Substance Use Disorders

This document has been endorsed by the American Academy of Family Physicians and the Society of Teachers of Family Medicine and was developed in cooperation with the Association of Departments of Family Medicine and the Association of Family Practice Residency Directors.

Alcohol and other drug problems are prevalent and cause much mortality and morbidity. Although abuse of other drugs often attracts more public attention, tobacco and alcohol continue to be the most commonly abused drugs. Physicians have the potential to identify patients at risk for substance use disorders, to identify patients with abuse or dependency problems, and to initiate treatment efforts. Despite the growing body of evidence that such efforts can be efficacious, physicians report and demonstrate that they, as a group, are inadequately trained to meet this challenge. These education guidelines are intended to assist family practice residency faculty in establishing educational programs that will produce family physicians with clinical competence in the treatment of substance use disorders.

Attitudes

Residents shall understand that:
1. Alcohol problems and other substance use disorders are preventable, diagnosable and treatable. These problems are chronic, commonly relapse and remit, and are both individual and family diseases.
2. Like people with other medical problems, individuals and families with substance use disorders are to be respected, supported and treated by their family physicians.
3. It is important to work with family members as a unit of care in the management of alcohol and substance abuse disorders.
4. Expressions of denial, dishonesty, anger, irrationality and other potentially offensive behaviors are often inherent symptoms of substance use disorders, to be expected, understood, accepted and managed by family physicians.
5. Family physicians, working in concert with other medical and mental health professionals and lay self-help groups, can maximize the effectiveness of treatment for substance use disorders.
Residents shall be aware of their own attitudes, their personal and family experiences, and the potential implications of these on the the therapeutic relationship.

Knowledge

Residents shall recognize:

