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Medical Interviewing and the Doctor-Patient Relationship
L. Sanchez, MD
Tufts University School of Medicine
Talking with Patients about Alcohol and Drugs
Many of the problems that doctors encounter stem from the use and abuse of alcohol and drugs by patients. Many of the treatments that doctors prescribe in their efforts to be helpful result in the abuse of substances by their patients. Many doctors themselves use and abuse alcohol and drugs. Collecting data from an individual about their alcohol and/or drug use is as difficult as it is essential. Broaching the subject feels awkward and intrusive. Effective handling of this issue by a physician is often, however, deeply appreciated by a patient. It is important that as students you learn early on to develop a level of comfort in asking your patients about alcohol and drugs. The goal of this lecture is not to teach you how to counsel or educate the patient, but rather to feel comfortable discussing the subject of drugs and alcohol and allowing the patient to educate you about their story of drug or alcohol use.
By the end of the lecture, you will be able to:
Recognize the importance of talking about drugs and alcohol with all patients.
Recognize why doctors and patients don’t talk about the subject.
Determine the consequences of that omission.
Specific competencies students are expected to perform within the context of practice after this lecture.
Describe the importance of talking about drugs and alcohol with patients.
Address drug and alcohol use with all patients.
Take a complete substance use history.
Ask the patient about their use of alcohol and other substances in a non-judgmental manner.
Demonstrate comfort talking about the subject of alcohol and drugs.
Use an effective screening tool for drug/alcohol abuse (CAGE).
Reflect on your own biases involved with the use of alcohol and drugs with your peers and section leader.
Why is this important?
Substance abuse is prevalent and is an enormous cost to our healthcare system. Despite the treatable nature of substance abuse, most people go undiagnosed and are not receiving treatment. If left untreated, substance abuse is often a progressive illness and can have significant and lethal health consequences. While there is no cure, treatment is available and can reduce the significant personal, social, medical, and economic costs of addiction. As health care providers, we must examine our own substance use because we are at a high risk for developing problems with drugs and alcohol.
By far the most common drug affecting this country is alcohol. We tend to forget that alcohol is a drug because it is social drug and many of us participate in its use. In this way, it can be easy to overlook a patient’s use of alcohol if the proper screening questions are not asked. Illicit substance abuse is also a concerning problem and in recent years there has been an epidemic in the abuse of substances such as marijuana, Adderall, and prescribed pain medication. Currently in Colorado, there is an epidemic of lower back pain in patients in their twenties. One thousand people per week are being cleared to smoke marijuana for this lower back pain. Another epidemic of increased substance abuse is the use of prescribed Oxycodone. Heroin, cocaine, and amphetamines are all substances that you will need to feel comfortable asking patients about.
It is essential that the patients feel comfortable disclosing information to you. In order to accomplish this, establish rapport and make a connection with the patient. There are often barriers that prevent physicians from adequately addressing drug and alcohol use. You may feel that you do not have adequate skills to do discuss these topics, but you don’t need to be an expert to have a conversation and offer patients an outlet for discussion about their drug and alcohol use.
Mindset to approaching the Interview
Drugs and alcohol are often regarded negatively by society and accompanied by some form of judgment. By asking open-ended questions and removing any assumptions and bias from the interview, you are more likely to gather honest information on drug and alcohol use from the patient. It is imperative that as physicians we are asking the appropriate questions in a non-judgmental manner.
How you phrase the questions is IMPORTANT!
You haven’t felt the need to cut down on the amount of alcohol you drink, have you?
The way this question is worded, it is confusing and it also leads the patient in one direction. It is framed so that the patient is expected say no. The question contains implicit judgment and bias and it is clear that the “correct” response would be to say, "no, I haven’t." If the patient HAS felt like cutting down, it becomes harder for them to answer this question truthfully. They must contradict the doctor and say, "Actually, yes I have felt like cutting down." This places the patient in a more vulnerable position and they may just answer "no" if the question is phrased this way.
Instead…Ask: Have you ever felt the need to cut down on the amount of alcohol you drink?
This open-ended question does not make any assumptions and allows the patient to answer "yes" or "no."
Asking questions in a non-judgmental manner is the key to getting the patient to disclose information regarding these sensitive issues. In order to ensure that you are not bringing your bias into patient interviews, you will need to reflect and come to terms with your beliefs on the use of drugs and alcohol. Being aware of implicit or explicit biases that you may have can ensure that you are not imposing these biases onto the patient during an interview. Biases will affect the way you ask questions, thus limiting your ability to connect with and extract the necessary information from patients. If you are unable to extract the necessary information, these patients will not receive the appropriate help and intervention.
At this point you haven’t learned about the neurobiology or clinical aspects of drug and alcohol addiction, but it will help to be aware of the nature of addictive illness. Addiction is painful illness, involving many psychosocial factors and affecting many spheres of an individual’s life. Aside from asking about the details of their drug or alcohol use, take a detailed social history.
It is important to understand and consider the definitions of substance abuse in the context of each individual patient. Depending on where an individual falls on the spectrum below, this will indicate the types of questions asked and will also dictate the nature of the discussion.
It is not imperative at this point that you understand each definition, but that you consider the context of the individual during an interview.
Consider the setting of the interview.
