Things I Wish I Knew About Addiction
That They Never Taught Me In Medical College

Mickey M. Greenfield, J.D., Ph.D., Executive and Clinical Director,
Greenfield Center, Jacksonville, Florida

Introduction

As physicians, you are frequently in the early bird seat when it comes to watching the process of addiction unfold. First, there are the ailments associated with poor general health such as frequent colds and other conditions associated with run down physical conditions. Secondly, as the disease progresses, you are frequently privy to the onset of family problems, legal problems, financial problems, and other societal problems. This is the middle stage. Lastly, you get to see the late stage of addiction; the one we refer to as body rot.

Some of you are very aware of the process, and attempt to intervene. Others are not so aware, and early opportunities are missed. Most of you can recognize the late stage, but most of you see these patients in the early and early part of the middle stage when treatment is much simpler, and the recovery process at those stages can save months to years of needless suffering by the patient and their loved ones.

Many of you have called me and others like me who specialize in the treatment of chemical dependency, with specific questions about your patients, and what they need to do to get them help. In this brief writing I shall attempt to provide you with easy to use diagnostic questions, information about the availability of help on the local and national scene, and some all important guidelines for making referrals.

Diagnostic tools

Most of you and /or your staff have a good sense of smell, and most of you can recognize the smell of alcohol. This, of course, is a red flag. This patient needs to be questioned and, most probably, referred. In lieu of this, most of your medical history questioners inquire about alcohol and other drug usage. But I have found it interesting to note that most alcohol/other drug users know how to give answers that let them slide through the process without raising too much attention. For example, most drinkers answer "socially" or "a couple" or "I take a toke off a joint every now and then at parties," etc. These answers may or may not be truthful. The question now is "How do I, the physician get more information without raising undo suspicion?" One simple way to do this is to ask "When did you take your last drink" rather than "Do you drink?" If the answer is within the past 24 hours, then you need to explore this with a more detailed history of their consumption beginning with the age at onset, frequency of use, and amounts used.

There are the CAGE questions that are easy to remember, and do not have to be asked at any certain time nor in sequence, nor all the questions at once. You can use them as they fit into your examination of the patient. These questions are:

C = have you ever tried to cut back on your drinking/use?

A = do you get annoyed when others question you about your drinking/use?

G = do you ever feel guilty about your drinking/use?

E = do you ever need an eye opener to get you started for the day?

If the answer to two or more of these questions is "Yes," then you need to explore further and probably refer.

Another simple tool is to ask, "Does your drinking/use cause problems in your life or the lives of those close to you?" If the answer is "Yes," and the patient continued to repeat the behavior, then it is almost certain that there is a problem that needs serious and immediate attention.

Of course there are many other diagnostic tools available, and I will be happy to provide you a list. I believe the above two simple methods lend themselves to your busy practices, and can be used by your nurse, physician's assistant, and just about anyone you have on staff. Most of you have probably identified patients who are in need of treatment, and have asked yourself that age old question, "Now that I've got it, what do I do with it?" Let's explore options.

Where to refer the patient?

Most of you do not have the time or the training to treat addictive problems, and without both you should definitely refer. Now the question is, "To whom should I refer?" Let us explore the facilities available in our immediate geographic area, and some of those lying outside the area. Unfortunately, today many of our resources are controlled by managed care, and there is no choice as to where the patient is referred. But, for that rare situation, let us examine what types of treatment are available.

Residential inpatient treatment is usually used to detox and stabilize the patient. In some instances it is necessary for a patient to live away from his/her environment because of the high probability of relapsing, an abusive spouse, etc. Once the condition requiring the inpatient setting has been solved, the patient needs to be in the real world. Everyone can abstain while in a locked facility, but you do not know if the patient has the tools necessary to live a sober life until you place him/her into their real world. The period of time necessary to achieve this detox/stabilization must be determined on an individual basis. Unfortunately, it is usually determined by managed care or other financial ability.

The next level of care following the detox/stabilization period, when one is needed, is usually an intensive outpatient program where the patient lives at home and continues to work or go to school. Most patients are able to begin treatment at this level. This level, in my opinion, is the period of true recovery. This is where everything is put to the test. This is where the patient learns what s/he needs to stay sober. Here, as in most inpatient facilities, they receive group and individual therapy that deals with developing coping skills, which do not include alcohol or other drugs. Most programs are Twelve Step oriented, and patients frequently complete Steps 1 through 3, and sometimes they also complete Steps 4 and 5. Additionally, they are usually required to attend Alcoholics Anonymous or Narcotics Anonymous or both depending on the drug(s) of choice.

