Training Module Two
- The goal of this module is to enable physicians to recognize and deal with scams, resistance, and denial in the substance-abusing patient.
- Understand the methods and guidelines for screening, referring and treating drug-abusing patients.
- Recognize the common signs of patient resistance and apply the FRAMES approach to treatment.
- Identify the goals of patient placement and understand the American Society of Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders.
- Understand and apply the guidelines for prescribing addictive medications.
- Screening, referring and treating patients
- Patient resistance
- Patient placement
- Prescribing Guidelines
Module Time Frame - 25 minutes
According to the Institute for Health Policy, abuse of drugs (including alcohol and tobacco) is the number one cause of preventable illness and death in the United States It is important to keep in mind the following rules when screening, referring, and treating patients with substance abuse issues:
- All good treatment proceeds from empathetic, hopeful, clinical relationship.
- Consequently, promote opportunities to initiate and maintain continuing empathetic, hopeful relationships whenever possible.
- Never discontinue medication for a known serious mental illness because client is using substances.
- Never deny access to substance disorder evaluation and/or treatment because a client is on prescribed non-addictive psychotropic medication.
- When mental illness, medical, and substance disorders co-exist, all disorders require a specific and appropriately intensive primary treatment.
Screening for alcohol and drug disorders can either be incorporated into routine history taking or can be done when a patient indicates specific problems associated with problematic use of drugs or alcohol (see Table 1). Most patients should be asked whether they use tobacco and about how much alcohol they use. This flows naturally as part of taking a social history or immediately after reviewing the patient's allergies and use of prescribed drugs.
Agitation, irritability, dysphoria, difficulty in coping, mood swings, hostility, violence, psychosomatic symptoms, hyperventilation, generalized anxiety, panic attacks, depression, psychosis
Chronic stable family dysfunction, marital problems, behavioral problems and decline in school performance in children, anxiety and depression in family members, divorce, abuse and violence
Alienation and loss of old friends, gravitation toward others with similar lifestyle
Decline in performance, frequent job changes, frequent absences (especially on Mondays), requests for work excuses, initial preservation of work or school function among highly motivated groups such as professionals in practice or training
Arrests for disturbing the peace or driving while intoxicated, stealing, drug dealing
Borrowing or owing money, selling personal or family possession
The patient is far more likely to respond to questions regarding drug use if the physician remains direct, empathetic, respectful, and nonjudgmental. When utilizing a direct approach, the physician should ask specifically about the amounts and frequency of alcohol use and other drug use in the past month, week and day. This line of questioning provides the physician with a quick means of learning the extent and consequences of the patient's drug and alcohol use. The disadvantage is that the physician may have difficulty estimating the true extent of the problem if the patient gives vague or dishonest responses.
If the physician is unable to get a sense of the patient's problems from these unstructured questions, an alternative approach is to ask the following "CAGE" questions:
"Have you felt that you ought to cut down on your drinking or drug use?"
"Have people annoyed you by criticizing your drinking or drug use?"
"Have you felt bad or guilty about your drinking or drug use?"
"Have you ever had a drink or used drugs first thing in the morning to steady your nerves, to get rid of a hangover or to get the day started?"
http://ncadi.samhsa.gov (SAMHSA's national clearinghouse for AOD information)
The primary barrier to diagnosis is patient resistance. The patient may resist the physician's questions for the following reason:
- Patient is ashamed, afraid, does not want to stop
- Non-sympathetic, non-confidential setting
- Co-morbid conditions such as depression, borderline, anti-social
- Physician is perceived as being unknowledgeable or too busy
- Patient fears government agencies and legal consequences of substance use
- Patient fears they will lose their family role with legal and child-custody implications
- Societal Stigma
Enabling by others may reinforce patient denial. For example, friends and family members may cover for the substance abuser at work or school, may minimize or ignore the substance abuse problem, or provide drugs to avoid confrontation or unpleasantness. Because addictive disorders are viewed negatively, loved ones may refuse to admit the patient can fall into such an undesirable category. This denial can reinforce the patient's refusal to acknowledge a problem. However, family and friends are often willing to discuss their concerns if given the opportunity in a non-threatening environment.
- Feedback regarding personal risk or impairment is given to the client following assessment of substance use patterns and associated problems.
- Responsibility for change is placed squarely and explicitly on the client (and with respect for the client's right to make choices for him/herself.
- Advice about changing-reducing or stopping-substance use is clearly given to the client by the clinician in a nonjudgmental manner.
