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...
Key Feature 5: Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan.
Skill: Patient Centered
All patients should be screened for substance use, be it during a new consultation or periodically from time-to-time as substance use patterns naturally can change over time. Patients who screen positive for a potential substance use disorder deserve a dedicated comprehensive substance use assessment. The following is my approach to gathering an addiction focused history and physical examination. This assessment helps to identify the presence, severity, and complications of substance use disorders.
Patients who have risk factors for infectious diseases should be screened accordingly (not to mention they deserve to be screened for cardiovascular diseases and cancers much like the general population as well). Specific risk factors that go along with substance use include intravenous drug use, intranasal drug use, and any sort of shared drug paraphernalia. Such patients warrant screening as frequently as every 3-6 months and at least once a year for HIV, HBV, and HCV. Also consider screening for anemia with a CBC and ferritin, for liver disease with liver function testing, and pulmonary function testing if they have a significant smoking history and chronic respiratory symptoms.
While I will address the treatment of the substance use disorders proper in a separate post, what I will do here is just briefly touch on the management of comorbidities that may be detected in the workup of a substance use disorder.
*When learning about what social supports a person may or may not have, it is important to have a high index of suspicion for domestic or intimate partner violence, as well as for the possibility of codependence, which may appear at first as a very loving and supportive relationship. As defined by Wikipedia, "Codependency is a type of dysfunctional helping relationship where one person supports or enables another person's drug addiction, alcoholism, gambling addiction, poor mental health, immaturity, irresponsibility, or under-achievement." Wikipedia goes on to explain that the concept arose from Alcoholics Anonymous and that "...the term 'codependent' was first used to describe how family members of individuals with substance abuse issues might actually interfere with recovery by overhelping." It may be important to involve a patient's partner or main support(s) in the patient's clinical care so as to communicate ways in which helping behaviours may actually be causing more harm than good. Counselling to address these issues both as individual and as couples therapy may be helpful.