Help patients with substance use issues

Dr. Schneider: Hi, I'm Dr. Alan Schneider. I'm originally a psychiatrist and a geriatric psychiatrist and then I became an addictionologist. And I have the pleasure today to be joined by Dr. Pamela Sheffield, and the two of us will be talking about dealing with issues of substance abuse and primary care. So let me turn it over to Dr. Sheffield for a moment so she can introduce herself.

Dr. Sheffield: Thanks. Hi, I'm Pam Sheffield. I'm a family doctor. I'm up in the Seattle area and was in practice for about 25 years up here. Thanks for having me.

Dr. Schneider: Thank you for letting me join you. So let me get started. Pam, I know that you practice primary care and that there's a lot of primary care physicians that we see, urgent care, OBGYNs, pediatricians. How do you think most primary care physicians now deal with the issue of substance abuse in the area of relatively short visits in their office? What do you think the problems they encounter?

Dr. Sheffield: I think that there's a lot of news and information about the urgency of the problem. Everybody is well informed that we're in a crisis in relation to substance use and I think that piece of it, the urgency is there. I think the thing that's challenging is the time, like you mentioned. There was just another article that showed that the average primary care provider, if they tried to do everything they're supposed to do in a visit their day would be 27 hours long. So we know that we're dealing with an incredible pressure for primary care to do all the things that they're supposed to do in a visit and we have a lot of very well meaning doctors trying to navigate that reality. And so it can be a challenge for any one issue to kind of rise to the top and to get the attention that it deserves in any given visit.

Dr. Schneider: Pam, it's interesting that you say that. It just got me thinking because I go to a colleague of mine who's a concierge internist, and he gives me excellent care, actually, I trained with him, and it occurred to me as you were talking that despite all of the things he goes into with me, he rarely asks about whether I drink. And I'm a very modest drinker, but it almost never comes up. So it really speaks to that issue about the intensity of the visit and the time of the visit and where issues of substance use comes in an average visit.

Dr. Sheffield: And it talks to the issue of bias too, right, because that's one of the things that comes up when looking at substance use issues is that if you're looking across the desk at someone who looks like you and acts like you and has your background, it's really easy to make assumptions about whether that person could have this type of problem or not. And so I think that in the era of health equity and wanting to be providing excellent care and consistent care to all of our patients, we need to think about how we integrate this into our practice universally and we don't make assumptions about who has a problem and who doesn't have a problem. And I think that's the challenge of screening and how do we work universal screening into, again, that really busy schedule.

Dr. Schneider: Pam, I think those are really excellent points, and I think we're going to get back to the issue of universal screening in a moment. But let me ask you something, do you think that the average primary care physician or even specialist has enough resources available to them to deal with such an immense problem that we have here?

Dr. Sheffield: Yeah, I think that's an area where there are some gaps. And I think that the issue of having the resources at hand and having simple resources that providers can become facile with that they feel confident that they have that in their toolkit to manage is a challenge and that was one of the things I was hoping we could talk about today is how do we introduce some reasonably quick but effective interventions and tools for the primary care providers to have on hand.

Dr. Schneider: Good. Well, let's delve right into that if we can. So primary provider gets a patient who comes in and they have a sense that maybe there's a substance issue here. What are some potential strategies that you see that they can employ? I'll talk a little bit about some of them too, but let's go first with you. What do you see as a strategy that can be employed?

Dr. Sheffield: Yeah, I think that there are a couple pitfalls that people get into, and one of them is trying to do everything all at once. And so I think that with all the pressure of there's a crisis, people are dying, the primary care providers can get overwhelmed and feel like they really have to address the issue in a comprehensive way in order to be effective and also to achieve abstinence. And so I think that that can end up overwhelming people and if they can find a way to break it down, break it down into reasonable pieces that you know can employ in your practice, it can be less overwhelming and use tools that primary care providers already have because we have tools for dealing with tobacco cessation, smoking cessation, and when we can use those simple tools like motivational interviewing for example, where is the patient in their journey so that you know what resources to connect them with.

