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Asking about substance use

Do primary care providers routinely ask about substance use?

Substance use disorders often go undetected in the primary care setting for a variety of reasons:

  • Patients do not usually volunteer information about their substance use, and physicians and other health care providers often forget to ask about it.
  • Health care providers may want to avoid causing a patient discomfort or embarrassment, but it may in fact be their own discomfort or lack of knowledge that they want to avoid.
  • Physicians tend to avoid asking about things they are not good at, not comfortable with or unsure about. Many primary care providers do not ask about substance use because they do not feel confident in their ability to support and treat patients with substance use problems.

Physicians with knowledge about and confidence in treating a particular health problem are more likely to ask about and detect it.

Who to ask about substance use

All patients aged 10 years and over should be screened for substance use, and the results should be documented in the cumulative patient profile in the chart.

For positive responses, document daily and weekly use. All tobacco use, all alcohol use above the low-risk drinking guidelines and all use of illegal drugs should be followed up with a brief assessment.

Time is often the limiting factor in making these assessments. A stepped approach is often the most practical:

  • If you have no concerns about a patient and time is limited, simply ask one or two questions.
  • If you have clinical reasons to be concerned, a more thorough substance use history and assessment, perhaps at a later time, is warranted.

Approaching the subject of substance use

Asking all patients if they smoke has become an accepted and expected practice in the clinical setting. This provides a convenient entry point for asking about other lifestyle issues.

Example:

"So, you smoke about a pack a day. Do you drink alcohol?"

When asking patients sensitive, intimate or potentially intrusive questions, it is best to "signpost" your intentions – tell the patient what you are going to do before you do it.

Example:

"Now that I understand the problem you have been having, I would like to ask a few routine questions about your lifestyle that I ask all my patients."

The signal that you are now going to enquire about issues that may not be directly related to the presenting complaint allows you to ask a well-rehearsed list of potentially uncomfortable questions, which makes them seem more routine and less threatening.

Example:

"Do you smoke?"

"Do you drink alcohol?"

"Do you use any other substances?"

"Are you currently sexually active?"

"Do you have sex with men, women or both?"

Denial

People with addictions may use various defence mechanisms to deflect criticism or minimize the perceived consequences of their substance use. Use of these defence mechanisms is commonly referred to as "denial."

People in denial may admit that there are problems in their lives, but do not make the connection between the problem and their substance use. For example, a person may admit to having lost a job, but not see the relationship between the job loss and absence from work due to hangovers.

Denial is not the same as lying. People who lie know what is true, but choose to speak or act falsely. In denial, people become confused about what is true and what is false. As a result, they begin to believe their own "lies."

Common defence mechanisms used in denial include:

  • Rationalizing: "I only drink because I'm under so much pressure."
  • Intellectualizing: "Health experts recommend drinking two ounces of alcohol per day."
  • Blaming: "I wouldn't smoke so much weed if my parents would stop nagging me."
  • Switching: "I have problems to deal with. The whole world is a big mess. The problem is all the phony people out there."
  • Minimizing: "I only smoked half a joint."
  • Joking: "I can stop drinking any time I want. In fact, I stop once a week."
  • Agreeing: "You're right. I really should stop using crack."
  • Projecting: "John really has a drinking problem. I'm not as bad as he is."
  • Threatening: "Just try and stop me from going out with my friends."
  • Generalizing: "Yeah, I smoke. We all have a bad habit or two."