UBC Objectives: Addiction Medicine & Priority Topic: Chronic Disease

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...

• Undertake an appropriate addiction history and focused physical exam
• Assess and manage common comorbidities including chronic pain, abscess, endocarditis, HIV, hepatitis and mental illness
• Describe the processes of codependence and enabling in the context of addiction, and can identify these processes when happening in a therapeutic relationship

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
Phase: History

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.

History

1. What substances does the patient use ever? (Note: If a patient endorses any sort of opioid use, it's particularly important to clarify whether they drink alcohol and use benzodiazepines, both of which significantly increase the risk of opioid overdose.)
2. Route of substance administration (ex: IV, oral, smoking, snorting, IM, rectal)
3. Quantity used 
4. Frequency used
5. Age of initiation
6. Time of last use
7. Tolerance 
8. Withdrawal history
9. Overdose history (personal, witnessed)
10. Treatment history
    1. Pharmacologic (ex: OAT, nicotine replacement)
    2. Outpatient (ex: counselling, day treatment program, support groups)
    3. Inpatient (ex: detox, rehab)
11. Abstinence history (along with treatment history, this is very useful information in planning next steps)
    1. Protective factors (i.e., What helped them achieve this?)
    2. Precipitating factors (i.e., What led to relapse?)
12. Comorbidities or medical complications secondary to substance use (ex: chronic pain, mental illness)
13. Obtaining a complete medication history, as would always be done as part of a consult, but also confirming the patient has been taking any medication prescribed specifically for treatment of a substance use disorder such as methadone (in BC we can look on PharmaNet, a record of all of the substances a patient has received from a pharmacy within the province). Also important is looking for prescriptions the patient may be receiving from other clinicians.
14. Per usual, gathering a social history, considering issues such as stable housing, finances, and social supports*
15. Assessing a patient's motivation and stage of change regarding their substance use disorder. Depending on where a patient is at, this advises a clinician on the most appropriate interventions that a patient may be more likely to consider. Addressing substance use disorders is not cut-and-dry, and if a patient is totally not ready for change yet, being assertive about cessation of substance use could do more harm through damaging patient rapport.
    1. Precontemplative: Patient is not ready to quit. Appropriate intervention includes: Asking the patient what they think about their substance use, including ascertaining their knowledge about the associated risks, along with the benefits they derive, from use of the substance. A neutral conversation without judgment can help a patient be more informed about their substance use, and it may plant a seed to create motivation for substance use cessation. It is important to avoid argument about the benefits of stopping substance use if a patient is in this stage of change. Simply make an offer to help the patient when they are ready to reduce or cease using.
    2. Contemplative: Patient is considering quitting but not now. Appropriate intervention includes: Explore the patient's ambivalence, providing information to help clarify the pros and cons of substance use and what may be done to support them should they wish to make a change. 
    3. Preparation: Patient has decided they want to quit, and is planning to do so within the next month or so. Appropriate intervention includes: Smart goal setting, exploring in what way the patient could benefit from supports that could be made available, and helping the patient identify high risk situations in which it may be hard not to use and helping to create strategies to mitigate those anticipated challenges.
    4. Action: The patient is actively in the process of behaviour modification. Appropriate intervention includes: Providing support and positive reinforcement, and discusses the successes and pitfalls that occur along the way. 
    5. Maintenance: The patient has previously made changes to their pattern of substance use and are having success in maintaining their substance use goals. It is important to recognize the high risk of relapse when it comes to any drug or process addiction. Appropriate intervention includes: Continuing support and positive reinforcement, and being available to help should relapse occur. Frame relapses as learning opportunities to create new strategies to overcome factors that led to the relapse.

Physical Examination

1. ​General inspection
2. Vital signs
3. Mental status examination
4. Cardiovascular examination (be on the lookout for a murmur suggesting endocarditis in the patient who uses IV drugs)
5. Respiratory examination
6. Head and neck examination  (pupillary size can be a helpful indicator of substance intoxication or withdrawal)
7. Abdominal examination (assess the liver and for signs of decompensated liver disease)
8. Musculoskeletal examination (when a patient describes areas of focal pain, it's important to have a high index of suspicion for infection as patients with risky substance use can be at increased risk for serious infections such as septic arthritis or osteomyelitis)
9. Dermatological examination (looking for track marks or other lesions/excoriation, and be on the lookout for abscesses or cellulitis, as indicated)

Investigations
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. 

1. Chronic pain and mental illness warrant a complete assessment in their own right, but often chronic pain, mental illness, and substance use all go hand and hand in a chicken or egg tragic love triangle. There may in fact be little utility in trying to get down to the route precipitants, and any co-occuring pain and psychiatric issue simply warrants comprehensive, integrated, and multidisciplinary management, as much as the patient will buy into and follow through  with.
2. Patients who inject IV drugs and who are otherwise immunocompromised are at risk for developing skin abscesses - these warrant incision & drainage with deep wound culture and antibiotic coverage. For a mild presentation that can be managed as an outpatient, empiric antibiotic coverage for MRSA could be cephalexin 500 mg PO QID + cotrimoxazole DS 2 tablets PO BID) x 10 days.
3. A high index of suspicion is warranted for endocarditis in a patient who uses IV drugs with a fever. In this case, obtain blood cultures and order a TTE as initial workup. The modified Duke criteria help with diagnostic clarity.
4. Treatment of HIV and hepatitis in a patient with substance use is similar to treatment of the same disease processes in patients without substance use, but more vigilant screening is warranted in patients with risky substance use as they are at increased risk of acquiring these infectious diseases (or alcoholic hepatitis in the setting of chronic alcohol use). Naturally, they may also pose a greater risk of further transmission to others if it was their behaviours that may have led them to contract an infectious disease in the first place. And then in general, their lives are often disorganised and it may be more difficult to provide comprehensive management of these diseases secondary to the chaos. Just like pain and mental illness, concurrently treating the comorbidities can improve outcomes for both disease processes. 

*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.