Dr. Schneider: Yes, and I know you and I have spoken about this before, the value of a very brief motivational interviewing that even that, just one intervention, can make a great deal of difference in many people with mild use disorders. And as I was talking with you about the other day, even a patient of mine who was drinking a little bit more, just the idea of talking to her about how much she was consuming, two glasses of wine a night, was enough to get her to cut down and say, "I really have to reduce this down to one and just one maybe only a couple of times a week." And that was just a brief intervention and very easy to do. So not seeking to achieve complete abstinence, but maybe just one brief discussion at times would be enough.

Dr. Sheffield: Right. And I think that physicians, we're high achieving people, very well meaning and wanting to do the right thing and one thing I hear physicians time and time again is, "Well, I didn't do anything. We just talked." And I think that it's good to remind people that just having a brief conversation and repeating that over time can really impact outcomes for people in regards to their substance use. And I guess one of the things I want to do is just encourage people that you don't have to fix it in one visit, but saying something is better than ignoring and if you screen and you have the opportunity to have even a very brief conversation that's valuable. And over time that can lead to real change and impact.

Dr. Schneider: And the idea of multiple brief interactions so that if it doesn't get done the first time, you get a chance to revisit it with a patient at a later time and not to feel defeated because you didn't get an outcome on that first intervention.

Dr. Sheffield: Right. I think the more gentle providers can be with themselves and understanding the limitations of what the reality of the visit is and doing your best, but not expecting complete success at one visit.

Dr. Schneider: Exactly. I also wanted to take this opportunity, if it's okay with you, to talk about providers having an understanding of what's in their community in terms of resources, because there are various levels of care in the community and I think a provider needs to know that if it's a more severe condition, they can refer out to higher levels of care and higher levels of care start with intensive outpatient programs, for example, that meet three times a week to... or sometimes even five times a week, to partial programs that go longer during the day, five to six hours a day and those meet five times a week up to six times a week. And then there are residential programs where people go 24 hours a day all the way up to inpatient detox and that one doesn't feel like they have to do everything themselves, they can recognize a more severe problem and they can use a community resource to help them so that they don't have to feel saddled with the entire responsibility of treating a patient.

Dr. Sheffield: Right. And we know that if we're going to manage patients well given the time constraints, we need a team around the patient. The primary care provider can't carry that burden all themselves.

Dr. Schneider: Exactly. I know you were interested in screening tools, weren't you?

Dr. Sheffield: Yeah. So I think this goes back to it's difficult to keep track of all the things that you need to do and so if we can encourage people to use a simple screener and to get that conversation started, then when that question's asked, you tell people, I just ask everybody, and you can bypass the pitfall of picking and choosing who you screen, but it needs to be something quick and simple. So what do you recommend?

Dr. Schneider: I think that's really an excellent question. And I think that it depends on which tool you want to use, obviously and how long they are. But there are very simple tools like the SISQ, which is a single question screener that asks somebody if they've used drugs in an inappropriate manner, there's the audit or the audit C, which looks at alcohol, the audit is longer, the audit C is shorter. These are validated tools over time. There's the DAST 10, which looks at drugs of abuse. There's the Craft, which is for adolescence. And the idea behind all this is there's plenty of tools, there's no shortage of tools, screeners that you can use. The concept being that you choose one that you like, you become familiar with it, you adopt it for your office and you really give it to your population And it can be used in the waiting room where somebody fills it out on their own, these are very quick tools to fill out, and then it becomes a springboard for discussion after that. And I have routinely used these and people tend to fill them out fairly... with fair validity actually. And then if I pick up anything, I use it as a discussion point after that. And I think it's a very easy way to go about screening people and talking with people and really kind of interesting discussions emanate from that with people who otherwise would not necessarily offer up a history of alcohol or substance use.

Dr. Sheffield: Exactly. Yeah. And I mean, as a family doc, I like the idea of one question because with every visit, we're screening for multiple things and we need something that's simple, embedded in the EMR and just embedded in the rooming process so that we can pick up the people that aren't obviously having a problem related to substances.

