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| ASSEMBLY EDITION • ORLANDO, FLA |
When assessing suspected substance abuse in patients, remember this: "Asking a patient how much he or she drinks does not qualify as a substance abuse assessment," says Raymond Pomm, M.D. He is the medical director of Florida's Physicians Recovery Network, a program for addicted physicians.
Pomm illustrated the futility of the drink question with a photo of a man with a fishbowl-sized drink in his hand and the caption, "I only have one drink a day." That picture was one of several humorous pictures and cartoons used by Pomm and his wife, Heidi Pomm, Ph.D., during the two-hour seminar yesterday, "Addicted Patient: Pathophysiology and Management."
Heidi Pomm, director of behavioral sciences at St. Vincent's Family Medicine Residency Program in Jacksonville, Fla., says that even though as many as 15 percent of the general population meet the diagnostic criteria for addiction or alcoholism, "family physicians usually receive no training in addiction." As a result, she says many FPs regard the addiction patient as a problem patient.
"But no matter what label you use for these patients - loser, difficult, druggie, junkie, drunk, crackhead - remember that the patients have an even worse opinion of themselves," she says.
Several standard questionnaires are useful for assessing substance abuse, says Raymond Pomm, but the four-question CAGE questionnaire and a check for classic symptoms called the three C's are probably the easiest tools to use in the primary care office. CAGE asks the patient if he or she has ever:
• Cut down on drinking?
• Been Annoyed by criticism of his or her drinking?
• Had Guilty feelings about drinking?
• Needed an Eye-opener (a drink in the morning)?
The three C's refer to loss of Control, Compulsivity and use of addictive substances despite adverse Consequences.
Heidi Pomm says that once the addicted patient is identified, cognitive behavioral therapy may be the best treatment tool for family physicians. CBT works because it targets thinking, which is a key element driving addiction. "I tell patients to identify the monkey that each of us has inside - the constantly chattering, automatic thought that is usually distorted and creates distress," she says.
For example, the monkey takes the person to the future (where the addict worries that he or she will die without the drug or drink, thus triggering anxiety) or the past (where shame and remorse generate depression), she explains.
CBT teaches a patient to find the "wise self" that can keep him or her in the present, "where all happiness and joy reside," she says. She often asks patients to "write down what their wise selves would say about the addiction. I tell them to keep these statements and to read them back to themselves during times of stress," she says.
Beyond CBT, she says the "undisputedly best treatment for substance disorders are 12-step programs such as Alcoholics Anonymous or Narcotics Anonymous." She says she urges residents to attend an AA meeting so they can reassure patients who might be fearful of attending such meetings.
FP Report is
published by the AAFP News Department.
Copyright © 2003 by American Academy of Family Physicians.