How Should Primary Care Physicians Talk to Patients About Drug Use?

    All primary care physicians should screen their patients for drug use, recommended an independent panel of medical experts in an August 13 draft statement issued by the US Preventative Services Task Force. Engaging patients about substance use is legitimized by the proposed recommendations, but some doctors pointed out to Filter that this is already practiced by many physicians, often in informal ways. For them, the most important part is for doctors and patients to be speaking honestly about drug use.

    In the statement published for public comment, the Task Force concluded that screening tools have “moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred.”

    No particular screening tool—which is just a formalized set of questions—is endorsed or recommended. “We don’t want doctors and nurses to get hung up on one tool or another,” Dr. Carol Mangione, an author of the proposals who is a professor of medicine and public health at the University of California Los Angeles, told the New York Times. “Just that they do it.”

    For physicians like Dr. Gary LeRoy, a family doctor in Ohio and the president-elect of the American Academy of Family Physicians, the utility of screening does not come from which tool is used, but rather how it is used. Screening is “about recognizing variances and being present in the lives of our patients, and recognizing when we do have to ask those questions [about substance use], and offering a space to have that discussion,” LeRoy told Filter.

    When the Task Force last made recommendations about drug screenings in 2008, they concluded that evidence did not prove their benefits. Since then, more evidence has emerged—totaling around 45 studies as listed in the statement’s citations—to confirm benefits.

    The Task Force also concluded that illicit drug screening poses no “serious adverse events” for patients. But Dr. Peter Grinspoon, a primary care doctor in Massachusetts who is himself in recovery from addiction, explained to Filter that screenings, when done insensitively, could potentially be harmful to patients.

    “The doctor could either build bridges or burn them, depending on how they ask the questions,” he said. “A lot of Americans have a really stigmatizing perspective of people who abuse drugs. Doctors are people—they have the same prejudices. If they’re forced to bring this up and they don’t want to or they’re not sympathetic to it, then it certainly could be harmful.”

    Dr. Elizabeth Ryan—a family physician and associate medical director at Reach Medical, a low-threshold, harm reduction practice in Ithaca, New York, who has written about her work for Filter— recognizes that some doctors may have good intentions but lack the competency to broach the topic of drug use, which can leave patients vulnerable and providers uncomfortable.

    There is a fear on behalf of providers—a fear I shared to some extent before I moved to REACH Medical and got a bit of experience—that we will be inadequately prepared to close or at least manage the opened can of worms,” she said. “There is a potential problem any time a provider screens for a disorder but is not equipped to intervene in the case of a positive result.”

    Grinspoon added, though, that he thinks “the benefit [of screening] far outweighs the harm.”

    LeRoy believes it’s no coincidence that the recommendations are only now being issued. “There’s a political urgency. There’s a social urgency. There’s an emotional urgency,” he said, referring to the national crisis of fatal drug overdoses, which reached an all-time high of 70,000 in 2017.

    But some groups, like the Center for Addiction, a national science-based nonprofit, have been urging family doctors to talk with patients about substance use for nearly two decades.

    “The failure of most primary care physicians to identify, diagnose, intervene and treat substance abuse and addiction, especially in its early stages when the potential for success is high and medical and social costs are relatively low, is a lost opportunity that imposes enormous cost on individuals, families and public resources,” wrote Joseph A. Califano, Jr., the founder of the Center, in an accompanying statement to a May 2000 report. The report found that the vast majority (94 percent) of family doctors failed to diagnose “substance abuse” when presented with its early symptoms in adult patients.

    Nearly 20 years before the Task Force’s draft recommendations, the Center for Addiction report urged doctors to screenand even proposed that physicians “should be held liable for negligent failure to diagnose substance abuse and addiction.”

    But for LeRoy, this proposal misses the point of screenings: They “are a tool that we use to verify a suspicion. It’s not something that is negligence if you don’t do [it]” at every appointment. Since his time with a patient is around 20 minutes, LeRoy assesses whether he needs “to ask those pointed questions” by looking for deviations from the patient’s “baseline” and from what he already knows through their “overall relationship.”

    Grinspoon believes the Task Force’s proposed recommendations will help “systematize” screenings. “It’s helpful that they are being explicit about it, instead of it being [considered] ‘just a good thing to do.’ It codifies it and legitimizes it.”

    Photograph of a doctor speaking with a patient; by Zackary Drucker via The Gender Spectrum Collection

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