Physical Medicine and Rehabilitation - Case Two
Mr. Hansen is a 27-year-old male with pain secondary to a T-12 spinal cord injury resulting in paraplegia. He saw a previous physician of whom he is critical. He is very happy with you, his new doctor: "You understand me so much better than Dr. Frank did. She didn't care that I'm in pain. She didn't want to hear about it. You're the only one who really understands what is going on." He tells you "I've tried everything and Dilaudid is the only one that helps." He refuses to consider any other medication and claims he doesn't have time to go to physical therapy.
- 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?
(The goal is to develop a positive, non-judgemental rapport with the patient?)
- Use your rapport. Wait to address the alcohol issues until after you have discussed non-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.
- Phrase the question appropriately. For example, ask, "Tell me about your alcohol use," instead of "Do you drink?" And "What kinds of drugs do you use?" instead of "Do you use drugs?" (Avoid the term "illegal drugs".)
- 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. Administer the AUDIT or ask the following questions:
- a. When did you first start drinking? How often? How much?
- b. Have you tried to cut back before? What happened?
- c. Does it take you more alcohol to feel intoxicated than it used to?
- d. Have you ever had periods where you don't recall what you did while you were drinking?
- e. Have you ever had to have a drink in the morning in order to calm your nerves or stop shaking?
- f. Have you ever had a seizure after you've stopped drinking?
- g. Has anybody ever told you that they think you drink too much?
- 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 ever missed work, school, or family responsibilities because you were too hung over?
- k. Do you typically drive when you drink?
- l. Do you find that you are depressed after an episode of drinking?
- m. Do you have arguments with people in your life regarding your behavior while you are drinking?
- n. Would you consider cutting down your alcohol intake?
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.
- 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.)
- Review history of illegal drug use. If currently using 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 of change, facing the knowledge that they have a serious problem, reprisals, treatment, being branded as an alcoholic or addiction.
- Embarrassment and shame.
- Fear of rejection by friends or culture.
- The patient's belief that his drinking is not problematic.
- Lack of insurance for treatment.
- Residing with a problem drinker.
- 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
- Society's stigma and blame
- Belief that addiction is a moral issue and not a medical issue.
- Lack of treatment availability (affordability, waiting-lists, services not available in community)
- Physician's discomfort with addressing substance abuse issues
- Physician uses his or her own pattern of drinking as a barometer of what is alcohol misuse. (Physician may be drinking as much without significant clinical impairment.)
- 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 and any biopsychosocial concerns identified in part B)
- Express concern about the patient returning home safely. Request permission to contact a family member or friend for transportation home.
- 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 alcohol abuse is treatable
- Ask the patient how he feels about your concerns
- Address the stigma associated with having an addiction by reassuring the patient that both are medical illnesses and this is not a question of moral character
- Assuming that the patient is not referred to treatment, physician can initiate discussion of a plan for reduction or elimination of drinking. This might include, finding new friends who are not excessive drinkers, dealing directly with stress producing problems, as well as a specific strategy for reducing or eliminating drinking alcohol.
- Consider prescribing Campral
H. How does the physician make a referral?
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 ask them what they would like to do, give them the referral on a prescription, and encourage them to consider following through with the referral.
- Ask the patient if you can 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 pre-contemplation stage of change.
(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.