Individual outpatient treatment is where most complete their course of treatment. Here, they are seen in group as with continued care programs, individually or combinations thereof.

Who decides at which level the patient begins treatment?

This is best decided by a professional who specializes in the treatment of addiction. He or she is trained and experienced in placing your patient into the proper level of care.

How effective is treatment?

In addition to stopping drug use, the goal of treatment is to return the patient to productive functioning in the family, workplace, and community. Measures of effectiveness typically include levels of criminal behavior, family functioning, employability, and medical condition. Overall, treatment of addiction is as successful as treatment of other chronic diseases, such as diabetes, hypertension, and asthma.1

How long does drug addiction treatment usually last?

Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate lengths of treatment. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated.2

Good outcomes are contingent on adequate lengths of treatment. Many patients drop out before receiving all the benefits that treatment can provide. Successful outcomes may require more that one treatment. Many addicts have multiple episodes of treatment, often with a cumulative impact.3

It appears that inpatient treatment vs. intensive outpatient treatment makes little statistical difference in long-term recovery.4 The critical factor seems to be length of treatment. The longer the treatment the better the results. [It almost hurts to know this in light of managed care limits.]

How to make the referral

It has been my experience that when you make the referral the patient should be seen immediately by the person who will be doing the assessment. Generally, if the patient is not seen immediately s/he cools off, and the whole process has to be redone. When a physician sends a patient directly from his/her office to us we have a 95 percent chance that the patient will keep the appointment. When the appointment is not until the next day, the chances of seeing that patient drop to about 60 percent. When the appointment is not until the following week the percentage of seeing that patient is too small to measure.

As you can see from our statistics, speed of seeing the patient following the referral is paramount. If your sources cannot accommodate you then I suggest you call someone who can.

What is an intervention?

Intervention is a process by which the harmful, progressive, and destructive effects of alcohol and other drug dependency are interrupted. The chemically dependent person is then helped to stop using alcohol and other drugs, and to develop new, healthier ways of coping with his/her needs and problems.5

Who conducts the intervention?

The intervention should be conducted by a team comprised of two or more persons who are close to the alcoholic and other drug user, and who have witnessed his or her behavior while under the influence. These people should be meaningful to the person such as a spouse, employer or supervisor, parents, children, close friends or neighbors, coworkers, clergy, etc.

Now the team gathers the data. There are two types of data that should be compiled in preparation for the intervention: facts about the users drinking or using behavior, and information about treatment options.

Each team member makes a written list of specific incidents or conditions related to the users drinking or drug use that legitimatizes their concern. Each item should explicitly describe a particular incident, preferably one that the writer observed firsthand.

Compile information about the treatment options in your area. Do not rest until you have at least one treatment option that seems workable. You are NOT ready to do the intervention until you have performed this critical step.

The team now rehearses the intervention: 1) designate a chairperson or hire a professional; 2) go over each item on the written lists that the team members have prepared; 3) determine the order in which team members will READ their lists during the intervention; 4) choose someone to play the role of the chemically dependent person during the rehearsal(s); 5) determine the responses that team members will make to the user, and 6) conduct the rehearsal.

Choosing the place to hold the intervention is very important. It is strongly recommended that the intervention NOT be conducted on the user's turf, if possible. This would give him/her the upper hand. Choose a neutral location or one where you have the upper hand; e.g., employer's office, doctor's office, minister's office, et cetera.

NOTE: If you still have doubts about what to do, you can consider calling in a professional. Most treatment centers can furnish you with the names of experts in the field. If you would like more information about intervening please call. Now, JUST DO IT!6

References

  1. National Institute of Health. (1999). Principles of drug addiction treatment. A research-based guide. (NIH Publication No. 99-4180.) Washington, DC: U.S. Government Printing Office.
  2. Ibid.
  3. Ibid.
  4. Harrison, P.A. and Hoffmann, N. G. (1988). Cator report, adult outpatient treatment perspectives on admission and outcome. St. Paul: CATOR.
  5. Johnson, V.E. (1986). Intervention How to help someone who doesn't want help. Minneapolis: Johnson Institute Books.
  6. Ibid.
Jacksonville Medicine / March / April, 2002

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