8 Things Every Primary Care Physician Should Know About Addiction
“Once an addict, always an addict.”
“One drink and you’re right back to the bottle.”
“Because of your history of alcoholism, you have an addictive personality so I can’t give you any painkillers.”
Who would talk to patients this way? Physicians, that’s who – when communicating with patients having a history or in the throes of addiction.
In addition to doing extensive research for two books on addiction and recovery, I’ve now had the opportunity to work in an outpatient substance use and mental health disorder treatment facility for more than a year. I’ve also had experience with loved ones dealing with addiction, mental health, and medical systems. In the process, I’ve seen first-hand how such people are often mistreated and misunderstood.
Addiction and Treating People with SUDs
Many primary care physicians – and other such providers, including nurse practitioners, physician assistants, and emergency medicine professionals – lack adequate training in substance use disorders (SUDs), have archaic ideas about addiction, and lack knowledge of relatively simple interventions that can help all the while saving time and money for patients, health insurance companies, and the overall health care system.
Amy Colley, PhD, a New York-based clinical psychologist and addiction specialist in private practice said:
“In many cases, primary care physicians are on the front lines of diagnosing a substance abuse problem before any other professional. They don’t need to avoid patients with substance misuse, thinking they’re hopeless or that they lack skills for helping them. [They can] empathically ask a few questions about their use of alcohol and whether they think they might benefit from treatment…”
“Give these people hope and caring rather than judging them. Sometimes, it is these micro interactions between a doctor and a patient that can save lives.”
Thoughts on Addiction Education and Treatment
Following are some of my thoughts and ones I’ve gathered from other treatment professionals regarding things primary care health providers should know about addiction and treating people with SUDs:
- #1 People struggling with SUDs don’t have to hit proverbial bottom to be ready for help – and you can play an important role in preventing the fall.
Jim Carter, Ph.D. a psychologist who specializes in behavioral health said:
“Like most other health-related behaviors, substance problems can be positively impacted with early screening, evaluation, and feedback for patients. Primary care providers are in a unique position to serve in this role and already possess the most important qualities that are needed to be effective with the process – being compassionate, collaborative, respectful, and evocative.”
“Screening and Brief Intervention (SBIRT) practices are science-based strategies lasting from 5 to 30 minutes and designed to motivate individuals to change their behavior by helping them understand how their substance use puts them at risk and to reduce or give up their substance use. Health care providers can also use brief interventions to encourage individuals with more serious problems to accept more intensive treatment.”
Here are some videos showing various scenarios of communication with patients, contrasting SBIRT communication strategies with less effective ones.
And this page has a good listing of SBIRT online courses.
- #2 Residential rehab and 12-step meetings (as in Alcoholics Anonymous and Narcotics Anonymous) are not the only and not always the best ways to deal with addiction.
Although the most familiar, there is no evidence that these are the best ways to help someone recover. Research finds no advantage of residential/inpatient treatment over outpatient. (See my article, “Do You Really Need to Go to Rehab?”) And despite the prevalence of 12-step groups and the many stories of lives they’ve saved, many people don’t connect with the 12-step philosophy and drop out over time.
As I reported previously, one review of the scientific literature suggested, “Between 55 and 80 percent of alcoholics encouraged to attend AA while in treatment will stop attending AA within nine months.”
Primary care providers should take the time to find out about local addiction professionals and what types of treatment they offer, as well as alternative recovery support groups such as SMART Recovery and Women for Sobriety.
- #3 Just because a patient is addicted to one substance doesn’t mean that he or she will be addicted to or will abuse all substances that have potential for abuse.
I’ve known of clients recovering from alcohol use disorders to be denied painkillers despite suffering from severe dental pain or to be denied or taken off benzodiazepines that they were using responsibly, despite receiving benefit for their anxiety.
Indeed, it’s not uncommon for someone with a history of being addicted to one substance to be have difficulty getting medications in a different category altogether. Yet Mark Willenbring, MD, founder and CEO of Alltyr treatment clinic in St. Paul, MN and former director of treatment and recovery research for the National Institute on Alcohol Abuse and Alcoholism, said in one of his articles for Pro Talk:
“It has been conclusively demonstrated that ‘cross-addiction,’ where a person stops using one drug but becomes addicted to another one, seldom occurs, if at all. For example, in my practice, I find that opioid addicts seldom like alcohol, and vice versa.”
Paula DeSanto, MS, LSW, Director of Minnesota Alternatives in Spring Lake Park, MN (where I work part-time), who has more than 25 years of experience with people having mental health and/or substance use problems, advises:
- Take patients seriously, addressing pain management issues.
- Do not assume complaints are drug-seeking behavior.
- And consider using benzodiazepines to treat anxiety in selected patients – preferably with Klonopin as it is longer acting and has less risk for abuse.”
- #4 Many people with alcohol use disorders are sent to inpatient detox unnecessarily and can go through the process as outpatients.
When doing research for Inside Rehab, I learned that medically supervised withdrawal from alcohol – or what’s commonly known as “detox” – is often done in inpatient settings unnecessarily. I heard from several people with alcohol use disorders who were sent to detox even though they hadn’t had a drink for a week or two!