Is this a primary care visit in which I am asking questions to screen the individual for alcohol use OR is this interview at a drug-rehabilitation center and I am asking about the current state of recovery? When you ask your questions make sure they are tailored to the individual person and situation.
Consider the continuum of denial.
Denial is often a component of addictive illness and it is crucial that you are cognizant of this fact when asking questions regarding drug and alcohol use. Make sure to be aware of an individual’s state of denial and do not take everything the patient says as the truth. Reviewing a patient’s record may reveal discrepancies in the patient’s story and provide a more accurate history of substance use.
Consider the stages of addiction.
Recognize that there are stages of addiction and recovery and that your questions have to be tailored to the current state of that patient. It is also important to understand that relapse is extremely common in the road to recovery from addiction. Try to remind yourself of this fact so that you do not judge a patient if they reveal they have had multiple relapses.
Guide to asking about Alcohol and Drugs
When asking about drugs and alcohol, do not assume that the person understands the meaning of your questions. Many substances go by different names and the street name used by the individual may be different than how you refer to the substance; this will influence the quality of the information you obtain. Be empathetic with patients when discussing these issues. Drug and alcohol use can be a sensitive and painful topic, so take an empathetic stance during the interview. Make the individuals feel that they are in a safe environment and that you are on their side. Be alert for any red flags for substance abuse as you gather the history. Take the time to listen when you ask questions about drugs and alcohol, use the 2-minute rule!
You can start the conversation about alcohol by simply asking:
Do you drink alcohol?
You must explain what is meant by an “alcoholic beverage”: 12 oz. beer, 5 oz. wine, 1.5 oz. hard alcohol
If they answer NO, you may ask:
Did you used to drink? Follow-up with appropriate history if "yes."
Why not? The patient may reveal a history of personal alcohol abuse or a family history of abuse.
If they answer YES, you may ask:
Detailed questions about their alcohol use
A good place to start is to use the Alcohol Screening tools, which are commonly used to assess a patient’s alcohol use.
CAGE: a classic screening tool
But, CAGE has limitations – it misses many people with moderate problems with alcohol use.
C – Have you ever thought you should CUT down?
A – Are you ever ANNOYED by others’ complaints?
G – Have you ever felt GUILTY over drinking?
E – Have you ever had an EYE OPENER?
Single Alcohol Screening Question (SAQS):
"When was the last time you had more than 5 drinks in one day?" (4 drinks for women). Any positive response within the last year is positive and requires evaluation (Canagasby & Vinson, 2005).
Normal drinkers typically don’t feel need to cut down or quit, while problem drinkers consider cutting down a sign of good control. If responses to screening questions suggest a problem, explore further with more detailed questions.
Other things to consider when asking about alcohol use:
Quantity (concrete amount)?
What is type of alcohol do you typically drink?
When did you start drinking?
Who do you drink with?
Where do you normally drink?
What time of day do you drink?
Have you ever tried to stop drinking?
How do you pay for the alcohol?
Why do you drink?
How does drinking make you feel?
You can start the conversation about drugs by simply asking:
Do you use any recreational drugs?
If they answer YES, you may want to ask:
What type of drugs?
When did this start?
Method of administration
Have you ever been in trouble because of your drug use?
Who do you do the drugs with?
Have you ever tried to stop using?
How do you pay for the drugs?
How do they make you feel?
If they answer NO:
Make sure the patient has understood your question (If the patient is confused by this question, it is often helpful to list some: Cocaine, Heroine, Amphetamines, etc.)
Ask if they have ever used drugs in the past
Do you use any prescription drugs other than as directed by your doctor?
If may be helpful to ask this as a separate questions because individuals may not consider taking prescription drugs to be in the same category as recreational drugs.
Be aware that there are many methods of administering drugs. DON’T ask: Do you smoke? The question is too broad and can be interpreted in several ways by the patient. They may answer "No" because they think you are referring to cigarettes, but they may smoke marijuana regularly. If you are referring to cigarettes ask specifically, "Do you smoke cigarettes?" or "Do you use marijuana?" If you are asking about cocaine it is not sufficient to ask, "Do you snort cocaine?" The patient may answer "No" because they don’t snort it, they inject it. Depending on how you phrase a question, you may miss important information.
DOs and DON’TS when asking about Drugs and Alcohol:
Ask open-ended questions
Make sure they understand what one drink means
Quantify the drug or alcohol use
Be alert, suspicious, and circumspect
Be willing to be inquisitive
Ask leading questions
Ask questions in a judgmental way
Judge a patient based on their response
Assume that they are answering truthfully
Settle for answers such as "sometimes," "not very often," "occasionally"
Some helpful example questions to ask patients:
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day when you are drinking?
Have you ever found that you were not able to stop drinking once you started?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or someone else been injured as a result of your drinking?
Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
TL Delbanco, “Patients Who Drink Too Much, Where are their Doctors?” JAMA. February 5, 1992, Vol. 267, No. 5.
Saitz, R. 2001 Feb 10. Unhealthy alcohol use. N Engl J Med, 352(6):596-607.
Samet, JH, Rollnick S, Barnes H. 1996 Nov 11. Beyond CAGE. A brief clinical approach after detection of substance abuse. Arch Intern Med, 156(20):2287-93.