Substance Abusing Patients in the Primary Care Setting: They Deserve Treatment Too
Kendall M. Campbell, MD
Assistant Professor, Department of Community Health and Family Medicine, Assistant Dean for Minority Affairs, University of Florida College of Medicine

Abstract
The world of primary care can be complex and challenging. With an ever increasing body of medical knowledge, primary care physicians must make it a priority to think outside the box when diagnosing patients. This is especially true when it comes to the consideration of substance abuse as a diagnosis. Managing common medical problems such as hypertension and diabetes are familiarities of care, but substance abuse can be easily dismissed or overlooked. It is proposed that 20% of patients encountered for a primary care visit have a problem with substance abuse. Primary care providers should add substance abuse to differential diagnosis, treat when trained and refer when appropriate. Automatically discharging patients who are found to carry this diagnosis is inappropriate, as this patient population deserves and needs to be treated as much as any other patient population. This article will provide tips for the primary care physician to aid in the diagnosis of substance abuse and provide recommendations by which these patients can receive treatment.

Keywords: substance abuse, primary care

Substance abuse in the primary care setting is no strange bird. For the purposes of this article, substance abuse will be defined as any prescription or nonprescription substance that has abuse potential. Data indicates that about 20% of patients seen by family physicians have a substance abuse problem. (1) Tobacco use was excluded. In the everyday practice of medicine it is important to consider substance abuse as part of the differential diagnosis. Substance abuse can lead to significant social and family dysfunction and cause problems with finances, relationships and employment. Medical problems can be difficult to manage, and chronic conditions can be exacerbated, leading to increased morbidity and mortality. The prevalence of this problem in the primary care setting underscores the importance of its recognition and treatment. This article is written in reference to substance abusing patients in general and does not target any specific population such as the mentally ill, teen or geriatric.

Substance abuse in primary care can be a touchy subject for many reasons. There are concerns surrounding both illicit substance abuse as well as prescription medication abuse. Abuse in either setting is dangerous and produces adverse outcomes. Oftentimes the most concerning for physicians is prescription driven substance abuse, as the physician will have had a role in the abuser obtaining his or her substance of abuse. Concerns regarding prescription drug abuse settle around physician comfort with prescribing and facilitating misuse and diversion. The patient-physician relationship is one that is generally nurtured by both patient and physician, and certain responsibilities for each party are assumed. Substance abuse undermines the trust of this relationship and causes rapid deterioration with sometimes unsalvageable communication problems. In exploring reasons for prescription writing discomfort, data has demonstrated physician-perceived inadequate training for treatment of conditions requiring opiates or narcotics. (2) There is also concern that in those who are treated, the treatment course is difficult, and the satisfaction rate is low. (2)

The most concerning aspect for providing care for those who have substance abuse problems is recognizing the diagnosis as a problem. Primary care providers are known to be diagnosticians able to carefully weigh subjective and objective data to arrive at an assessment and plan of treatment. A problem is encountered when substance abuse is not entertained as part of the differential diagnosis, which causes a delay in diagnosis and treatment of a potentially life threatening problem. In a Great Britain study of general practitioner (GP) awareness of cannabis use, inquiry by the GP regarding use was noted to be rare, even though cannabis had long been known in Britain to be the most widely used and prevalent illegal substance.(3) Similarly, in a study performed by Saitz et al, patients who were underserved, without insurance and with mental illness were not likely to have their physician aware of their problem with substance abuse. (4) Recognizing substance abuse as a potential problem within the primary care arena begins by increasing physician awareness. Screening tests for prostate cancer, breast cancer and colon cancer are known standards of care likely due to the morbidity and mortality associated with the diseases. Screening for substance abuse should be just as much at the forefront of primary care offerings for our patient population. A thorough history for any ailment should involve questions that may lead to the diagnosis of substance abuse, whether this is the primary diagnosis or a secondary one. Searching for alcohol abuse may not be as difficult as looking for abuse of other substances, as tools have been developed specifically for alcohol to aid in diagnosis. When looking for other substances, checking for past history of substance abuse by patient admittance or through old records can be of great benefit. A family history of substance abuse can also raise suspicion of current substance abuse in a patient. The social history is probably the most important to obtain, and questions that go beyond simply establishing use are important. In obtaining a social history, it is important to be specific regarding substances used, as it is surprising how patients classify substances in terms of abuse. It is not uncommon for a patient with a history of alcohol abuse to request narcotic pain medications by name and indicate in the history that the problem was with alcohol alone, and this should have nothing to do with benzodiazepine or narcotic prescribing. This categorization of addiction is oftentimes noted as patients will report a history of wine drinking, but report abstinence from beer and mixed drinks, as if this may change the treatment plan or cause different patient perception.