According to Richard Saitz, MD, MPH, director of the Clinical Addiction Research and Education Unit at Boston University School of Medicine:
“Three or more days without a drink and symptoms, and there’s absolutely no question that withdrawal medications and detox would be unnecessary.”
For people who do need medically supervised withdrawal, only a minority needs to be in an inpatient or residential facility, and few know that the process can be accomplished on an outpatient basis. DeSanto’s advice to primary care physicians is:
“Prescribe medications to allow responsible patients to detox at home.”
More specifically, outpatient detox is most appropriate for individuals who have mild to moderate withdrawal symptoms, no major co-occurring psychiatric problems, a support person willing to monitor the person’s progress closely, and a living situation supportive of sobriety. Although outpatient detox requires daily contact for several days to monitor progress and adjust doses of any prescribed medication, it’s much less expensive than inpatient detox.
Guidelines for inpatient medically supervised withdrawal can be found here, starting on page 58.
- #5 All people with addiction are not liars.
Jerry Costly, LCSW, owner of De Novo mental health and addiction clinic in Salt Lake City, stated, “One myth that needs to be addressed is, “If their lips are moving addicts are lying.”
I was shocked when a renowned expert in the field said to me while writing Inside Rehab: “They’re all liars,” as he defined addiction.
Costly added, “Like most of us, individuals with addictions who feel their survival is threatened will lie. But if we treat them with respect and stop beating them up when they are honest about their struggles, we will often get honesty. Certainly we can and need to extend some level of trust to the people who come to us for help or we will never develop a therapeutic relationship.”
From extensive research on the topic, respected addiction experts Mark Sobell, PhD, and Linda Sobell, PhD, psychologists at Nova Southeastern University in Florida, summed up their findings with:
“If people believe what they are telling you will be confidential – particularly that it will not incur adverse consequences – and they are asked in a clinical or research context, then what they say tends to be reliable and valid.
But people are not stupid – if telling the truth about using drugs or drinking to a significant other, probation officer, schoolteacher, or work supervisor is going to bring trouble, why not lie and avoid the negative consequences?”
“In short, if people have no reason to lie to you, the evidence suggests they will be truthful.”
This holds if people have no substances in their system at the time of an inquiry.
- #6 The idea that “alcoholism” is a progressive disease that can only be arrested by treatment and becoming abstinent from alcohol is wrong.
Most people who overcome substance problems do it without going to any type of formal treatment program. (AA and NA are not treatment – they’re support groups.) A major 2006 study published in Addiction from one of the largest and most ambitious surveys ever done on alcohol problems and treatment, called the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), revealed that seven out of ten people who were in recovery for the previous year attained their status without seeking any help at all or by going to AA meetings.
Only only about three out of ten had recovered with the help of formal treatment or formal treatment plus AA. And although a 2007 study published in the journal Alcoholism: Clinical and Experimental Research suggests that abstinence is the most stable form of recovery for most people with drinking problems, research clearly shows that people who were once addicted to alcohol are sometimes able to drink again without problems.
Consider young people. From his extensive review of scientific studies on teen alcohol problems published in Addiction in 2004, Duncan Clark, MD, PhD, at the University of Pittsburgh Medical Center, estimated that:
- Of teens in the general population with an alcohol use disorder, about half will continue to have a problem in young adulthood and half will not.
- Of teens with an alcohol use disorder, fewer than 20 percent will become and remain abstinent through young adulthood, while about 30 percent will go on to drink in a non problematic way.
- #7 Lecturing and confrontational approaches don’t work or motivate patients to change.
Kenneth Anderson, M.A., Executive Director of the HAMS Harm Reduction Network, feels that it’s important for primary care providers to know:
“Every positive change should be encouraged; confrontation and demands for perfection are always bad and lead patients to disengage and get worse. Change by small increments is very common.”
Indeed, scientific studies suggest that lectures and confrontational approaches are among the least effective ways to help someone get sober. It’s far more effective to recognize that change takes time, recurrence of old behavior is not uncommon, and it’s important to help clients pick themselves up and move forward without shame should that happen.
- #8 Become educated about anti-relapse medications and prescribe accordingly.
Mulitple medications, including naltrexone and antabuse, are available for the treatment of alcohol use disorders, as I wrote in
What Medications Can Help You Get Sober? and in The Realities of Prescribing and Taking Meds for Alcohol Problems.
However, most addiction treatment facilities don’t prescribe them. There’s no reason why primary care physicians cannot fill the gap here. Also, given the many people addicted to opioids, including prescription painkillers and heroin, we need more physicians certified as buprenorphine (Suboxone) prescribers. Buprenorphine is one of the most effective ways to treat opioid addiction.
On October 21,2015, in a comprehensive announcement on “Public and Private Sector Efforts to Address Prescription Drug Abuse and Heroin Use,” the Obama administration announced as one of its goals a doubling of the number of physicians certified to prescribe buprenorphine for opioid use disorder treatment, from 30,000 to 60,000 over the next three years.
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