Dr. Schneider: Right. And most of these tools are available in standard EMRs. They're out there, so it's not hard to incorporate them in. So let me ask you, should we be screening any particular groups when they come in? Should screening be universal? What do you think about that?

Dr. Sheffield: Honestly, I have strong feelings about that. And I know in my own practice, I have had the experience of managing a patient who was really giving me a lot of red flags. And this was a woman who looked like me and talked like me and had a similar background to me, and I just completely missed the fact that she was spiraling down in using her substances. And so I think we've all had those experiences on both sides of it where we were suspicious of someone based on how they looked or how they talked or what their background was and we were wrong about that. I think the thing that happens more frequently is we overlook certain populations because we have bias about what their risk is. And so I am a strong believer in universal screening, as I said before. I think that that makes sense from a health equity standpoint. And then when you do have people that come in and they're nervous about feeling like they're being profiled or accused of something, then you have the option to tell them, "I'm not singling you out. This is something we ask every single patient." And you just ask it along with what are their medications and do they drink alcohol? And it's just another question you ask. And so you can normalize it. And I think patients will often say, "You're accusing me of something." There's such a stigma associated with using substances that doesn't apply to a lot of other medical conditions. And you want to avoid making people defensive. You want it to be an open conversation where they can share with you.

Dr. Schneider: Yeah, I agree wholeheartedly, and I think this is a very strong take on point, that universal screening is really necessary, even though we know that there are higher risk groups, for example, people that are perhaps 18 to 24 or 24 to 30 with higher uses of cannabis, for example, in this country. Nonetheless, there are these groups, for example, the geriatric group, where you see someone come in who looks like your grandmother, and you say, "Well, this person can't possibly be using cannabis or an opiate." And you find out, in fact, they are. And there is this inherent bias in a lot of groups that they wouldn't be using substances, and you find out that they are. So that's really the purpose of universal screening and it's the recommendation that everyone be screened. And what you said is actually correct, that people tend to be put off by it, but it has to be normalized as this is just a standard part of what we do for everyone.

Dr. Sheffield: So here's a question for you from a family doctor perspective, what age do you start screening?

Dr. Schneider: You really start screening in the early preadolescent stage, believe it or not, because we have the monitoring the youth population studies that show that even back in eighth grade and even a little younger kids start using alcohol, they start using cannabis and they need to be screened too. So it goes from them all the way into the seventies and eighties where we know that people in that age group are using alcohol, they're using cannabis and believe me, they're still actually using opiates starting from an earlier age, or sometimes even from a later age when they've been treated with opiates for pain and then it gets out of hand. So there's no age not to screen, except perhaps in neonates, but it's really everyone.

Dr. Sheffield: Yeah. Yeah. I had a practice I covered for a while doing medication assisted therapy and listening to the stories of people, most of them started their opiate use in high school or younger, so it'd be good to catch those early.

Dr. Schneider: Early intervention is the thing.

Dr. Sheffield: And I think the next thing that primary care docs will say after we say you're going to screen and you've got these questions, I think the next pitfall that people run into is hopelessness, feeling like the problem is not easily treatable that people are doing this to themselves and so that's something I hope we can address is injecting some hope and helping people understand where these brief interventions can be helpful, what kinds of tools there are to really impact the toll, I guess, of substance abuse on the population.

Dr. Schneider: Well, we can jump right into that. I mean, there's no reason for therapeutic nihilism in any of these folks. Even if you're not doing the primary treatment yourself, there's the concept of harm reduction, which has been accepted for many years now that I think even primary care physicians can jump right into, which is if the person's not going to stop completely, what can I do to minimize their risk? And this can be a whole host of things. For example, starting with even offering someone who's using opiates naloxone, which is considered just standard now for people to do. And that's a lifesaving maneuver prep, for example, for people who are injecting drugs. Giving options for safe sex, condoms, is very important, or birth control. Needle exchanges, not everybody does that, of course, but it's out there. People do that. Fentanyl test kits, again, a lot of physicians don't necessarily offer that, but you can direct people to that. And these are lifesaving maneuvers and people don't necessarily think about that. But given that fentanyl is incorporated into just about everything these days and people don't know they take it, they have sudden overdoses. So when you take a step back and you think about, "I could do this and I could save lives," and the number needed to treat is remarkably so low for some of these procedures and the effect size is so great that it is such an important thing to consider to do some of these things office based, or at least refer them to people who can do it, that in some ways it outstrips the idea of let's go for total abstinence and refer them to a facility right away.