A most important aspect of the history is to look for concurrent or past mental illness. It is well established that substance abuse in the setting of mental illness is not a rarity, making it a priority for primary care providers to look for concurrent mental illness. Social disruption and dysfunction may also lead to substance abuse, as when patients are stressed. Relief is thought to be found in substances that can dull or numb the pain or provide temporary relief from a difficult situation or problem. Of social concerns that can impact abuse, financial strain and family dysfunction can be two of the most challenging, and it is important for the primary care provider to be aggressive in screening for these problems. Primary care physicians should be suspicious when requests for specific medications and strengths are made, and refill histories are inaccurate. It is well known that substance abusers may request refills early and ask for increasing quantities. Primary care providers need to be aware of behavioral changes as these can be signs of abuse. Sexual dysfunction is commonly caused by drugs of abuse and should be investigated as potentially caused by illicit substances. (5) It is important to remember that even if the diagnosis of substance abuse is refuted, history regarding this diagnosis is an ongoing duty, and persons who are suspected abusers should be followed regularly by the practice to ensure abuse is not a problem.

The physical exam may not lend itself to much utility in diagnosing substance abuse; however, track marks and changes in nasal mucosa can be indicators. The physical exam can expose stigmata of disease, and with these findings substance abuse must be entertained as a possible cause. Findings may include hypertensive urgency or emergency in the setting of usual normotension. There may also be skin cellulitis from injectable drug abuse or changes of chronic liver disease from alcoholism. In addition, laboratory and imaging data can be helpful in confirming a suspicion of substance abuse. The gamma-glutamyl transpeptidase (GGT) can be a helpful indicator in the setting of alcohol abuse as can the mean corpuscular volume. The urine drug assessment is always a helpful tool. Imaging may be helpful in diagnosing liver disease or pancreatitis, or even cerebellar degenerative changes from alcohol.

The importance of substance abuse recognition by the primary care physician is paramount as literature has demonstrated that treating substance abuse can be a successful venture. (6) There is literature to suggest that brief interventions can be of benefit within the constraints of a typical primary care visit. (7) Increasing primary care physician awareness of substance abuse as a problem can be approached methodically and intentionally, and there is data to show increased awareness as an outcome measure being possible. (8) Awareness can be increased by mandating substance abuse training as part of the curriculum of primary care residency training programs. Requirements can also be added to license recertification requirements and annual privacy and security renewals. Office methods to aid with managing substance abuse include chart review and targeted interventions for known abusers. For example, it is important to assign clinical staff to make scheduled calls to offer support, encouragement and for treatment. Referral for treatment is a viable option for any primary care physician who is inexperienced or desires to have no experience with managing addiction and substance abuse. It is important for the primary care physician to recognize addiction as a problem and refer promptly and appropriately. However, even if a patient is referred for treatment, the primary care provider should remain in contact with both the patient and treating physician as this allows for better continuity of care. Recommendations for treatment of a substance abuser are described in the figure.

In conclusion, increasing primary care physician awareness of substance abuse as a true and chronic condition will lead to more rapid diagnosis and better treatment, whether treatment occurs in the primary care office or in the office of the subspecialist. Substance abusers are people with chronic disease who need treatment too. Let’s not dismiss or overlook this problem completely as we provide comprehensive care for our patients.

Author Information
Kendall M. Campbell, MD, is an Assistant Dean in the Office of Minority Affairs and an Assistant Professor in the Department of Community Health and Family Medicine at the University of Florida College of Medicine. His medical interests include cardiovascular disease, hypertension and diabetes. He is passionate about caring for underserved patients and serves as Medical Director of Eastside Community Practice, an interdisciplinary, underserved practice in Gainesville, Florida. He is also a community lecturer in east Gainesville and has given numerous lectures on various health topics. Dr. Campbell teaches medical students and has been recognized as an outstanding teacher by the college of medicine. He holds membership in the Society of Teachers of Family Medicine and has given national presentations on caring for the underserved.

References
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