UBC Objectives: Mental Health, Priority Topic: Crisis, & Priority Topic: Substance Abuse

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Screen for and have an approach to caring for patients with concurrent substance use and mental health disorders
  

Crisis

Key Feature 10: Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
Skill: Professionalism
Phase: Treatment

​Substance Use

Key Feature 1: In all patients, and especially in high-risk groups (ex: mental illness, chronic disability), opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).
Skill: Clinical Reasoning
Phase: History

Key Feature 2a: In intravenous drug users: Screen for blood-borne illnesses (ex: human
immunodeficiency virus infection, hepatitis).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Investigation

Key Feature 2b: In intravenous drug users: Offer relevant vaccinations.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 5: Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (ex: alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients).

Key Feature 7: In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 8: In substance users or abusers, routinely determine willingness to stop or decrease use.
Skill: Patient Centered
Phase: History, Treatment

Key Feature 9: In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (ex: poverty, crime, sexually transmitted infections, mental illness) and long-term complications (ex: cirrhosis).
Skill: 
Phase: 

Asking about substance use is something I do routinely when gathering a medical history, with all patients, but re-inquire more frequently if a patient's circumstances have  changed or they have increased risk (ex: stressors, psychiatric illness, family history of addictions). I ask about alcohol use, tobacco use, or any other substances such as marijuana, stimulants such as cocaine or crystal meth, or sedatives such as benzodiazepines or opioids. If a patient endorses using any substances, I then attempt to quantify how much of each that they use. If they endorse anything other than alcohol or tobacco, I also ask if they have ever injected any substances, which comes with a whole other set of health risks aside from a potential substance use disorder. Namely they are at risk for certain blood-borne illnesses and so I recommend screening (bloodwork for HIV, hepatitis B, and hepatitis C) and vaccinations accordingly (hepatitis A and B).

Most illicit substances can be harmful to the body. So, when patients endorse any substance use, it prompts me to assess for the presence of substance abuse. Alcohol is a bit of an exception, in that culturally and medically it is not harmful in (very) low quantities, but in high quantities contributes immensely to chronic disease. That being said, with alcohol I assess for the presence of alcohol abuse when the quantity of drinking suggests it is not low risk, defined as no more than 4 drinks on any given day or more than 14 drinks on any given week for men under 65 years old, and defined as no more than 3 drinks on any given day or more than 7 drinks on any given week for all others. Conversely, when patients present with any of the many symptoms that could be attributed to use or withdrawal of substances, I ask about substance use as it is in the differential diagnosis. More times than not it can often be a cause or can aggravate of patient's complaints. It can also be a reason for why patients aren't getting better as expected once treatment forgiven disease has been started. Substance use has such extensive ramifications that not asking about it could be considered a form of neglect. 

Once a patient has screened positive for alcohol (i.e., not low risk alcohol consumption), tobacco, or any other substance use, I then ask them for permission to explore a little bit more about their use of the substance(s). (Note that this may not occur on the same medical encounter depending on whether there are other/unrelated acute medical issues that need to be addressed more urgently.) If a patient is open to it, I then take a history to assess for the substance use disorder(s) that may apply to them, per the DSM V. If they meet the diagnostic criteria for a substance use disorder, I explain this to them and solicit their thoughts about this, which helps me as part of the treatment of substance use disorders that is front and central is motivational interviewing and gauging where patients are at with respect to the Stages of Change (precontemplation, contemplation, preparation, action, or maintenance). The diagnostic criteria for alcohol use disorder, a common substance use disorder, are as follows: 

Once it is clear that a patient has a substance use disorder, whether they agree or disagree, and regardless of where they are motivated for change, it is important to screen them for the many comorbid issues and long-term complications that frequently travel with those who abuse substances. In the midst of the opioid crisis, this includes death by overdose. This really means getting a good social history and being aware of the evidence-based recommendations for screening for people who use particular substances. (For people who use illicit opioids this includes screening for risk factors for overdose and death, including whether the patient uses alone and whether they have a take-home naloxone kit and know how to use it to help those around them who are also using, or to have with them for someone to use on them if needed.) It can be extremely challenging to screen for social and medical issues in patients with substance use disorders as they often present infrequently for medical attention, or else in times of acute crisis. It is important that health care providers be able to respond medically (ex: providing rescue naloxone in a patient with an acute overdose, referring patients with comorbid mental health disorders to see a psychiatrist) and socially (ex: by understanding what community resources are available and that the patient may benefit from accessing). There may be no better example of the need for primary care physicians to practice opportunistic medicine.