Dancing with the Addict Oyen Hoffman, LMFT, LAC, MAC

Substance Use Disorders in the Clinic:

How to talk to the Addict and keep the

relationship

Objectives:

• By the end of this short talk you will understand how to identify, assess, monitor, and especially how to talk to a patient with a Substance Use Disorder (SUD)

• You will be able to follow this illness in all phases of its pathology

• You will know what to say and when to say it

• You will know when to refer to higher level of SUD care

• You will leave with a cheat sheet to use in your office and exam rooms

• You will have exposure to evidenced based measures and protocols

Some Basic Statistics

• 38 Million adults drink too much

• 88,000 alcohol related deaths per year

• Another 64,000 drug related deaths per year

• $244 Billion in costs

• Only 1 in 6 patient have discussed their drinking with their PCP

• Even less about their drug use

• Center for Disease Control, 2014

First Line assessment for Drug/EtOH Use

• NIDA 1 question measure

• Can also include Cannabis in your questions

• Cannabis is our new normal

AUDIT-C

First line interventions for EtOH

• AUDIT-C

• Full Audit

DAST-10

Possible Social Indicators

• Locked up recently • DUIs • Relationship issues (family, SO, professional, DV) • Recent loss or death • Recent employment problems (e.g. another job loss) • Accidents and Injuries • Secondary reports • Patient “seen around town” don’t underestimate the “word on them

streets” • “What are you doing to take the edge off all your stress? What are you

doing to cope?”

Brief Education & Intervention

• “Substance Use Disorders are real and very much a medical issue, I think we should monitor this”

• “When you, or others who know you, have a concern about your substance use, there could be a real problem”

• “It’s not about how much you use/take/drink, it’s what happens when you do”

• “If you find it hard to stop once you have started you could have an issue”

• “You don’t have to keep living this way; you can decide to deal with this”

Brief Interventions

• Let’s talk a little bit about your alcohol / drug use. (Don’t ask)

• Tell me about your drinking / drug use.

• What does a typical day drinking or using look like?

• How does your use get in the way of your overall life goals?

Raise the Subject

• I recommend that all my patients drink less than or even abstain from alcohol and drugs altogether

• Most people who drink or use at high levels (males 4 daily & females 3 daily) have trouble cutting back and repeatedly experience negative consequences. This is why I recommend that people cut down

Provide Feedback

Valuable questions to KEEP asking your patients with SUD

• Enhance Motivation • What do you like about your drinking / drug use?

• What do you not like about it?

• What are your concerns?

• Has anyone else expressed concern about your use?

• On a scale of 0 to 10, how ready are you to cut back or receive help for this?

• Why that number and not _____________ (lower number)?

Negotiate a Plan

• Summarize the conversation (if patient is ready to change):

• “What steps can you take to reach your goal?”

• “Can we schedule a future appointment to see how it’s going?”

• “Usually there are people, places, or things that can get in the way; what are some of yours?”

• “I’d like to refer you to behavioral health or to specialized care if you have trouble abstaining or reaching your goals”

• “Would you like to discuss medications for help with this? e.g. Naltrexone, buprenorphine, etc…”

Follow-up, Reassess, and persevere

• Patients with SUD are necessarily dishonest, manipulative, evasive, and very challenging to treat

• Their illness requires these unfortunate behaviors in order to stay alive and well

• This illness has just a few goals • Isolate the host body (the addict)

• Destroy the healthy relationships (because they get in the way)

• Kill the addict

• Move on to another host

Evidence Base: Clinical & Financial Talking about Substance Use in the clinical setting works!

• Can reduce drinking by 25% in people who drink too much

• Improves health outcomes

• Reduction in risky behaviors associated with drinking (e.g., unprotected sex, injection drug use)

• (Centers for Disease Control, 2014)

• Decreased medical use and system costs

• Healthcare cost savings can range from $3.81 to $5.60 for each $1.00 spent

• (Fleming et al., 2000)

Review

• Don’t ever give up, especially on your SUD patients!

• Continue to reassess and reevaluate their SUD illness

• Use the exam room interventions

• Refer the experts who can treat and/or make appropriate referral

• Congratulate any progress (no matter how small) make it a BIG deal

• When someone can do this (get, or try to get, clean and sober) they can do anything!

Discussion, Questions, Feedback

• This would be the time for us to actually TALK

• Colin

• Joshua

• Beth