The epidemiology of substance use disorders and their impact on American society, including:
1. Overall prevalence
2. Risk factors for substance abuse and dependence
3. Contribution to major causes of morbidity and hepatitis mortality by age groups, including cardiovascular disease, cancer, hepatitis, cirrhosis, homicide, suicide, motor vehicle accidents, trauma and acquired immune deficiency syndrome (AIDS).
4. Association with family dysfunction, child and spousal abuse, violence and crime
5. Risks to children and adolescents with parents who abuse alcohol and other drugs
6. Risks of adolescent alcohol and other drug use
Commonly abused drugs, their physiologic effects and metabolism:
1. Tobacco
2. Alcohol
3. Cannabis
4. Sedative/hypnotics - including prescription medications
5. Opioids - including prescription medications
6. Amphetamines/designer drugs
7. Cocaine
8. Hallucinogens
9. Anabolic steroids
10. Inhalants
11. Other drugs common in the community served by the residency, as well as awareness of current drug use "trends"
A practical definition of alcohol and substance use disorders with reference to:
1. Cultural and subcultural norms
2. Tolerance and withdrawal
The disease concept of substance use disorders, including information on:
1. Criteria for distinguishing substance use, abuse, dependence and hazardous use
2. Evidence regarding genetic transmission and neurochemistry lesions
3. The similarity of substance abuse to other chronic medical diseases
4. Application of the disease concept in facilitating patient acceptance of a diagnosis of substance abuse and appropriate treatment
Familiarity with effective prevention strategies and an understanding that strategies may be primary (trying to dissuade starting), secondary (trying to curb early use before organic disease begins) and tertiary (trying to minimize the consequences of existing organic disease)
The natural history of substance use disorders
Relevant pharmacology, including:
1. Concepts of tolerance, cross-tolerance, physical dependence, psychologic dependence, addiction and withdrawal
2. Routes of administration and physiologic effects of commonly abused drugs
3. Pharmacologic equivalents of various alcoholic beverages and the dose-response effect of alcohol on psychomotor skills including driving
4. Presence of alcohol in commonly used medications
5. Appropriate prescribing of potentially addictive medications, include opioid analgesics, sedative-hypnotics, and stimulants, with methods of monitoring for and preventing diversion, abuse, and addiction
Signs and symptoms of early and later substance use disorders, including:
1. Psychosocial and behavioral changes in the individual and the family
2. Symptoms, physical signs and laboratory evidence (e.g., chronic liver disease, track marks)
3. Co-morbid biomedical and psychiatric diagnoses: Anxiety disorders, depression, hypertension, diabetes, hepatitis C, pancreatitis
Information on treatment and its effectiveness, including:
1. Different stages of the disease and the relevant goals of treatment at each stage
2. The potential advantage and disadvantages of various treatment modalities including:
  1. Brief office interventions with patients and families
  2. Lay, self-help groups for persons affected with a substance use disorder and their families (e.g., 12-step programs)
  3. Professionally administered psychotherapies for individuals, families and groups
  4. Inpatient treatment programs
  5. Partial residential programs, including day programs and half-way houses
  6. Pharmacologic treatment, including management of withdrawal, pharmacotherapy of addiction and treatment for coexisting biomedical and psychiatric disorders
  7. Pharmacologic and group treatment of nicotine addiction
3. Outcomes of different treatment modalities - e.g., harm reduction, abstinence based programs, family systems
4. The symptoms and signs of impending relapse - and appropriate interventions
Special considerations in prevention, diagnosis, and treatment for:
1. Pregnant women
2. Children and adolescents
3. Elderly
4. Homeless
5. Cultural groups represented in the residency's patient population
6. Children in families with a history of alcohol and/or substance abuse disorders
Family dynamics, including:
1. Dynamics of families with substance use disorder in one or two parents
2. Dynamics of families with substance use disorder in a child or adolescent
3. The possible psychosocial effects on adults who were raised in families with substance use disorders
4. Enabling behavior
Information on health professional impairment, including:
1. Preventive measures, including coping strategies, stress reduction and self-monitoring
2. Symptoms and signs of substance use disorders
3. Legal requirements and ethical implications for health professionals who suspect impairment in a colleague
4. The role of hospital-based impaired-physician committees, state impaired-physician programs and state licensure boards
Legal and ethical issues concerning:
1. Confidentiality of medical records
2. Chain of possession and informed consent for serum and urine drug testing
3. Laws regarding driving and substance use disorders
4. Court-appointed treatment
Community activism
1. Knowledge of local resources and unmet needs in the community

Skills

Residents will demonstrate skills in the following areas:

Prevention
1. Providing primary prevention as appropriate, especially for children and adolescents with a substance abusing parent, women contemplating pregnancy and persons at particular risk for tobacco, alcohol and drug-use problems
2. Community advocacy
  1. Support maintenance of effective local resources
  2. Advocate for resources to address unmet needs
Screening with appropriate instruments:
1. All patients for tobacco/nicotine, alcohol and other drug use
2. Adolescents, pregnant women, the elderly, and individuals of particular cultural and ethnic groups represented in the residency's patient population
Assessment
1. Patients who use tobacco/nicotine, for types of tobacco products used and for nicotine dependence
2. Social, psychologic and physical problems in patients who screen positive for hazardous drinking or for alcohol abuse or dependence
3. Symptoms of dependence in patients who use potentially addictive prescription drugs
4. Current level of use, problems related to use and symptoms of dependence in patients who use illicit drugs
5. Readiness to change in all patients with hazardous or harmful tobacco, alcohol or other drug use
Treatment, office-based:
1. Brief intervention
  1. With a goal of secondary prevention in persons with hazardous drinking but without symptoms and signs of alcohol dependence
  2. With a goal of abstinence, harm reduction or referral for further treatment in patients with alcohol or other drug dependence
2. Motivational interviewing to facilitate behavior changes
3. Inclusion of family in assessment and initial treatment
Pharmacotherapy and medical management
1. The management of alcohol or drug intoxication, overdose, and withdrawal
2. The management of biomedical complications of tobacco, alcohol and other drug use
3. The management of nicotine dependence with medications
Referral to specialized treatment programs and other community resources:
1. Consultation with and referral to specialized treatment programs
2. Consultation with and referral to community tobacco, alcohol and drug treatment programs
3. Working with and referral to self-help programs for tobacco, alcohol and other drug problems
4. Performing ongoing monitoring to help the patient and family achieve desirable outcomes
5. Recognizing symptoms and signs of relapse and engaging patients and families in additional treatment
Management of acute and chronic pain, including appropriate use of opioid analgesics
1. In hospitalized and ambulatory settings
2. In patients with and without a history of substance use disorders
3. In patients on methadone maintenance
Clinical indications for drug testing:
1. Selecting and interpreting alcohol and other drug tests, including:
  1. Illicit-drug toxicology
  2. Blood alcohol levels
2. Ensuring informed consent before and open communication after alcohol or drug testing to facilitate entry into further care
Care of affected family members
1. Recognizing families in which substance use disorders are likely
2. Recognizing adverse effects of a person's tobacco, alcohol or other drug use on others in the family or community
3. Counseling, treating, referring and following persons in the family or community affected by another's tobacco, alcohol or other drug use, including children and adolescents with a substance abusing parent
Physician impairment
1. Assisting such persons' entry into care, maintenance of successful behavior changes and re-entry into professional practice as appropriate

