General Practitioners: Dealing With Patient Addiction

By Nancy Wurtzel

General practitioners are often the first health care professionals to identify addiction in their patients.  Dependence on alcohol and nicotine were once the most common culprits, but the this has shifted in recent decades, altering the types of addiction that are being seen.  A greater understanding of the brain, the rise of prescription drug abuse, as well as new definitions of what constitutes addictive behavior, has altered the landscape of addiction.

Now, front-line providers, especially family doctors, are seeing patients struggling with dependence to a wide-range of substances and behaviors, including opioids, other illicit drugs, food, sex, gambling, spending, hoarding, self-harm, violence, and more.  The “more” involves modern technology such as videogames, smartphones, and social media.

Society once viewed addiction as a habit or choice that could be solved with sheer willpower.  However, addiction – in all its many forms – is now seen as a psychological/physical condition that a person is unable to control without intervention.

According to the American Society of Addictive Medicine, “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

While more resources have gone toward the study of addiction, consensus in the medical community is still lacking.

Meanwhile, front-line doctors are usually the first health care provider to see that something is amiss.  While they are not addiction specialists, they have one significant advantage: They know their patients.

The signs may be obvious, such as physical and personality changes.  He or she may display erratic, caustic or unpredictable behavior.  Other markers could include noncompliance with office protocol and an unwillingness to follow a course of treatment.

On the other hand, most addicts, especially those who are high-functioning will go to great lengths to mask their problems and come across as if everything is normal.

Casey Heidenreich writes in “How to Spot-High-Functioning Addicts, “Many people have preconceived ideas of what an addict looks like and how they act. They are often depicted as skinny and stringy-haired, with ratty clothes and no job. This is no longer, and really never was, an accurate portrayal of an addict.”

Physicians may find that in cases of high-functioning addicts, it is often a family member who will voice concern, point out symptoms, and ask for help on the patient’s behalf.

Here are some ideas to help you get started.

• Throw out your preconceived ideas about addiction. There is no typical addict.  Age, sex, and socioeconomic background are not barriers to addiction.
• Ask yourself the following: Has the patient’s behavior, demeanor, and physical appearance changed significantly?  Is the patient noncompliant?  Has the patient requested unwarranted pain prescriptions?
• Create a safe environment for the patient to open up.
• Use the three-prong “Ask-Tell-Ask” approach. Ask permission to discuss addiction. Tell the patient your professional viewpoint and assessment.  Ask what he or she thought of what you just said.
• Avoid long lectures, be clear in your communications, and emphasize your concerns.
• Point out that addiction is a compulsive problem with negative consequences.
• Show empathy, but also be firm.
• Listen closely and gauge the patient’s willingness to confront the addiction.
• Ask to inform and involve family members or friends.
• Tell patient you want to help him or her get the necessary help
• If the patient agrees, establish a course of treatment.

Treatment is often based on insurance or the patient’s ability to pay for private treatment programs.

If you have leeway for referrals, start by recommending an addiction specialist who can dig deeper to identify the best treatment avenues.  If access to this type of specialist isn’t possible, then research recommendations for local programs.  Things to consider are a programs’ admission policy, the average stay, therapies, what happens in an average day, and aftercare follow up.

However, treatment isn’t usually seamless.  It’s more likely your patient will be in denial or exhibit signs of anger, rather than jumping at the thought of treatment.  And, if he or she does opt for treatment, it might take multiple treatment programs over the course of months or years.

Addiction is a chronic condition, and treatment will be a life-long process.  Front line physicians can act as a positive presence in the recovering addict’s life, acting as a valued resource and cheerleader.

In a first-person opinion piece in STAT, Dr. Julian A Mitton writes about the importance of the general practitioner in combating addiction, “Continuity of care lets us identify and address the underlying causes of addiction and help patients build supportive networks, secure stable housing, and avoid familiar triggers of relapse.”