- Menus of self-directed change options and treatment alternatives are offered to the client.
- Empathetic counseling-showing warmth, respect, and understanding-is emphasized.
- Self-Efficacy or optimistic empowerment is engendered in the client to encourage change.
Physicians should remember that behavior change is rarely a discrete, single event. Physicians sometimes see patients who, after being advised to change negative behavior, readily comply. More often, physicians encounter patients who seem unable or unwilling to change. Understanding the process of change provides physicians with additional tools to assist patients, who are often as discouraged as their physicians with their lack of change.
The Stages of Change Model, developed by Prochaska and DiClimente, shows that, for most persons, a change in behavior occurs gradually, with the patient moving from being uninterested, unaware or unwilling to make a change (precontemplation), to considering a change(contemplation) to deciding and preparing to make a change. Genuine, determined action is then taken and, over time, attempts to maintain the new behavior occur. Relapses are almost inevitable and become part of the process of working toward a life-long change.
During the precontemplation stage, patients do not even consider changing. Smokers who are "in denial" may not see that the advice applies to them personally. Patients with high cholesterol levels may feel "immune" to the health problems that strike others. Obese patients may have tried unsuccessfully so many times to lose weight that they have simply given up.
During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I need to, doc, but ...") as well as the benefits of change.
During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, sampling low-fat foods may be an experimentation with or a move toward greater dietary modification. Switching to a different brand of cigarettes or decreasing their drinking signals that they have decided a change is needed.
The action stage is the one that most physicians are eager to see their patients reach. Many failed New Year's resolutions provide evidence that if the prior stages have been glossed over, action itself is often not enough. Any action taken by patients should be praised because it demonstrates the desire for lifestyle change.
Maintenance and Relapse Prevention
During the maintenance and relapse stage prevention is essential. The patient will need to alter their lifestyle in order to reduce their susceptibility of relapse. This may involve developing drug free socialization, identifying social pressures that my predict use, and learning new ways to manage distorted thinking. Discouragement over occasional "slips" may halt the change process and result in the patient giving up. However, most patients find themselves "recycling" through the stages of change several times before the change becomes truly established.
- To place a person in the least intensive level of care that will achieve alcohol, tobacco, or drug treatment objectives without sacrificing safety or security.
- Improve the quality of care.
- Ensure access to affordable care.
- Support the development of cost effective treatment systems.
I. Diagnosis. First and foremost before prescribing anything, establish a diagnosis which is supported by adequate history and physical examination and the results of appropriate diagnostic tests. Unfortunately it is often found taht a symptom, rather than a diagnosis, is the basis for a given treatment.
II. Management Plan. Formulate a treatment plan that includes appropriate non-addictive modalities. Make referrals to appropriate specialists, if necessary, to establish the diagnosis and insure that alternative treatment modalities are tried. Include all correspondence and test results in the patient's chart.
III. Eliminate Alternatives. Before beginning a regimen of controlled drugs, make a determination through actual clinical trial or through patient records and history that non-addictive regimens have been inadequate or are unacceptable by comparison, e.g., intolerance or allergy to nonsteroidal anti-inflamatory drugs. The assertion by a patient that a certain narcotic, e.g., Percodan, works well for him/her is not an adequate history of failure of other methods or drugs. Too often physicians who have come under review have instituted treatment with potent opioids apparently without ever considering other forms of treatment.
IV. Be Aware of Drug Seekers. Make sure you are not dealing with a drug seeking patient. If the patient is new or otherwise unknown to you, obtain, at a minimum, an oral drug history, and discuss chemical use and family chemical history with the patient. If you have any doubts, you may consider obtaining a chemical dependency evaluation prior to prescribing a potentially addictive substance.
- Drug Seeking Clues:
- exaggerates or feigns symptoms
- loses prescription or medications
- runs out of medications ahead of time
- obtains same prescription from multiple doctors
- claims refill need but original doctor not available
- insists that only one drug will work
- demands an immediate prescription for a chronic illness
- threatens when physician does not comply
V. Informed Consent. Before prescribing a potentially addictive drug, assure that the patient has an understanding of the relative risks and benefits of the drug, based on relevant published literature, e.g., PDR, AMA Drug Evaluations, USP DI. It may be beneficial to obtain written informed consent in selected patients. When the possibility of long term use of potentially addictive substances exists, it may be helpful to educate the family to the risks and benefits of the medication.
