History
Screening for alcohol and drug disorders can either be incorporated into routine history taking or can be done when a patient presents with specific problems associated with problematic use of drugs or alcohol. Most patients should be asked whether they use tobacco and about how much alcohol they use. This flows naturally as part of taking a social history or immediately after reviewing the patient's allergies and use of prescribed medications, OTC preparations, vitamins and supplements, alcohol, tobacco and then other drugs. Few patients will be found to abuse other drugs who are not also tobacco addicts.
TABLE 4: Common Psychosocial Manifestations of Mild to Moderate Drug Disorders
Psychological/Behavioral
Agitation, irritability, dysphoria, difficulty in coping, mood swings, hostility, violence, psychosomatic symptoms, hyperventilation, generalized anxiety, panic attacks, depression, psychosis
Family
Chronic stable family dysfunction, marital problems, behavioral problems and decline in school performance in children, anxiety and depression in family members, divorce, abuse and violence
Social
Alienation and loss of old friends, gravitation toward others with similar lifestyle
Work/School
Decline in performance, frequent job changes, frequent absences (especially on Mondays), requests for work excuses, initial preservation of work or school function among highly motivated groups such as professionals in practice or training
Legal
Arrests for disturbing the peace or driving while intoxicated, stealing, drug dealing
Financial
Borrowing or owing money, selling personal or family possessions
Adapted from Brown RL. Identification and office management of alcohol and drug disorders. In: Fleming MF, Barry KL, eds. Addictive disorders. St. Louis: Mosby Year Book 1992. Used with Permission.
The patient is far more likely to respond to questions regarding drug use if the physician remains empathic, respectful and nonjudgmental. When utilizing a direct approach, the physician should ask specifically about the amounts and frequency of alcohol use and other drug use in the past month, week and day. If the patient denies recent use, it is appropriate to ask about previous history to determine whether the patient has ever abused alcohol or used other drugs. Even currently abusing patients in denial may be able to reveal excessive substance use in the distant past. If the patient currently uses alcohol, the physician should determine how many days per week, on average, the patient has done so during the past three months, how much alcohol was consumed on each occasion and, especially, whether the patient ever consumes five or more drinks at a time. In addition, the physician should ask whether the patient has used marijuana more than five times in his or her life; statistically, use of marijuana on more than five occasions seems to correlate with an increased likelihood of substance abuse. Use of prescriptions from multiple doctors and use of illicit drugs should be specifically investigated.
If the patient's answers raise concern, the physician should try to elicit information about the effects of the alcohol or drug use on the patient's life. Problems may exist with his or her health, family, job or financial status or with the legal system. The patient may admit to a history of blackouts or motor vehicle crashes. Also, the patient may be aware that a family member or friend has been affected by the patient's drinking or drug use.
This line of questioning provides the physician with a quick means of learning the extent and consequences of the patient's drug and alcohol use. The disadvantage is that the physician may have difficulty estimating the true extent of the problem if the patient gives vague or deceptive responses.
If the physician is unable to get a sense of the patient's problem from these unstructured questions, an alternative approach is to ask the following four "CAGE" questions:
- Have you felt that you ought to cut down on your drinking or drug use?
- Have people Annoyed you by criticizing your drinking or drug use?
- Have you felt bad or Guilty about your drinking or drug use?
- Have you ever had a drink or used drugs first thing in the morning (Eye Opener) to steady your nerves, to get rid of a hangover or to get the day started?
Any positive answer should be pursued. For example, if the patient admits to feeling guilty about drinking, an attempt should be made to find out specifically why. A positive answer to two or more of these questions suggests the need for additional assessment of drug or alcohol problems.
If the physician senses that the patient may feel threatened by this direct approach, a more subtle style of questioning may be indicated. The physician can first obtain a general social history to assess the potential consequences of alcohol or drug use. It is useful to begin with open-ended questions such as "What brought you here?" or "What's going on in your life?" Use of standard interview techniques such as paraphrasing the patient's responses and acknowledging their emotional content will help build rapport and minimize the patient's defensiveness. Eventually, the patient may reveal problems such as marital difficulties or legal or financial trouble, which may signal a drug or alcohol problem. Responding to these difficulties with a sympathetic, nonjudgmental attitude can encourage a considerable degree of openness in the patient. Then, when the questions about drug and alcohol use are asked, the patient may give more honest answers than he or she would have otherwise.
The disadvantage of this approach is that it can be relatively time-consuming. For family physicians who want to utilize a routine method of screening for drug abuse with all new patients, the 10-question Drug Abuse Screening Test (DAST-10) may be a useful form to include in patient questionnaires.
Physical Exam and Laboratory Tests
Early drug abuse disorders are rarely diagnosed on physical examination. A few cases of alcohol abuse are signaled by labile or refractory hypertension or mild upper abdominal tenderness. Some cases of cocaine snorting can be identified by damaged nasal mucosa and some instances of injection drug abuse by hypodermic marks. The single most useful examination is of the eyes. Nystagmus is often seen in abusers of sedatives/hypnotics or cannabis. Mydriasis is often seen in persons under the influence of stimulants or hallucinogens or in withdrawal from opiates. Miosis is a classic hallmark of opioid effect. Evidence of multiple minor (or past major) injuries can also be an indication of substance abuse.
Most laboratory tests for alcohol abuse identify end-organ damage (e.g., impaired liver function and hematologic disorders) rather than the primary disorder [34]. However, sometimes spot checks of urine or breath may reveal the presence of alcohol that would not have otherwise been noticed by the clinician. Likewise, urine testing for drugs of abuse can be very helpful when positive, but the limited slice of time reflected by urine tests for most drugs, other than the lipid-soluble cannabinoids, renders urine testing relatively insensitive for intermittent drug abuse. Testing of hair for drugs of abuse may eventually become a useful adjunct because hair content reflects drug use over a longer period of time; however, false positives due to environmental exposure and false negatives due to various technical problems are common.
Barriers to Diagnosis
Denial is the major barrier to the diagnosis of addictive disorders34. Some patients may not recognize their denial, whereas others intentionally refuse to acknowledge an addiction because they are apprehensive about being able to satisfy their drug craving and afraid of the consequences of discovery. Thus, persuading the patient to acknowledge the addictive disorder can be difficult. It is generally counterproductive to tell the patient flatly that he or she has a problem, since this can elicit defensiveness. An alternative is an expression of concern that the drug use may be causing some difficulties. Some patients who already suspect they have a problem will confirm the diagnosis. Others may respond with astonishment, insincere acceptance or outright hostility.
Physicians should not argue with patients who deny drug use. Instead, in the context of the role of a health care professional, they can stress the negative effects of drug use on the patient's physical, psychosocial and economic well-being. It is essential to keep the lines of communication open so that additional discussions can continue during future visits. Because accepting a diagnosis of substance abuse is difficult and painful, patients often take months or years before they do so.
Family members and friends may likewise deny even obvious substance abuse in a patient. Because addictive disorders are viewed negatively, loved ones may refuse to admit that the patient could fall into such an undesirable category. This denial can reinforce the patient's refusal to acknowledge a problem. However, family and friends are often willing to discuss their concerns if given the opportunity in a nonthreatening environment.
Identification of an addictive disorder may also be impaired by the physician's attitudes. Pessimism about the likelihood of recovery may make a physician reluctant to undertake what he or she might feel is a hopeless task. A judgmental attitude may likewise hinder diagnosis and treatment by leading a physician to indicate overtly or subliminally that a patient with such problems should keep them under cover.