Mark S. Gold, MD, knows how difficult it is to identify and treat substance abuse in primary care. An addiction specialist and chair of psychiatry at the University of Florida in Gainesville, he once failed to notice when a colleague was addicted to cocaine, misinterpreting some warning signs as depression.
Diagnosis is so challenging that only about 4% of patients in addiction treatment were referred there by physicians, Dr. Gold told attendees at Internal Medicine 2009.
“How can that happen? You ask them one question and they lie, and that's the end of it,” he said. During his lecture on substance abuse, Dr. Gold offered some tips for better screening and treatment and news about the latest research in the field.
Despite the risk of dishonesty, asking one question is the screening method currently recommended by the National Institute on Alcohol Abuse, he said. “This question is a pretty good one: ‘On a typical day when you are drinking, how many drinks do you have?’”
If the patient's answer is three or more, physicians should move on to the 10-question Alcohol Users Disorders Identification Test (AUDIT).
The AUDIT is a popular tool because it's standardized, easy to administer and available through the World Health Organization, Dr. Gold said. “The patient who is identified [by AUDIT] is the patient who's a heavy drinker. You miss the person who might have an accident. You miss the person who might drink episodically in an amount that's unhealthy. And you also miss the person that loves drinking but just controls themselves.”
Another factor to keep in mind when screening patients is whether they have a family history of alcohol problems. “That is a family that you have to ask, ask, ask about alcohol,” Dr. Gold said. Researchers are currently working to uncover a genetic marker for alcoholism, he noted.
From diagnosis to treatment
Once you've identified the patient with a substance abuse problem, the question is how to treat. The key to a successful intervention is timing. “The assumption in an intervention is that you get the person at a time when their relationship with the drug is weaker than the relationship with somebody or a group of people in their family,” he said.
Detoxification—the obvious first step—is often overemphasized as a solution to alcoholism, Dr. Gold said. “If you could treat an alcoholic with detoxification, we would have cured alcoholism when we invented benzodiazepines. Since we haven't done that, keep in mind that many experts do not believe that detox should be considered a treatment,” he explained.
If you and your alcoholic patient want to try ambulatory detox anyway, the requirements are fairly simple: ability to take oral medications, a reliable family member, a commitment to daily visits, no major or psychiatric comorbidities, no abuse of other substances. “It's pretty easy to do: benzos in, detox complete, and it has no effect on outcome,” Dr. Gold said.
Researchers do know what treatment course leads to positive outcomes, however. It's the one offered to physicians with substance abuse issues. “Why do over 80% of physicians who become an alcoholic or an addict return to work and return to health and function at five years?” asked Dr. Gold. “I don't know any other example I can give where physician treatment is so different from what everyone else gets.”
Addicted physicians, as compared to non-physician addicts, are more often given long-term treatment, regular urine tests, intervention if they have a slip, and support groups of like-minded peers. These are the factors that determine the success of treatment, Dr. Gold said. It could be greater ability to pay for treatments, the close involvement of medical boards, or just physician practice patterns for treating peers that put addicted docs more often on the successful path.
Of the physicians who are treated for addiction, a surprisingly high percentage of them are anesthesiologists. In Florida, 24% of the doctors referred for treatment of drug addiction specialize in anesthesia, while only 4% of the state's practicing doctors work in the specialty.
Why? “Our group has made the hypothesis that anesthesiologists are over-represented among addicts because of the quality of operating room air,” he said.
Samples of the air in operating rooms, but particularly from the work space of anesthesiologists, include propanol and fentanyl. This idea of inadvertent exposure to drugs leading to addiction is an interesting new issue, Dr. Gold said. His group is also researching environmental exposure to opium residue in Afghanistan.
Addictions patients don't report
In the U.S., the same kind of secondhand exposure problems come up with tobacco, particularly transmission from mothers to fetuses. “The No. 1 drug pregnancy problem is not alcohol. It's tobacco,” Dr. Gold said. “Tobacco-smoking mothers tend to have boys that have conduct disorders.” An experimental trial currently underway is treating some children with nicotine-replacement therapy.
Stigmatization of smoking has helped to reduce rates, but it's also made patients less likely to admit their use. “Eleven percent of mothers say they smoke during pregnancy. If you check the baby after they're born, it's probably more like 25% in our area of Florida,” said Dr. Gold.
Another common activity which your patients probably aren't telling you about is abuse of pain medications. “Why buy heroin when you can get opiate pain medicine that has the milligrams on it and you know it's pure?” asked Dr. Gold. “Heroin addiction is fading; opiate addiction and dependency is increasing at an alarming rate.”
Marijuana dependency is also on the increase as a problem in the U.S., Dr. Gold reported. At the University of Florida, he sees students who use marijuana multiple times a day, then take psychostimulants to reverse the drug's effects and drink alcohol to get to sleep. Part of the problem is continuing increases in the potency of marijuana.
“Today you can smoke a marijuana cigarette and it would be equal to smoking 26 cigarettes at Woodstock. It's no wonder than cannabis dependence is the No. 1 drug problem precipitating the need for treatment among young people today,” he said.
Dr. Gold did offer some hope from the forefront of addiction research. “There will be vaccines for many of the drugs that we use that you'll see popping up pretty soon.”
In the meantime, internists should keep trying to help. “Drug abuse is as treatable as other chronic diseases that everyone here treats,” Dr. Gold said.