Dr. Sheffield: So what you're saying is a provider in primary care prescribing naloxone could save more lives more quickly than prescribing diabetes medications or high blood pressure medications.

Dr. Schneider: That's actually true and the ratios are really astounding when you look at that. The number needed to treat to save one life when it comes to a hypertensive medication versus naloxone is very different. Naloxone comes out much higher. So, something to consider.

Dr. Sheffield: Yeah. And I think that's the hopeful message. The hopeful message is if you screen for this and you find it, you have an intervention, you have multiple interventions and tools that really can make an impact. And I think sometimes the sensationalism of the media about the death, it can overwhelm people and make them feel hopeless. And one thing I'm hoping that we can achieve is to give people hope, to give providers hope that this is something that if you find it, you can make a real positive influence. And that's what providers and practice want. They want to help people.

Dr. Schneider: Absolutely. And I think people really minimize the idea that a small intervention, we've been talking about this back and forth, can have a large effect size. So even someone who drinks and says, 'Doc, I'm not really ready to stop all my drinking right now," to say, "Who drives you home?" "Well, I drive myself home." "Well, have you ever thought about getting somebody to drive you home or Uber?" There's a large effect size right there in terms of deaths from motor vehicle accidents and those kind of small interventions are very important and something that can be done in the office very easily.

Dr. Sheffield: Oh, I was going to ask about, can we touch on some of the other forms of therapy for substance use?

Dr. Schneider: Sure. So we can move on to medication assisted therapy. So there's several major forms of medication assisted therapy for alcohol and opiates at this time. So for alcohol, we have naltrexone and naltrexone injectable, there's the oral and the injectable, acamprosate. Disulfiram has really fallen out of favor for many years because of the metabolic disturbances of the drug can cause when people get sick. And interestingly enough, if you go back into the literature, disulfiram really did not show a positive effect when it was first studied in the 1950s and forward. So there's a small group of people who are disulfiram advocates, and I mean patients, not physicians as it turns out, who still believe the drug works and for those people, that's great. And I've had people like that and they preferentially want to take it and that's fine, but they're really a minority these days.

Dr. Schneider: So naltrexone really is an outpatient medication. You do not need to go into a facility to get it. You can give it in the office. It's easily administered, including the injectable form. It works very well as long as people remain adherent to it. And it's not hard to set up a schedule to get somebody to come back and take the injectable form. Acamprosate, a little more difficult to give to people, tends not to be as easy to take, so it hasn't been a number one drug for alcohol use disorders, but still there. And then when we move into opiate use disorders, a lot of people don't recognize that buprenorphine is something that's really office based. Talking about buprenorphine and methadone, these are the two most effective drugs we have in our armamentarium really appropriate use disorder. The drawback of methadone and excellent drug is that you have to be associated with the methadone clinic, of which there are limited numbers in the community. When I was at the VA, it was easy to have access to a methadone clinic. We had one right there. Major VAs have them.

Dr. Schneider: But then there's a sparsity of them in the community often where they're privately run and they don't always have treatment programs associated with them, which is very important. You have to have a treatment program associated with the dispensation of either of these drugs. Buprenorphine, it can be done out of the office, it can be done in an outpatient treatment program, what's called an OBOT, you can do induction, as I mentioned, in the office. Very effective medication like methadone. Both have an extended half-life, and both can be used for pain management, which is a great concept there. Where you have drugs that are long lasting, 30 hours, can be split up into BID or TID dosing so that you have the issue of the hyperalgesia, which is kind of covered when people are coming out shorter acting opiates. And that's a real strength. And plus their ability to reduce recidivism for people who've been in and out of the hospital a lot with opiate detoxes, these are wonderful agents to use. Buprenorphine either in oral or injectable forms or long-acting injectable forms. So a lot in our armamentarium to treat these patients.

