Helping doctors ask about drug, alcohol problems

[May 05, 2009]  WASHINGTON (AP) -- If more doctors started asking, would more drug and alcohol abusers 'fess up so they could get help?

It's a huge irony of health care: Go to the emergency room and you'll be asked about a tetanus shot, even though "most of us have never seen a case of tetanus," says Dr. Gail D'Onofrio, emergency medicine chief at Yale-New Haven Hospital.

Yet although up to half of ER visits involve illegal drugs or alcohol, typically "we don't ask it. It makes no sense whatsoever," says D'Onofrio, who teaches new doctors to break that chain of silence.

A new program from the National Institute on Drug Abuse aims to help health workers past the stigma and ensure that more patients are asked for simple clues to addiction at every visit -- not just in the ER, but anytime they see a doctor.

It's a step-by-step computerized guide that takes patients' answers to various behavior questions, analyzes their risk for a serious substance use problem and tells doctors what next steps to take.

A patient admits to experimenting with heroin? A few more questions about how often, when and if he felt cravings can guide how big his risk is for ongoing drug use and what intervention is needed -- plus remind the doctor to administer an HIV and hepatitis test.

Someone else insists she's a social drinker? If she's ever had four or more drinks in a day, she may have a bigger problem.

The goal: To get substance abuse treatment for more of the 23 million Americans estimated to need it. Only about 2 million today get that help, NIDA says.

Better would be finding people early, when substance abuse is just taking hold and a doctor intervening might keep it from getting worse. A government study last year found that some simple doctor steps -- brief in-office counseling or referral to a specialty center -- could help slash drug use by patients coaxed to come clean.

They have plenty of opportunity. Studies suggest people with brewing drug or alcohol problems actually see the doctor more often than their sober counterparts. They have a lot of injuries, and a tougher time with problems ranging from high blood pressure to liver disease.

"There are all sorts of people who are using alcohol, drugs, who are continuing to work and do their jobs and slowly spiraling down, who are not the hard-core users," says Dr. Brian Jack, a family medicine specialist at Boston University Medical School. "Those are people who are in the clinics every single day for all sorts of different things."

Hence the push for better substance abuse screening. The American College of Obstetricians and Gynecologists in December urged its members to ask every patient about alcohol or drug use. Top-level trauma centers must screen trauma patients as part of their accreditation. The government adopted new insurance payment codes last year so doctors could bill for screening time.

The new federal program, called NIDAMED, aims to break another barrier: How doctors not trained in addiction medicine can tell the difference between experimenting and abuse, and what they should do for a patient with a problem. Already, New York City officials have told the government they're planning to incorporate NIDAMED into the health department's electronic medical records, enabling more than 1,000 providers in underserved parts of the city to use it.

Don't patients just lie? Sure, some do. "Help your doctor read between the lines," says patient information accompanying NIDAMED.

There are consequences. Lie about what's in your system and you might be prescribed a legal drug that could trigger a deadly interaction. Lie if you're pregnant and you can hurt your baby. The key, say doctors who routinely screen, is earning patients' trust and explaining they're not being judgmental: Substance use is a medical problem.

"We're not the police," says D'Onofrio. Medical information is confidential.

"Get to know them as a person and treat them as a person, and care, frankly," adds Jack.

Dana Moulton of Boston recalls long ago being hospitalized with hepatitis and concealing that he was trying to kick a nearly 20-year heroin addiction. But one doctor sat by his bedside, talking about a mutual love of books and eventually coaxing Moulton to reveal his struggles in methadone treatment. Moulton credits that doctor's help with his success in going drug-free a decade ago.

"It was the first time someone did not stigmatize me, showed me genuine concern about my health issues despite the fact that I was a substance abuser," recalled Moulton, now 58 and with Massachusetts' substance-abuse office. "He dealt with me as a human being."

[Associated Press; By LAURAN NEERGAARD]

Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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