Familly and Preventative Medicine - Case Three
Dan, a 45 year old newly diagnosed type II diabetic, has returned for a follow-up visit. He shows poorly controlled blood sugars, and variable adherence to the hypoglycemic medication that you prescribed for him at the last visit. He acknowledges greatly increased alcohol intake (3-4 drinks per night, 5-6 nights per week).
- A. How would you approach the patient (either cooperative or resistant)?
- B. What data do you need to collect or what initial screening should be done?
- C. What other medications/drugs is the patient using?
- D. What is the pattern of patient's medication/drug use?
- E. What internal/external obstacles and biases might the patient face?
- F. What internal/external obstacles and biases might the physician face?
- G. What do you do now?
- H. How does the physician make a referral?
- I. When and how should the physician follow up with the patient?
A. How would you approach the patient (either cooperative or resistant)?
(The goal is to develop a positive, non-judgemental rapport with the patient?)
- Tell her you need to see her in person. Depending upon the etiology of her pain you may decide to leave her a prescription for a few days worth of Percocet (until her appointment).
- Use your rapport. Wait to address her Percocet refill request until after you've discussed less threatening issues.
- Don't be afraid to explore the issue.
- Display compassion and concern.
- Ensure confidentiality.
- Use a neutral, matter of fact, tone of voice
- Acknowledge it may be difficult for the patient to share this information.
- Be nonjudgmental. Remember this is a disease. The more nonjudgmental you are the more likely the patient is to reveal information.
- 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.
- 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.
- Be redundant. If your questions are not being completely answered ask again.
(The goal is to gather relevant history and barrier information.)
- The potential overuse of Percocet in this patient should raise concern of liver toxicity and drug tolerance.
- The motivation for use will help you determine if there is an addiction or whether the pain is being under managed.
- An addiction (according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)) is defined by the biopsychosocial consequences of use, not just frequency and amount. Ask the following questions:
- a. Tell me how you are taking the Percocet.
- b. Have you been prescribed pain medication in the past? (Get history of pain medication use, for what purpose, for how long it was used.)
- c. Have you ever lost prescriptions in the past or run out of your refills early?
- d. What types of symptoms do you experience when you go without the Percocet?
- e. What kind of pain are you still experiencing?
- f. How do you feel after you've taken the Percocet?
- g. Has anybody expressed concern regarding your Percocet use?
- h. Have you ever been in treatment for alcohol or drug abuse?
- i. Have you ever had any alcohol or drug-related arrests?
- j. Have you been missing work, school, or family responsibilities?
- k. Do you typically drive after taking Percocet?
- l. Do you have arguments with people in your life regarding your behavior when you are taking Percocet?
- m. Would you consider approaches other than medication for managing your pain?
- Review the patient's medication use to look for interactions or contraindications in a patient who is using Percocet.
- Review medications from any other prescriber. If you suspect the patient is minimizing or omitting other sources of medication, do a search on the Utah State Controlled Substance Database. (csdb.utah.gov) (This could have also been done after her initial phone call and before her appointment.)
Ask specifically about "pills." Such as "Do you ever take any other 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.)
- Review history of alcohol and illegal drug use. If currently using alcohol or illegal drugs, ask questions as noted in section B. (Reminder: Do not use the term "illegal drug". Instead ask "tell me about your drug use." Or ask specifically about certain drugs such as "tell me about your marijuana 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.)
(The goal is to determine how receptive/resistant the client will be to a discussion regarding his/her drug use. 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.)
- Fear that her pain won't be treated. (Keep in mind that individuals with addictions may still have real pain that needs to be treated.)
- Fear of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an addict.
- Embarrassment and shame.
- Fear of rejection by friends or culture.
- The patient's belief that his prescription drug use is not problematic.
- Lack of insurance for treatment.
- Residing with somebody who has an addiction.
- Being a primary care-taker of children (Childcare may be needed while patient is participating in treatment.)
- Fear of loss of employment.
- Fear of legal ramifications if they feel they are divulging sensitive information.
- Society's stigma and blame.
- Belief that addiction is a moral issue and not a medical issue.
- Belief that she couldn't possibly be in this much pain.
- Belief that people with addictions don't deserve to be treated for their pain.
- Belief that treating pain among people with addictions will exacerbate their addiction.
- Belief that treating pain with opioids will cause an addiction.
- It is easier and quicker to just fill the prescription rather than assess for pain and addiction.
- Lack of treatment availability (affordability, waiting-lists, services not available in community)
- Physician's discomfort with addressing substance abuse issues.
- Time constraints.
- Physician's family history causes countertransference (misperceptions based on personal experiences).
(This provides the physician with the information he/she needs to provide appropriate referral/treatment services.)
- Discuss evidence for concern (possible elevated LFTs due to excessive use of Percocet, running out of prescription early, possible results of Utah State Controlled Substance Database, any biopsychosocial concerns identified in part B)
- 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.)
- Provide reassurance that it is treatable.
- Ask the patient how she feels about your concerns.
- 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.
- If it is determined that the patient is not experiencing pain but does have an opioid addiction, consider prescribing Suboxone for detoxification or maintenance treatment and coordinate with a substance abuse treatment provider.
If it is clear that there is significant clinical impairment in the patient's biopsychosocial functioning as a result of his alcohol use, the patient should be referred to a substance abuse treatment provider for further evaluation and treatment.
If the patient is receptive:
- If the patient 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.
- If the patient is a veteran, eligible for VA services (this typically means having been honorably discharged) refer to VA Salt Lake City Health Care System at 582-1565.
- 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.
- 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. If there is sufficient time, it would be helpful for the patient to make the phone call in the physician's office; this demonstrates concern and active interest on the part of the physician.
If the patient is not receptive:
- If the patient remains resistant then consider restricting her to weekly prescriptions that she must pick up at the office and request Utah State Controlled Substance Database checks regularly. Some physicians have patients sign a pain management contract.
- The physician should write down the name of the agency and the phone number and encourage her to follow through with the referral.
(This provides the physician with the opportunity to coordinate with other agencies/providers in order 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.)
If there was a referral:
- Physician should obtain a release of information from the patient and provide referral information to the treating agency regarding concerns. Respond to any requests for information from the treating agency.
- Physician should ask the patient if they followed up with their referral and discuss resulting actions. Reinforce and encourage continued participation in treatment.
- In case of severe addiction, physician should coordinate directly with treating agency.
If there was no referral:
- Discuss patient's progress toward reducing or eliminating alcohol use. Ask specifically about activities or strategies that the patient used to accomplish that goal. Congratulate successes.
- If patient is making no progress and appears to be struggling in this area, then provide referral as noted above.