Utah Addiction Center

Familly and Preventative Medicine - Case Nine

Dorothy is a 15 year old female high school sophomore. Drastic changes in her appearance and behavior, plus the development of significant tooth decay, have alarmed her parents (who are also patients of yours) and led them to wonder about methamphetamine use. She comes to clinic for treatment of a foot infection.




A. How would you approach the patient (either cooperative or resistant)?

(The goal is to develop a positive, non-judgemental rapport with the patient.)

  1. Use your rapport. Wait to address the methamphetamine issues until after you have discussed non-threatening issues.

  2. Don't be afraid to explore the issue.

  3. Display compassion and concern.

  4. Ensure confidentiality

  5. Use a neutral, matter of fact, tone of voice

  6. Acknowledge it may be difficult for the patient to share this information.

  7. Be nonjudgmental. The more nonjudgmental you are the more likely the patient is to reveal information.

  8. Allow any resistance, pre-contemplation, and minimization to be okay. Remember to be nonjudgmental and avoid any power struggles. At this time it is unnecessary for the patient to admit that he has a problem.

  9. If patient is resistant, acknowledge that it is difficult and uncomfortable and explain that you believe this is a health issue and is part of your over all approach to patients. Continue to gently ask questions.

  10. Be redundant. If your questions are not being completely answered ask again.

  11. Phrase the question appropriately. For example, ask, "Tell me about your methamphetamine use," instead of "Do you use methamphetamine?" And "What kinds of drugs do you use?" instead of "Do you use drugs?" (Avoid the term "illegal drugs".)

B. What data do you need to collect or what initial screening should be done? (The goal is to gather relevant history and barrier information.)
  1. This patient's use of methamphetamine is of great concern. At the minimum it is affecting her health.

  2. According to the Diagnostic and Statistical Manual of Mental Disorders, an addiction is defined by the biopsychosocial consequences of use, not just frequency and amount. Ask the following questions and don't hesitate to inquire when encountering unfamiliar terminology or street language:

  • a. When did you first start using methamphetamine? How often? How much?

  • b. What is the route of administration?

  • c. Have you tried to cut back before? What happened

  • d. Does it take you more methamphetamine to feel the same effects than it used to?

  • e. Have you ever had periods when you did something that you wish you hadn't when you were using methamphetamine?

  • f. Has anybody ever expressed concern regarding your methamphetamine use?

  • g. Have you ever been in treatment for alcohol or drug abuse?

  • h. Have you ever had any alcohol or drug-related arrests?

  • i. Have you ever missed work, school, or family responsibilities because of your methamphetamine use?

  • j. Have you noticed any changes in your mood or sleep or appetite?

  • k. Would you consider quitting methamphetamine use?

If the person becomes resistant or uncooperative try to reassure the patient that you are gathering this information to provide the best care for his health. If the patient remains resistant then ask them what they would like to do, ask them if you could ask about this issue again next time, and schedule a follow-up appointment. It is likely that fear and stigma is contributing to the patient being in the pre-contemplation stage of change.

C. What other medications/drugs is the patient using?

  1. Review the patient's medication use. Chronic methamphetamine use may render some medications, such as antidepressants, ineffective.

  2. Review history of hyperkinetic disorders. Patients who have such disorders that are not being treated tend to gravitate toward stimulant use.

  3. Ask specifically about "pills." Such as "Do you ever take any kind of pills?" and "Do you ever take anyone else's pills?" (Note: It is important to ask specifically about pills, as many people do not consider pills to be drugs of abuse.)

  4. Review history of alcohol and other illegal drug use. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your other drug use." Or ask specifically about certain drugs such as "tell me about your marijuana use.") 

D. What is the pattern of patient's medication/drug use?

(The goal is to determine when, how often, and under what kind of stress/pain conditions is the patient using/abusing the prescribed medications or other drugs.)
N/A

E. What internal/external obstacles and biases might the patient face?

(The goal is to determine how receptive/resistant the client will be to a discussion regarding her family situation. The physician needs to be aware of the internal/external stigma and biases that the patient faces. The physician will need this information to determine how best to approach the patient and/or his parents).

  1. Fear of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an addict

  2. Embarrassment and shame

  3. Fear of rejection by friends or culture

  4. The patient's belief that her methamphetamine use is not problematic

  5. Lack of insurance for treatment

F. What internal/external obstacles and biases might the physician face?
  1. Closest friends or someone else in the home also using methamphetamine

  2. Transportation

  3. Fear of legal ramifications if they feel they are divulging sensitive information

  4. Society's stigma and blame

G. What do you do now?

(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)

  1. In addition to treating the foot infection, this patient needs a comprehensive physical examination.

  2. Discuss evidence for concern (appearance, any weight loss, tooth decay, origin of foot infection, and concern expressed by parents)

  3. If using needles test for diseases such as HIV and Hepatitis C.

  4. Display compassion (Remember that addiction is a life threatening disease thus show the same sensitivity as you would for identifying any other life-threatening illness, such as cancer.)
  5. Provide reassurance that it is treatable

  6. Ask the patient how he feels about your concerns

  7. Address the stigma associated with having an addiction by reassuring the patient that this is a medical illness and not a question of moral character

  8. Tell the patient that her parents expressed concerns regarding methamphetamine use and that you would like to share your findings with them. (Because the parents asked you to see her due to their concerns regarding her methamphetamine use as well as the foot infection it is important to involve them even if the patient is uncomfortable with that decision.) 

H. How does the physician make a referral?

Ideally the referral to treatment should be discussed with the patient while her parents are present. Because the patient is a minor, the parents can admit her to treatment without her consent. The patient should be referred to a substance abuse treatment provider for further evaluation and treatment.

  1. If the family does not have insurance that covers substance abuse treatment, or does not have the ability to pay for treatment, or if the physician has no knowledge of substance abuse treatment agencies, refer to SL County Division of Substance Abuse at 468-2009 or refer directly to Interim Group Services.

  2. Ideally physicians should begin to develop relationships with substance abuse treating agencies and can refer to a specific agency for treatment. However, the physician should encourage the patient to call his insurance company to determine what services are covered.

  3. Regardless of the specific referral, the physician should list the name of the agency and the phone number on a prescription blank and give to the patient and her parents.

  4. Explore possibilities for support and/or counseling for the parents and any other affected family member(s), such as Alanon, Families Anonymous, or a private practitioner.

I. When and how should the physician follow up with the patient?

(This provides the physician with the opportunity to coordinate with other services provides to deliver comprehensive services for the patient. It also provides the physician the opportunity to take an active role in the patient's substance abuse problems. The physician can treat/oversee the substance abuse problem as any other medical condition that can have a positive outcome.)

  1. Physician should provide ongoing treatment for the physical problems.

  2. Physician should provide referral information to the treating agency regarding concerns and respond to any requests for information from the treating agency.

  3. Physician should ask the patient if they followed up with their referral and discuss resulting actions. Reinforce and encourage continued participation in treatment.

  4. In case of severe addiction, physician should coordinate directly with treating agency.