VII. Control. Make sure that you are in control of the drug supply. To do this, at a minimum keep detailed records of the type, dose, and amount of the drug prescribed. You must monitor, record, and control all refills. One way to accomplish this is to require the patient to return to obtain prescriptions. Routine call-in of prescription drugs is to be avoided. The physician should keep a chronological drug log of controlled substances, e.g., a flow sheet. Communicate with other treating physicians and the patient's pharmacist. The patient should use one physician and one pharmacy for his/her controlled substance prescriptions. If either changes, the other should be notified
Common Problems. Problems faced by physicians when coming under review and investigation by the Board of Licensure and other entities, such as governmental agencies or civil litigation, include:
- Inadequate records/documentation.
- Failure to establish a diagnosis. Subjective complaint of pain is not a diagnosis, it is a symptom.
- Utilizing controlled substances in treatment without alternative methods having been explored and exhausted.
- Failure to monitor the side effects of a drug, e.g., monitoring for potential indicators of drug addiction.
- Failure to document why the continued use of controlled substance(s) is necessary
The ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R) was created in response to requests for criteria that better meet the needs of patients with co-occurring substance-related disorders ("dual diagnosis"), for revised adolescent criteria and for clarification of the residential levels of care.
The ASAM PPC-2R provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of care for each group. The levels of care are: Level 0.5, Early Intervention; Level I, Outpatient Treatment; Level II, Intensive Outpatient/Partial Hospitalization ;Level III, Residential/Inpatient Treatment; and Level IV, Medically-Managed Intensive Inpatient Treatment. Within these broad levels of service is a range of specific levels of care.
For each level of care, a brief overview of the services available for particular severities of addiction and related problems is presented; as is a structured description of the settings, staff and services, and admission criteria for the following six dimensions: acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery environment.
|Level||Description||Limitations/Intensity||Staff/Client ratio||Suggested Length of Stay|
|0.5||Early Intervention||For high-risk youth services typically do not exceed 8 hours of contact a week.||N/A||6 months|
|I||Outpatient||Services typically do not exceed 8 hours of contact per week.||N/A||One Year|
|II.1||Intensive Outpatient||Services typically range from 9-19 hours per week (6-19 for adolescents) over a minimum of 4 days during the week.||N/A||3 Months|
|II.5||Day Treatment||Services are typically 20+ hours a week over a minimum of 4 days during the week.||1:10||2 months|
|III.2-D||Social Detox.||24-hour program to safely detoxify clients without on-site medical personnel.||1:10||7-14 days|
|III.1||Low Intensity Residential||Clients typically receive treatment services at least 5 hours per week.||1:15||6 months|
|III.3||Med. Intensity Residential||Clients typically receive treatment services ranging from 10-24 hours per week.||1:12||6 months|
|III.5||High Intensity Residential||Clients typically receive treatment services exceeding 25+ hours per week.||1:10||4 months|
|IV||Inpatient/Hospital||Limited to Medical Detoxification services for pregnant women or high risk youth.||As Needed||5-10 days|
|Transitional Housing||This level used for transitional hoursing programs. Service intensity is not defined.||N/A||Indeterminate|
The Program: The Utah Controlled Substance Database Program, created by legislation that went into effect on July 1, 1995, is used to track and collect data on the dispensing of Schedule II-V drugs by all retail, institutional, and outpatient hospital pharmacies, and in-state/out-of-state mail order pharmacies. The data is disseminated to authorized individuals and used to identify potential cases of drug over-utilization, misuse, and over-prescribing throughout the state.
The Requirement: All retail, institutional, outpatient hospital pharmacies and instate/out-of-state mail order pharmacies in Utah that dispense prescriptions for Schedule II-V drugs are required to report. Controlled substances dispensed (administered) to an impatient at a licensed health care facility are exempt from reporting. A record of each Schedule II-V dispensed must be completed and submitted by the pharmacist-in-charge to the program manager at the end of every calendar month. Submissions for the previous month's activity must be received by the tenth day of each month.
Collection of Data: The required date may be reported by modem, floppy disk, an encrypted attachment to e-mail, or paper. Generally, the media used is dependent on the pharmacy software used. All transactions must be submitted at the end of each month no later than ten days following the end of every calendar month. Data month by submitted monthly or more often i.e. weekly or calendar month. All submissions are required to include a Data Transmission Form.
For more information contact Marvin Sims at 801-530-6232 or at firstname.lastname@example.org or if you would like to submit a database inquiry please call 801-530-6220 or fax to 801-530-6315.