient’s life.

Understanding the linkages between the initial role of alco­hol and other drugs in helping patients solve normal obstacles in life and then later creating challenges can be a very effective tool in providing patients with the information they need to make changes. There is a concept in mental healthcare called a “therapeutic alliance.” It refers to a collaborative, trust-based relationship between a patient and a therapist as a key ingredient in working toward a common goal of success in therapy.

While a patient’s relationship with a physician is inherently different from that with a mental health therapist, features of a therapeutic alliance can improve the outcome of a physician’s ap­proach to alcohol and other drug use. Factors that are essential include empathy, acceptance, compassion, and collaboration. Conversely, statements that sound judgmental, don’t offer op­tions, and appear to lack an understanding of the patient’s world­view or social context reduce trust and tend to lead to reduced effectiveness in interactions about alcohol and other drug use.

The amount of required collaboration between the provider and patient in making lifestyle changes, including the use of al­cohol and other drugs, is significantly greater than in many other medical situations. Framing the changes prescriptively is less ef­fective than seeking a patient’s perspective about what changes they are willing to make.

Balancing the need for collaboration is a need for honesty and transparency from the physician about the known risks and sci­ence behind alcohol and other drug use. In addition to a need to stay current with the literature, this requires a willingness to be direct and clear in efforts to educate a patient about the risks of alcohol and other drug use. Neither understating known factors to reduce tension nor overstating risks to create motivation are ef­fective in creating trust.

Two patient examples can help demonstrate some core chal­lenges for the medical provider.

John is a 35-year-old male-identifying patient who upon admis­sion to substance use disorder treatment reported not visiting his primary care physician for seven years to avoid questions about his drinking and what he perceived to be his doctor’s judgment of him.

Sarah is a 40-year-old female-identifying patient who was referred to outpatient care for substance use disorder by her pri­mary care physician as a result of misuse of prescription drugs following several family losses. She described feeling heard by her doctor and that he truly understood her struggles; thus she trusted his guidance.

When working with patients’ alcohol or other drug use prob­lems, it’s important that the physician has a critical awareness of his or her own experiences with family members and previous patients around alcohol and other drug issues and how those interactions impact the response to the current patient. Awareness of the ways that past experiences shape current perception of a patient can im­prove a patient’s experience of empathy and acceptance.

Efficiency in assessment within medical practices has led to a number of validated screening tools for several more common physical and mental health conditions from asthma to anxiety to safety in the home. They rely on patients’ independent trust in the safety of the relationship with a physician since the screening tools do not inherently build trust and at the same time require honesty and vulnerability from patients for the results to be valid.

Several of the most common validated screening tools—such as the Tobacco, Alcohol, Prescription medications, and other Sub­stance use (TAPS) Tool— use frequency and quantity of use as core measures. Although frequency and quantity are easily evaluated and frequently correlate with disordered use, they fail to address conse­quences of use, which is a core element of defining disorders and rec­ommended interventions related to alcohol and other drug use.

The CAGE (Cut-down, Annoyed, Guilty and Eye-opener) screening tool is focused on consequences of alcohol use and is a common tool utilized because it is very short and quick to ad­minister. A positive CAGE screening, however, requires a more detailed assessment to identify appropriate next steps.

The Alcohol Use Disorders Identification Test (AUDIT) and Drug Use Disorders Identification Test (DUDIT) are each 10-question patient self-administered tools that focus both on fre­quency and quantity of use but also on consequences of use such as missed obligations, symptoms of withdrawal, guilt, injury, and concern from loved ones. They can both trigger self-reflection for patients and provide a basis for discussion with a physician, social worker, or nurse.

For patients with alcohol and other drug use who are not see­ing challenges reflected in the above screening tools, family ge­netic history and high-stress life events can create platforms for a discussion with a physician about risk factors.

In summary, there are three core factors that can improve the effectiveness of a physician’s efforts to educate patients about the risks of their alcohol and other drug use:

• Seek to understand a patient’s psychosocial dynamics that initially influenced their use, such as social anxiety, desire to become socially connected, acute or chronic stressful life situa­tions, or physical pain.
• Work to ensure that clinical guidance, education, and interven­tion are likely to be heard in a context of trust, empathy, and efforts to build a collaborative plan.
• When utilizing validated screening and assessment tools, en­sure that the tools identify multiple dimensions of consequence of use in addition to frequency and quantity of use.

A common recommendation for patients that test positive for problematic alcohol and other drug use is to go to an emergency department in a local hospital to access services. While those recommendations may be useful for symptoms of acute medical withdrawal or suicide risk, emergency rooms are not equipped and physicians there are not prepared to evaluate and discuss the nuanced needs of a patient. The most effective recommenda­tions include evaluation and guidance by licensed alcohol and drug counselors and other licensed mental health professionals in private practice, or within substance use disorder treatment pro­grams in the community.