Substance Abuse and Treatment: Information for Practitioners

Practitioner Notification and OASAS Program

Dear Practitioner:

In the current health care environment, a practitioner must weigh many factors when prescribing a controlled substance medication, including medication efficacy, risk, cost, reimbursement, regulations and the potential for development of drug dependence.

The practitioner walks a fine line between prescribing controlled substances for appropriate treatment and recognizing that those same medications can also lead to possible dependency and drug-seeking activity in some patients.

OASAS is pleased to partner with the New York State Department of Health, Bureau of Narcotic Enforcement, to offer information for the practitioner in the hope that these resources will help you to intervene at an early stage with patients who may be abusing prescription medications for non-medical purposes. It is our hope that these resources can provide information to help your patients access chemical dependency treatment if needed and at the same time provide up-to-date medical information for your practice.

  • Steven Kipnis, MD, Medical Director
    New York State Office of Alcoholism and Substance Abuse Services
  • Kenneth W. Post, Director
    Bureau of Narcotic Enforcement New York State Health Department

Potential Signs of Drug-Seeking Behavior

  • Patient shows unusual knowledge of controlled substances, gives evasive or vague answers to questions regarding medical history, or gives medical history with textbook symptoms.
  • Patient is reluctant or unwilling to provide reference information and usually has no regular doctor or health insurance.
  • Patient requests a specific controlled substance and is reluctant to try a different drug.
  • Patient generally has no interest in diagnosis, fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation.
  • Patient exaggerates medical problems and/or simulates symptoms.
  • Patient exhibits mood disturbances, suicidal thoughts, lack of impulse control, thought disorders or sexual dysfunction.
  • Patient exhibits physical signs of drug abuse; tremors, profuse sweating, anxious behavior, unusually dilated or constricted pupils, skin tracks and related scars on the neck, axilla, forearm, wrist, foot or ankle.

Prescription Drug Abuse Facts

Statistics from the National Center on Addiction and Substance Abuse at Columbia University (CASA):

  • Almost half (47.1%) of the physicians who completed the CASA survey reported that patients often attempt to pressure them into prescribing a controlled substance medication.
  • More than 40% of doctors said they did not ask about prescription drug abuse when taking a patient's history and one-third said they did not regularly call or obtain records from the patient's previous physicians before prescribing a controlled and potentially addictive drug.
  • In 2003, 15.1 million people reported abusing prescription medications compared to 7.8 million in 1992. During this time the population increased by 14%, but the number of those abusing prescription medications increased by 94%.
  • Controlled substance medications contributed to 23%of the drug related emergency room mentions and was associated with one out of five emergency room deaths.
  • For prescription pain relievers, emergency departments report a 450 percent increase in mentions. More than 200,000 visits to emergency rooms around the country each year are because of prescription drug abuse.
  • 61.2% of physicians surveyed would like to obtain more education and training on prescribing controlled substance medications.

What to Say to the Reluctant Patient

Some patients who have a substance abuse problem may not be "ready" to hear that they have a problem. This does not mean that there is nothing a practitioner can do. Several studies have found a positive effect of very brief interventions.

Example 1

The patient says

"I am not abusing these medications, the doctors all gave them to me."

Provider response

Avoid direct confrontation or arguing. Ask what they know about the medications. Provide information about health consequences, then ask patient's opinion of the information and elicit concern.

Example 2

The patient says

"I am using because I feel so badly and I cannot stop."

Provider response

Empathize with feelings. Offer direct advice to change with a menu of options. Ask for past successes.

Example 3

The patient says

" I already tried treatment and it did not work."

Provider response

Inform that many patients need several attempts at treatment. Provide a menu of options, not just "one way" to get better. Express hopefulness.

Example 4

The patient says

"I am going through a hard time, but I am sure I'll be fine."

Provider response

Listen for inconsistency or conflict about goals, values and current behavior. Reframe and reflect their conflict and offer help to resolve through referral.

The Power of Intervention

There is growing empirical data to support the success of interventions that work with patients who are not "ready" to increase their motivation for treatment and ultimate success in recovery. Several studies on brief interventions show that even small interventions can have lasting effects on behaviors. Interventions that are respectful, directive, and empathetic can impact patient behaviors. Advice given

empathetically and skillfully can increase the likelihood that a patient will accept a referral to substance abuse treatment and increase the likelihood that they will attend the initial appointment.