Dr. Sheffield: So we have great tools to use to help people decrease or stop their use of opiates, harm reduction techniques. One of the barriers I see to more primary care providers incorporating this into their practice is some of the bias they have about people that use substances. And you'll hear providers say that they don't want to bring more people who use substances into their practice because people are going to behave badly and they're going to lie. And so how do we address that bias and help people understand and think more gently about people who use substances?

Dr. Schneider: Well, Pam, this is a really common misconception, that these patients look different than you and I. And it's really not accurate, that the vast majority of these patients come from the ranks of people we know. And many of them are working, many of them have families, and they're struggling. And in terms of treating them, they can be treated in the office setting many times they need a different structure of treatment in the sense that they don't look different, they're not going to disturb the rest of the population, they have a higher incidence of coexisting mental health disorders that need to be treated separately. But we have things that can help with their treatment. We can have, as I said, cures reports, PDMP to use in treatment to make sure they're not getting substance... treatment rather from other physicians. And we have urine testing in hand when we need it. And we have compacts that we enter in with the patients so that they know right up front what we're going to be doing, how we're going to be doing it, what they need to engage with. And when that's all set up properly with the patients, there's no reason why treatment can't go properly forward with most people. If it doesn't go well at that level, then we have this idea of what higher level of care do they need to be in for treatment to go properly? So that being said, there's no reason to not give it an attempt at a lower level of care first. I had a patient, as I was telling you privately, that was working in a medical office, this was a large worker's comp office, and he had free access to opiates and he became dependent on opiates. And he entered into our outpatient opioid clinic and was subsequently put on suboxone.

Dr. Sheffield: And through treating him, his employer was very generous with him and allowed him to keep his job, he was the manager of the clinic, and into his suboxone treatment, he lost all cravings for opiates. And he had the keys to the opiate cabinet, which was very interesting. He managed to go forward in full employment in that clinic. He was employed there. He had a family. He was one of many people that we treated that did beautifully and never had to rise to a higher level of care because he had this incentive to keep everything he had. And this just shows you that people can do very well if they're incentivized, if they had things that are important to them. These are not isolated cases. These were very common cases for us.

Dr. Sheffield: That's great. So we have simple screening, we have brief interventions that don't have to solve the problem and then we have options for primary care providers who want to do more for their patients with the option of prescribing medication assisted therapy.

Dr. Schneider: Absolutely. Any wrap up comments that you have? Any thoughts?

Dr. Sheffield: I want to make sure we're giving a hopeful message. We know we have a big problem on our hands, we know as physicians we contributed to the problem with prescribing behaviors in the past. It's not a problem that we're going to fix overnight, but with steady progress, with screening, with brief interventions, with therapy options, that we really can make an impact and some of the interventions we have might be some of the most impactful tools we have in our practice.

Dr. Schneider: I think you're absolutely right. And I want to put one feature in, which is that we've gone completely in the other direction and where for procedures, people will not even give two or three opiates to somebody after they've had an invasive procedure. And I won't say who this is, it's related to me, but they had an intervention on their shoulder, and this is an orthopedic group, and they said, "We don't give Vicodin anymore." And this was a fairly painful procedure. And that's not the take home message here, the take home message, we should still be giving pain management, we should still be trusting people. The idea here is not to eliminate all opiates and not to eliminate pain management, but to take the people who are really in need and treat them. And I think there's been so much press about "be careful who you prescribe for, don't prescribe anything," that we've kind of gone overboard and we need to be really careful about that. People still need treatment for pain, just in a thoughtful way.

Dr. Sheffield: Yeah, I agree. I think the pendulum has swung really far and for new providers coming out of practice, it's confusing because, you can get black and white and you can say these medications are bad, people that use these medications are bad people. And nothing's black and white like that in medical practice. And I agree. I think we need to treat pain in effective ways, but we can still use all the tools in our toolkit without causing harm.

Dr. Schneider: Yeah, I agree. Well, thank you, Pam, for joining me. This has been really very pleasurable and important topic to go over.

Dr. Sheffield: Thank you.