Guide to Substance Abuse Services for Primary Care Clinicians - New Module

Substance use disorders share many characteristics with other chronic medical conditions like hypertension. Among the similarities between the two are late onset of symptoms, unpredictable course, complex etiologies, behaviourally oriented treatment and favourable prognosis for recovery (Fleming and Barry, 1992).

Late Onset of Symptoms

Clinical problems related to substance abuse develop slowly and may remain undetected for a long time unless a traumatic injury, problem in the workplace, confrontation with the police, or other serious event calls attention to it before physical symptoms become apparent. As with hypertension, routine screening for substance abuse is necessary to identify problems in the early stages of development.

Unpredictable Course

At this time, it is difficult to predict with any certainty which subset of heavy drinkers and drug users will develop serious substance abuse problems. Further, it is not possible to predict whose problems are situational and transient and whose will remain chronic and progressive. Therefore, it is important to monitor each patient's status regularly, just as clinicians do for hypertension.

Complex Etiologies

The interplay between genetic familial predisposition and lifestyle influences the development of substance abuse disorders just as it influences hypertension (Gordis and Allen, 1994; McGue, 1994; Landry, 1994). Many now believe that individuals may inherit a genetic susceptibility to substance abuse that may be fueled or quelled by a combination of family and social norms (parental use of drugs, community or peer acceptance or rejection of drug use, or equation of heavy drinking with masculinity), traumatic events (death of a loved one, divorce, childhood physical or sexual abuse, or war), pharmacodynamic effects (affinity for developing tolerance or withdrawal or positive reinforcing qualities of the drug used), or environmental factors (poverty or easy availability of drugs) (Collins, 1986; Yokel, 1987; Koob and Bloom, 1988; Gardner, 1992; Johnson and Muffler, 1992). At the same time, people without inherited susceptibility may develop problems as a response to external stresses or internal discomfort if they continue using alcohol or other drugs over time. Individual patients, for example, may use alcohol and other drugs to ameliorate or "self-medicate" psychiatric symptoms or to titrate medications (Landry et al., 1991a; Meyer, 1986).

Behaviourally Oriented Treatment

Like treatment for hypertension, behaviorally oriented substance abuse treatment requires the patient to assume primary responsibility for making difficult behavioral changes. As with any chronic condition that depends on behavioral change to improve outcome, a patient will first have to accept that he or she has a problem. Compliance with treatment is ongoing and may be difficult.

Behaviorally oriented treatment includes a number of cognitive and behavioral approaches that help patients recognize and change maladaptive behaviors, develop new or enhanced social skills that will promote and sustain recovery and learn techniques for responding to cravings without relapsing. Motivational enhancement therapy, cognitive behavioral therapy, contingency contracting (e.g., use of positive rewards and negative consequences such as the threat of job loss to promote recovery) and cue exposure treatment are designed to promote resistance to those triggers or cues that prompt use and are among the most common behavioral therapies (American Psychiatric Association, 1995).

Favourable Prognosis for Recovery

Despite these problems, however, many substance abuse patients -- like patients with diabetes, elevated cholesterol and hypertension -- do respond to clinician recommendations and modify their behavior. The rate of 20 percent of problem drinkers who successfully reduce their drinking compares favorably with the prognosis rates of many chronic health conditions primary care providers routinely address (Kahan et al., 1995).

Data contradict the widespread belief that substance abuse treatment does not work. When treatment is available, there have been documented reductions in use, hospitalizations, medical costs and sick time, family problems and criminal activity as well as increases in employment, job retention, income and improvements in an array of other health indicators. For example, the National Treatment Improvement Evaluation Study (NTIES) completed in 1996 reports that clients served by federally funded substance abuse treatment programs were able to cut their drug use in half for up to 1 year after leaving treatment (Center for Substance Abuse Treatment, 1996).

As with other chronic conditions, the efficacy of substance abuse treatment is helped tremendously when family and friends support patients' efforts to change their behaviour, patients themselves are ready to make significant lifestyle changes and the effects of co-occurring disorders are minimized (Institute of Medicine, 1990; National Institute on Alcohol Abuse and Alcoholism, 1993).

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