Implementation

The knowledge, skills and attitudes of substance-use disorders should be taught in both experiential and didactic format. Training sites for residents should include substance abuse treatment programs and their own continuity practices. Through exposure to substance abuse treatment programs, residents can experience the process of recovery and gain familiarity with referral resources. With their own panel of continuity patients, residents should be able to demonstrate competence in substance abuse screening, assessment, intervention with families and individuals, and referral. Residents should also demonstrate competence in caring for families affected by substance use disorders and in the primary prevention of substance-use disorders, particularly for children, adolescents, and pregnant women.

Resources

Liese BS, Chiauzzi E. Alcohol and Drug Abuse. Home Study Self-Assessment Program. No. 189, Leawood, KS.: American Academy of Family Physicians, 1995.

SAEFP: Substance abuse education for family physicians. 2d ed. Leawood, KS.: Society of Teachers of Family Medicine, 1991.

National Institute on Alcohol Abuse and Alcoholism: http://www.niaaa.nih.gov

National Institute on Alcohol Abuse and Alcoholism. The physician's guide to helping patients with alcohol problems. Bethesda, Maryland: National Institutes of Health; 1995.

Miller WR, Hather N., eds. Treating Addictive Behaviors, 2 ed. New York: Plenum Press; 1998

Rollnick S. Mason P. Butler C. Health behavior change; a guide for practitioners. Edinburgh: Churchill Livingstone; 1999.

10th Special Report to the U.S. Congress on Alcohol and Health. National Institute on Alcohol Abuse and Alcoholism, Department of Health and Human Services. Washington, D.C. 2000. http://pubs.niaaa.nih.gov/publications/10report/intro.pdf.

Comerci GD, Schwebel R. Substance Abuse: An overview. Adol Med; 11(1)1 2000:79-101.

Liddle HA, Rowe CL. Family Measures in drug abuse prevention research. In R. Ashery (ed.). Drug abuse prevention through family interventions. NIDA Rsch. Monograph 177;2000:324-72.

Fleming MF, Mundt MP, French MT, Barry KL, Stauffacher EA. Brief physician advice for problem drinkers; long term efficacy and benefit cost analysis. Alcoholism and Clinical and experimental research 2002;26(1):36-43.

National Institute on Drug Abuse: (NIDA): http://www.nida.nih.gov

Training about alcohol and substance abuse for all primary care physicians. Conference sponsored by the Josiah Macy, Jr., Foundation, Phoenix, Ariz., October 1994. New York: Josiah Macy, Jr. Foundation, 1996.

http://www.alcoholics-anonymous.org, Key Word: 12 Step Program

Published 10/90
Revised/Retitled 07/96
Revised 06/02