Clinical Management of Patients With Substance Abuse Histories
To facilitate the early recognition of aberrant drug-related behaviors in patients who have been actively abusing drugs in the recent past, regular screening of urine for illicit or licit-but-unprescribed drugs may be appropriate. The patient should be informed about this approach, which should be explained as a method of monitoring that can be reassuring to the clinician and can provide a foundation for aggressive symptom-oriented treatments. Presented in this manner, screening is a technique that enhances a therapeutic alliance with the patient. Patients who protest excessively may be unwilling, or unable, to enter a collaborative relationship with the clinician in which the clinician can be confident of responsible drug-taking by the patient. Similarly, the patient can be confident that the clinician will respond to unrelieved symptoms with aggressive therapies. Such patients cannot be treated with the same willingness to use potentially abusable drugs for symptom control.
Utilize Nondrug Approaches as Appropriate
A variety of nondrug interventions may be useful in helping patients cope with the rigors of medical treatments. These include educational interventions designed to assist patients in communicating with staff and negotiating the complexities of the medical system, as well as numerous cognitive techniques that enhance relaxation and aid coping.
Taking a Substance Use History
Clinicians often avoid asking patients about drug abuse (and other socially undesirable behaviors) out of fear that patients will be offended or will become angry or threatened. Often there is the expectation that the patient will not respond truthfully. These attitudes are self-defeating and may reduce the likelihood of truthful communication and increase the problems associated with the monitoring of therapy over time.
The clinician must be nonjudgmental when taking a patient's history of substance use. Adopting a professional and caring demeanor often necessitates some degree of self-observation and exploration of one's attitudes about members of subcultures who hold different values.
The clinician should anticipate defensiveness on the part of the patient. It can be helpful to mention that patients often misrepresent their drug use for valid reasons: stigmatization, mistrust of the interviewer, or concern about fears of undermedication. Clinicians must tell the patient that they need accurate information about drug use to help keep the patient as comfortable as possible by avoiding withdrawal states and prescribing adequate medication for pain and symptom control.
The clinician must be inquisitive and knowledgeable about drug abuse. The use of street names for drugs should be avoided unless the clinician has current knowledge of the names in use. The interview should include a review of all drugs taken, including the chronology of use over time, the frequency of use, and triggers that initiate use. The so-called pyramid interview can be a useful way to slowly introduce the subject of drug use. This style of interviewing begins with broad and general questions about the role of substances in one's life, beginning with licit ones such as caffeine and nicotine. It then proceeds to more specific questions about illicit substances.
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