Spanning across all socioeconomic statuses, races, cultures and ages, addiction is one of the largest and most insidious problems our society faces today. And yet, for the medical doctors who are often tasked with treating addiction, identifying and treating it is not always a straight forward process.
In his new book, Addiction Treatment, Dr. Michael Weaver, a specialist in substance abuse disorders, provides a comprehensive review of addiction, dual diagnosis, pharmaceutical treatment and clinical advice about how to work with an addict.
“People are embarrassed to admit to using drugs partly because they worry others will see it as a personal weakness or defect,” writes Weaver.
But Weaver also writes that having the right screening tools can make a big difference.
Asking non-invasive questions, such as “A lot of people have tried things like LSD or mushrooms or acid. What has been your experience?” and beginning with the more socially-accepted drugs such as caffeine and nicotine are two key steps every physician can take to more clearly diagnose a substance abuse problem. Another efficient way to assess for substance abuse is to ask open-ended questions about the consequences of use.
Though controversial, drug screens can be helpful when patients have recurrent or remote substance abuse problems or are not responding to evidence-based treatment, or if a controlled substance medication has been prescribed. Weaver offers numerous helpful tips, including which drug tests to use, the detection periods in which they must be used and even how to broach the subject with patients.
Once addiction is uncovered, the next step is choosing the right treatment.
“For a variety of economic and historical reasons, the U.S. substance use treatment system has become quite complicated, and in some cases, separated from the rest of psychiatry,” writes Weaver.
From addictions counselors, interventionists, twelve-step programs, sober houses, residential treatment, outpatient treatment and detox programs, Weaver covers the entirety of treatment options along with the American Society of Addiction Guidelines for treatment matching.
Of particular importance in treating addictions is psychotherapy, and more specifically, motivational interviewing. While motivational interviewing was first developed for treating alcohol users its purpose is to help patients become aware if their intrinsic motivations to change their problematic behaviors.
Through familiarizing themselves with the stages of change, and interventions such as the FRAMES technique – which stands for feedback, responsibility, advice, menu of options, empathy and self-efficacy – physicians can work with addicts in ways that avoid resistance and result in better outcomes. One useful technique Weaver suggests is first asking about the good things associated with drug use and then asking about the less good things.
Identifying common causes of relapse is also a fundamental skill for physicians. According to Weaver, patients relapse for a variety of reasons including overconfidence, self-medication, temptation, anger, hunger, loneliness, boredom and feeling tired.
Weaver draws on the advice of Terence Gorski, an expert on relapse prevention:
“I will often have patients write down their life and addiction history and look at why they relapsed in the past. I will then have them develop a list of early warning signs of impending relapse…We will then work together to put into place strategies for preventing relapse.”
Becoming familiar with Alcoholics Anonymous and twelve-step programs is also important for physicians who work with addicts, as Weaver notes that in a review of scientific studies, they were found to be as effective as any other interventions they were compared to. Greater meeting attendance has also been associated with better outcomes.
However, it’s important to understand that underlying most addictions is a secondary diagnosis, which often complicates addiction treatment.
“Among patients who come to your office with psychiatric issues, at least 20-50% will have a substance abuse issue, with the rate highest in schizophrenia,” writes Weaver.
As these patients will often ask for medications that are addictive in nature, understanding the different classes of addictive substances and their pharmaceutical correlates becomes vitally important.
Weaver provides a comprehensive assessment of each class of addictive substance, the effects of long-term and short-term use, as well as the many pharmaceutical treatment options available. He also covers the interplay between specific psychiatric disorders and substance issues. For example, stimulant use may cause and be confused with mania, but once the effects of the drug wear off, the diagnosis typically becomes more clear.
Drawing on motivational interviewing techniques, advising patients about unknown side effects and knowing the common forms of denial are just a few of the invaluable skills Weaver offers his readers.
As informative as it is practical, Addiction Treatment should be required reading for anyone who treats patients with addictive disorders. It is a must have practical and hands-on guide in any addiction specialist’s library.
Michael Weaver MD
Carlat Publishing (2017)