Treatment of Patients With Substance Abuse Histories
Involve a multidisciplinary team
Set realistic goals for therapy
Treat related psychiatric disorders
Prevent or minimize withdrawal symptoms
The impact of tolerance
Treat chronic pain
Recognize drug abuse behaviors
Use nondrug approaches
Taking a substance abuse history
The following issues refer to palliative care for patients who are actively
abusing alcohol or other drugs, or who are in a drug-free recovery or methadone
program.
Involve a multidisciplinary team
Patients with histories of substance abuse are best treated for progressive
medical illness by a team of health care providers. A team of one or more physicians, nurses, social workers and, if possible, an expert in addiction medicine, will address the many medical, psychosocial, and administrative
problems that patients with drug histories and progressive illness may have.
Set realistic goals for therapy
Patients who have drug abuse and addiction problems experience periods of
recovery and relapse. The risk of relapse is increased when patients have a
life-threatening disease and have access to pain medication. In this
situation, the goal of treatment may not be the complete prevention of relapse,
but may be to provide a structure that will limit any harm done by abuse of the
drugs. Some patients who have severe substance abuse and related psychological
problems may never be able to use therapeutic drugs as prescribed. The health
care team should monitor and revise treatment goals for these patients as often
as necessary to avoid treatment that is not successful.
Treat related psychiatric disorders
Alcoholics and patients with substance abuse histories are very likely to also
suffer from depression, anxiety, and personality disorders. The risk of
relapse may be decreased if the patient also receives treatment for anxiety and
depression.
Prevent or minimize withdrawal symptoms
Many patients with a history of drug abuse consume multiple drugs. The health
care provider must be made aware of all drug use so the patient may be
effectively monitored to prevent withdrawal symptoms.
The impact of tolerance
Patients who are actively abusing drugs may have developed a tolerance that
limits the effectiveness of drugs prescribed for a medical condition.
Treat chronic pain
Opioid regimens used for long-term control of medical symptoms are
individualized for each patient so that the dosage is large enough to control
symptoms. In patients with substance abuse histories, prescribing dosages that
are not large enough may result in undertreatment of the symptoms. The undertreatment does not relieve the patient's pain, and may encourage drug abuse in
an effort to control the symptoms. This behavior may cause the physician to
become more cautious in prescribing opioids. The physician and patient must
work together closely to determine the necessary dosage and to agree on
guidelines for responsible use of therapeutic drugs.
Recognize drug abuse behaviors
While all patients who are prescribed drugs that may be abused must be
monitored closely, monitoring is especially important for people who have a
history of substance abuse. The patient may be reassessed frequently, and the
patient's significant others may be asked to provide observations about the
patient's drug use. The physician may find it appropriate to test the
patient's urine for illegal or unprescribed drugs. If a patient is agreeable
to drug testing and monitoring and uses prescribed drugs responsibly, a
trusting relationship may be established with the physician. A physician who
is confident that the patient will not abuse drugs is more likely to adjust therapies to control symptoms.
Use nondrug approaches
The patient may benefit from nondrug approaches, such as learning about the
complexities of the medical system, communicating with the medical staff, and
learning relaxation and coping techniques.
Taking a substance abuse history
To avoid offending a patient, a health care provider may choose not to ask
about drug abuse. The health care provider may assume that the patient may
become offended, angry, threatened, or may not tell the truth. Such attitudes
are not helpful in establishing truthful communication between health care
provider and patient and may cause problems in monitoring therapy.
A patient may withhold information about his or her drug use because of
negative attitudes the health care provider may have about drug users. The
patient may not trust the health care provider, or the patient may fear that if
his/her drug abuse history is known, inadequate medication may be prescribed to
control symptoms. The physician must know the patient's drug use history in
order to control symptoms and to keep the patient comfortable by prescribing
adequate medication to prevent withdrawal symptoms and reduce pain. The
physician needs to know which drugs the patient has taken, the length of time
drugs have been used, the frequency of drug use, and the situations that cause
the patient to use drugs.
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