We know not every resident gets comprehensive training on substance use or addictions medicine, but it's fair game for the exam and you may often come across this in practice.
So, to help you prepare, our next 3 blog posts will cover exactly how to do this, and in our third post we’ll give you some extra tips on how to manage patients who have this condition.
We’ll take a break in between this series to give you a SPECIAL GIFT next week, just for being signed up for this exam study tips newsletter!
So let’s talk about taking a comphensive substance use history.
First of all, you should be aware that the DSM 5 no longer uses the terms "abuse" or "dependence." Instead, the only category they use is "substance use disorder."
Secondly, you should be taking a detailed history in patients with substance use disorder when you see these patients. These history techniques can apply to any substance use disorder, but we'll use alcohol use disorder as an example here.
You should be screening all of your patients for unhealthy drinking, according to the Canadian recommendations endorsed by the CFPC and a helpful 2015 CFP article on primary care management of alcohol use disorder and at-risk drinking.
This article indicates that screening is best done by using a validated one-question screen: "How many times in the past year have you had 4 or more drinks for women or 5 or more drinks for men on one occasion?" A positive screen is once or more.
But do you know what to do when they screen positive?
To get bonus points on your substance use history exam, or to identify further problem areas in patients of your practice, there are 3 things you can do for a more comprehensive addictions history:
1) Quantify their substance use
2) Find out if there is another addictive disorder
3) Find out how severely their use impacts their life
Today we’ll cover Topic #1; here's how.
1) Quantify their substance use
Simply asking "How much do you drink?" won't get you a very detailed answer. To dig deeper, you could ask questions about:
Numbers: First / last use, Use in the last 30 days (more immediately relevant than historical use - gives you a current snapshot)
Amount
Abstinence periods - and what worked to encourage abstinence in the past (helpful for management)
Longest abstinence
Heaviest lifetime use
PEARLS FOR PRACTICE
Never forget safety. In any exam or practice setting, be sure to address driving if you have reason to believe that it will be impacted by their disease.
As well, if a patient is driving while at risk, be sure you are familiar with when you need to report. Check out our blog post on this topic for more info.
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Many, many thanks to Dr. Paul Sobey MD CCFP ABAM, the President-Elect of the Canadian Society of Addictions Medicine, for his inspiration on this topic. I attended his excellent lecture on addictions last month and he kindly granted permission for me to use many of his tips in this series. If this was helpful, let me know – even just a simple “thank-you” - and I’ll pass on your thanks to him!
(Updated Nov 1, 2015 with new terminology)